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Muishout G, El Amraoui A, Wiegers GA, van Laarhoven HWM. Muslim Jurisprudence on Withdrawing Treatment from Incurable Patients: A Directed Content Analysis of the Papers of the Islamic Fiqh Council of the Muslim World League. JOURNAL OF RELIGION AND HEALTH 2024; 63:1230-1267. [PMID: 36446918 DOI: 10.1007/s10943-022-01700-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 06/16/2023]
Abstract
This study investigates the views of contemporary Muslim jurists about withdrawing treatment of the terminally ill. Its aim is threefold. Firstly, it analyses jurists' views concerning core themes within the process of withdrawing treatment. Secondly, it provides insight into fatwas about withdrawing treatment. Thirdly, it compares these views with current medical standards in Europe and the Atlantic world on withdrawing treatment. The data consisted of six papers by Muslim jurists presented at the conference of the Islamic Fiqh Council in 2015. We conducted a directed content analysis (DCA) through a predetermined framework and compiled an overview of all previous fatwas referred to in the papers, which are also analysed. The results show that the general consensus is that if health cannot be restored, treatment may be withdrawn at the request of the patient and/or his family or on the initiative of the doctor. The accompanying fatwa emphasizes the importance of life-prolonging treatment if this does not harm the patient. It becomes apparent in the fatwa that the doctor has the monopoly in decision-making, which is inconsistent with current medical standards in Europe. Managing disclosure in view of the importance of maintaining the hope of Muslim patients may challenge the doctor's obligation to share a diagnosis with them.
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Affiliation(s)
- George Muishout
- Department of History, European Studies and Religious Studies, Amsterdam School for Historical Studies, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Gerard Albert Wiegers
- Department of History, European Studies and Religious Studies, Amsterdam School for Historical Studies, University of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke Wilma Marlies van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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2
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Anderson RJ, Stone PC, Low JTS, Bloch S. Transitioning out of prognostic talk in discussions with families of hospice patients at the end of life: A conversation analytic study. PATIENT EDUCATION AND COUNSELING 2021; 104:1075-1085. [PMID: 33199091 DOI: 10.1016/j.pec.2020.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To examine transitions out of prognostic talk in interactions between clinicians and the relatives and friends of imminently dying hospice patients. METHODS Conversation analysis of 20 conversations between specialist palliative care clinicians and the families of imminently dying patients in a hospice. RESULTS Following the provision and acknowledgement of a prognostic estimate, clinicians were able to transition gradually towards making assurances about actions that could be taken to ensure patient comfort. When families raised concerns or questions, this transition sequence was extended. Clinicians addressed these questions or concerns and then pivoted to action-oriented talk, most often relating to patient comfort. CONCLUSION In conversations at the end of life, families and clinicians used practices to transition from the uncertainty of prognosis to more certain, controllable topics including comfort care. PRACTICE IMPLICATIONS In a context in which there is a great deal of uncertainty, transitioning towards talk on comfort care can emphasise action and the continued care of the patient and their family.
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Affiliation(s)
- Rebecca J Anderson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK.
| | - Patrick C Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Joseph T S Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Steven Bloch
- Department of Language and Cognition, Division of Psychology and Language Sciences, UCL, London, UK
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3
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Tarbi EC, Gramling R, Bradway C, Broden EG, Meghani SH. "I Had a Lot More Planned": The Existential Dimensions of Prognosis Communication with Adults with Advanced Cancer. J Palliat Med 2021; 24:1443-1454. [PMID: 33534644 DOI: 10.1089/jpm.2020.0696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Communication about prognosis is a key ingredient of effective palliative care. When patients with advanced cancer develop increased prognostic understanding, there is potential for existential distress to occur. However, the existential dimensions of prognosis communication are underexplored. Objective: To describe the existential dimensions of prognosis communication in naturally-occurring palliative care conversations. Methods: This study was an explanatory sequential mixed methods design. We analyzed a random subset of patients from the Palliative Care Communication Research Initiative (PCCRI) parent study (n = 34, contributing to 45 palliative care conversations). Data were based on audio-recorded and transcribed inpatient palliative care conversations between adults with advanced cancer, their families, and palliative care clinicians. We stratified the study sample by levels of prognosis communication, and qualitatively examined patterns of existential communication, comparing the intensity, frequency, and content, within and across levels. Results: Existential communication was more common, and of stronger intensity, within conversations with higher levels of prognosis communication. Conversations with more prognosis communication appeared to exhibit a shift toward the existential and away from the more physical nature of the serious illness experience. Conclusion: Existential and prognosis communication are intimately linked within palliative care conversations. Results highlight the multiplicity and mutuality of concerns that arise when contemplating mortality, drawing attention to areas of palliative care communication that warrant future research.
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Affiliation(s)
- Elise C Tarbi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert Gramling
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Christine Bradway
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Elizabeth G Broden
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Salimah H Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Edmonds KP, Ajayi TA. Do We Know What We Mean? An Examination of the Use of the Phrase “Goals of Care” in the Literature. J Palliat Med 2019; 22:1546-1552. [DOI: 10.1089/jpm.2019.0059] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Kyle P. Edmonds
- Doris A. Howell Palliative Care, UC San Diego Health, San Diego, California
| | - Toluwalase A. Ajayi
- Scripps Research, San Diego, California
- Scripps Health, San Diego, California
- Department of Pediatrics, UC San Diego Health, San Diego, California
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Abstract
OBJECTIVES Evaluate the reasons why attempts at redirection, especially at the end of life, often fail, and patients and families insist on treating the underlying illness. SETTING Conflicts between patients and caregivers regarding the appropriate course of treatment. MAIN RESULTS Clinicians typically understand requests for treatment merely as means to obtain effective care. However, patients and families often request treatment as a way to exert their agency, avoid a sense of responsibility for unwanted outcomes, and express compassion. CONCLUSIONS In response to devastating illness, patients and families are frequently motivated by factors that go beyond obtaining effective care. Awareness of these factors can help clinicians to identify sources of potential conflict and continue to provide compassionate care.
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Ingersoll LT, Alexander SC, Priest J, Ladwig S, Anderson W, Fiscella K, Epstein RM, Norton SA, Gramling R. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:1098-1103. [PMID: 30642715 DOI: 10.1016/j.pec.2019.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/12/2018] [Accepted: 01/02/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication. METHODS We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity. RESULTS In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others. CONCLUSION Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity. PRACTICE IMPLICATIONS Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care.
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Affiliation(s)
- Luke T Ingersoll
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America.
| | - Stewart C Alexander
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Jeff Priest
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Susan Ladwig
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Wendy Anderson
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Kevin Fiscella
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Ronald M Epstein
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Sally A Norton
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
| | - Robert Gramling
- Department of Consumer Science, Purdue University, 812W. State St., West Lafayette, IN 47907, United States of America
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Thompson GN, Mcclement SE, Daeninck PJ. “Changing Lanes”: Facilitating the Transition from Curative to Palliative Care. J Palliat Care 2019. [DOI: 10.1177/082585970602200205] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little empirical work has been conducted assessing the perspectives of nurses regarding the barriers, facilitators, and strategies associated with achieving quality patient care at the end of life. A grounded theory study was conducted examining nursing behaviours and social processes inherent in the provision of quality end-of-life care from the perspective of generalist nurses (n=10) working in an acute care setting. An inductively derived preliminary model, “creating a haven for safe passage”, was developed based on the findings from this study and has been published elsewhere (1). This article provides a detailed description of one of the subprocesses of the model regarding the transition from curative to palliative care—the subprocess of “facilitating and maintaining a lane change”. The various strategies which nurses used to effect a lane change, as well as the facilitators and barriers they encountered in this process, are presented. The consequences associated with both successful and unsuccessful lane changes are reported.
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Affiliation(s)
| | - Susan E. Mcclement
- Faculty of Nursing, University of Manitoba, and Manitoba Palliative Care Research Unit, CancerCare Manitoba, Winnipeg
| | - Paul J. Daeninck
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Meeker MA, McGinley JM, Jezewski MA. Metasynthesis: Dying adults' transition process from cure-focused to comfort-focused care. J Adv Nurs 2019; 75:2059-2071. [PMID: 30734354 DOI: 10.1111/jan.13970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 11/30/2022]
Abstract
AIM To describe and explain the process of transition from cure-focused to comfort-focused health care as perceived and reported by patients, family members, and healthcare providers. BACKGROUND Moving into the last phase of life due to advanced illness constitutes a developmental transition with increased vulnerability for patients and family. DESIGN Qualitative metasynthesis. DATA SOURCES Medline, CINAHL, and PsycInfo databases searched from inception through March 2016. Primary research reports published from 1990 to 2015, using qualitative designs to report transition experiences of patients, family members, and/or healthcare providers were included. REVIEW METHODS Key elements were extracted and organized into matrices. Findings from each report were analysed using qualitative coding. RESULTS The sample was 56 unique reports from 50 primary studies. Patients and families emphasized the importance of receiving understandable information, emotional support, respect for personhood and control. The critical juncture of 'realizing terminality' preceded a transition to comfort-focused care. Subsequently, a shift in goals of care emphasizing comfort and quality of life could occur. Continued provision of information, effective support, respect and control promoted 'reframing perceptions' and capacity to embrace a changed identity. Reframing allowed patient and family to find meaning and value in this last phase of life and to embrace the opportunity to prepare for death, nurture relationships, and focus on quality of living. CONCLUSION Understanding the developmental process that can be engaged by patients and families at the end of life provides a theoretical basis that can inform choice and timing of interventions to reduce suffering and enhance positive outcomes.
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Hoerger M, Greer JA, Jackson VA, Park ER, Pirl WF, El-Jawahri A, Gallagher ER, Hagan T, Jacobsen J, Perry LM, Temel JS. Defining the Elements of Early Palliative Care That Are Associated With Patient-Reported Outcomes and the Delivery of End-of-Life Care. J Clin Oncol 2018; 36:1096-1102. [PMID: 29474102 DOI: 10.1200/jco.2017.75.6676] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose We describe the key elements of early palliative care (PC) across the illness trajectory and examine whether visit content was associated with patient-reported outcomes and end-of-life care. Methods We performed a secondary analysis of patients with newly diagnosed advanced lung or noncolorectal GI cancer (N = 171) who were randomly assigned to receive early PC. Participants attended at least monthly visits with board-certified PC physicians and advanced practice nurses at Massachusetts General Hospital. PC clinicians completed surveys documenting visit content after each encounter. Patients reported quality of life (Functional Assessment of Cancer Therapy-General) and mood (Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9) at baseline and 24 weeks. End-of-life care data were abstracted from the electronic health record. We summarized visit content over time and used linear and logistic regression to identify whether the proportion of visits addressing a content area was associated with patient-reported outcomes and end-of-life care. Results We analyzed data from 2,921 PC visits, most of which addressed coping (64.2%) and symptom management (74.5%). By 24 weeks, patients who had a higher proportion of visits that addressed coping experienced improved quality of life ( P = .02) and depression symptoms (Depression subscale of the Hospital Anxiety and Depression Scale, P = .002; Patient Health Questionnaire-9, P = .004). Patients who had a higher proportion of visits address treatment decisions were less likely to initiate chemotherapy ( P = .02) or be hospitalized ( P = .005) in the 60 days before death. Patients who had a higher proportion of visits addressing advance care planning were more likely to use hospice ( P = .03). Conclusion PC clinicians' focus on coping, treatment decisions, and advance care planning is associated with improved patient outcomes. These data define the key elements of early PC to enable dissemination of the integrated care model.
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Affiliation(s)
- Michael Hoerger
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Joseph A Greer
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Vicki A Jackson
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Elyse R Park
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - William F Pirl
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Areej El-Jawahri
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Emily R Gallagher
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Teresa Hagan
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Juliet Jacobsen
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Laura M Perry
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer S Temel
- Michael Hoerger and Laura M. Perry, Tulane Cancer Center, New Orleans, LA; Joseph A. Greer, Vicki A. Jackson, Elyse R. Park, Areej El-Jawahri, Emily R. Gallagher, Juliet Jacobsen, and Jennifer S. Temel, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; William F. Pirl, Sylvester Comprehensive Cancer Center/University of Miami, Miami, FL; and Teresa Hagan, University of Pittsburgh, Pittsburgh, PA
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Broom A, Kirby E, Good P, Lwin Z. Nursing futility, managing medicine: Nurses’ perspectives on the transition from life-prolonging to palliative care. Health (London) 2016. [DOI: 10.1177/1363459315595845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The shift from life-prolonging and palliative care can be fraught with interpersonal complexities as patients face dilemmas around mortality and the dying process. Nurses can play a central role in managing these moments, often with a focus on promoting and enhancing communication around: the meaning of palliative care, the nature of futility and the dying process more broadly. These sites of nurse–patient communication can be highly charged and pose unique challenges to nurses including how to balance nursing perspectives versus those of other stakeholders including doctors. Here, drawing on interviews with nurses, we explore their accounts of communication about futility and the process of transitioning to palliative care. The interviews reveal nurses’ perspectives on the following: the art of conversing around futility and managing patient resistance, the influence of guilt and individual biographies in shaping communication, the importance of non-verbal and the informal in communication, the impact of conflicting organisational expectations on nurses and the process of learning to effectively communicate. We argue that these transitional moments articulate important, and at times problematic, aspects of contemporary nursing and nurse–medical relations.
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Affiliation(s)
- Alex Broom
- The University of New South Wales, Australia
| | - Emma Kirby
- The University of New South Wales, Australia
| | | | - Zarnie Lwin
- Royal Brisbane and Women's Hospital, Australia
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11
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Laporte P, Vonarx N. Le « bien mourir » perçu dans une approche de l’auto-transcendance et de la transition : deux théories de soin utiles pour l’infirmière. Rech Soins Infirm 2016. [DOI: 10.3917/rsi.125.0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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12
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Gillick MR. Re-engineering shared decision-making. JOURNAL OF MEDICAL ETHICS 2015; 41:785-788. [PMID: 25926672 DOI: 10.1136/medethics-2014-102618] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 04/13/2015] [Indexed: 06/04/2023]
Abstract
Shared decision-making is widely accepted as the gold standard of clinical care. Numerous obstacles to achieving shared decision-making have been identified, including patient factors, physician factors and systemic factors. Until now, the paradigm is seldom successfully implemented in clinical practice, raising questions about the practicality of the process recommended for its use. A re-engineered model is proposed in which physicians elicit and prioritise patients' goals of care and then help translate those goals into treatment options, after clarifying the patient's underlying health status. Preliminary evidence suggests that each step of this revised process is feasible and that patients and physicians are comfortable with this strategy. Adoption of this model, after further testing, would allow the goal of shared decision-making to be realised.
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13
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Sohi J, Champagne M, Shidler S. Improving health care professionals’ collaboration to facilitate patient participation in decisions regarding life-prolonging care: An action research project. J Interprof Care 2015; 29:409-14. [DOI: 10.3109/13561820.2015.1027335] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Arbour RB, Wiegand DL. Self-described nursing roles experienced during care of dying patients and their families: a phenomenological study. Intensive Crit Care Nurs 2014; 30:211-8. [PMID: 24560634 DOI: 10.1016/j.iccn.2013.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 11/08/2013] [Accepted: 12/16/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Critical care nurses frequently care for dying patients and their families. Little is known about the roles experienced and perceived by bedside nurses as they care for dying patients and their families. OBJECTIVES The purpose of this study was to understand the experiences of critical care nurses and to understand their perceptions of activities and roles that they performed while caring for patients and families during the transition from aggressive life-saving care to palliative and end-of-life care. METHODS A descriptive, phenomenological study was conducted and a purposive sampling strategy was used to recruit 19 critical care nurses with experience caring for dying patients and their families. Individual interviews were conducted and audio-recorded. Coliazzi's method of data analysis was utilised to inductively determine themes, clusters and categories. Data saturation was achieved and methodological rigour was established. RESULTS Categories that evolved from the data included educating the family, advocating for the patient, encouraging and supporting family presence, managing symptoms, protecting families and creating positive memories and family support. Participants also identified the importance of teaching and mentoring novice clinicians. CONCLUSIONS The results of this study have important implications for clinical practice, education and research for optimal preparation in providing end-of-life care.
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Affiliation(s)
- Richard B Arbour
- In-Patient Liver Transplant Coordinator, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Debra L Wiegand
- University of Maryland School of Nursing, Baltimore, MD, USA
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16
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Norton SA, Metzger M, DeLuca J, Alexander SC, Quill TE, Gramling R. Palliative care communication: linking patients' prognoses, values, and goals of care. Res Nurs Health 2013; 36:582-90. [PMID: 24114740 DOI: 10.1002/nur.21563] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2013] [Indexed: 11/08/2022]
Abstract
Prognostic communication is a primary component of goals of care conversations in palliative care (PC) practice. Little is known about these conversations in the natural setting. This study's aim was to describe the processes of prognostic communication in PC goals of care consultations. Using line-by-line qualitative analysis, we examined prognostic conversation in 66 audio-taped PC consultations. We identified five processes by which clinicians link prognoses, values, and goals of care: (1) signposting the crossroads; (2) closing off a goal; (3) clarifying current path; (4) linking paths and patients' values; and (5) choosing among paths. The findings add to our understanding of PC consultation by describing how prognoses link with patients' values and choices in goals of care conversations.
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Affiliation(s)
- Sally A Norton
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642
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Wiegand DL, Grant MS, Cheon J, Gergis MA. Family-Centered End-of-Life Care in the ICU. J Gerontol Nurs 2013; 39:60-8. [DOI: 10.3928/00989134-20130530-04] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/10/2013] [Indexed: 11/20/2022]
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18
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Namasivayam P, Lee S, O'Connor M, Barnett T. Caring for families of the terminally ill in Malaysia from palliative care nurses’ perspectives. J Clin Nurs 2013; 23:173-80. [DOI: 10.1111/jocn.12242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Pathma Namasivayam
- St John of God Frankston Rehabilitation Hospital; Frankston Vic. Australia
| | - Susan Lee
- Palliative Care Research Team; School of Nursing and Midwifery; Monash University; Frankston Vic. Australia
| | - Margaret O'Connor
- Palliative Care Research Team; Monash University; Frankston Vic. Australia
| | - Tony Barnett
- University Department of Rural Health; University of Tasmania; Launceston Tas. Australia
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Gramling R, Norton SA, Ladwig S, Metzger M, DeLuca J, Gramling D, Schatz D, Epstein R, Quill T, Alexander S. Direct observation of prognosis communication in palliative care: a descriptive study. J Pain Symptom Manage 2013; 45:202-12. [PMID: 22652135 DOI: 10.1016/j.jpainsymman.2012.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/07/2012] [Accepted: 02/14/2012] [Indexed: 12/25/2022]
Abstract
CONTEXT Palliative care (PC) consultations result in improved patient understanding of prognosis and better quality of life, yet the content and processes of prognosis communication during PC consultations remain unknown. OBJECTIVES To describe prognosis communication during PC consultation with seriously ill hospitalized patients. METHODS We audio recorded 71 sequential inpatient PC consultations (initial visit) with seriously ill patients and their families who were referred for "goals of care" clarification or help with "end-of-life decision making." Conversations were coded using reliable methods and we then linked conversation codes to clinical record and clinician interview data. RESULTS Ninety-three percent of consultations contained prognosis communication. Participants communicated prognoses regarding quality of life more frequently than survival; focused prognosis estimates on the unique patient more frequently than on a general population; and framed prognosis using pessimistic cues more frequently than optimistic ones. Prognoses were more commonly spoken by PC clinicians than by patients/families. The following two factors demonstrated an association with the rate of prognostic communication and with the pessimistic framing of that information: whether the patient, family, or both participated in the conversation, and shorter expected survival (as estimated by the attending physician). CONCLUSION Prognoses are routinely communicated in PC consultations with hospitalized patients and their families. The rate and characteristics of prognosis communication differ based on the length of time the patient is expected to live.
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Prognostic communication of critical care nurses and physicians at end of life. Dimens Crit Care Nurs 2012; 31:170-82. [PMID: 22475704 DOI: 10.1097/dcc.0b013e31824e0022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Many critical care nurses express reluctance to communicate prognostic information to patients and family members, especially prior to physician communication of this information. Yet, the findings from this study indicate that critical care nurses play a crucial, complementary role to physicians in prognostic communication. Nurses' contributions result in a broader picture of prognosis to patients and family members and facilitate end-of-life discussions.
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Billings JA. The end-of-life family meeting in intensive care part II: Family-centered decision making. J Palliat Med 2012; 14:1051-7. [PMID: 21910612 DOI: 10.1089/jpm.2011.0038-b] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J Andrew Billings
- Harvard Medical School Center for Palliative Care, Boston, Massachusetts, USA
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Quinn JR, Schmitt M, Baggs JG, Norton SA, Dombeck MT, Sellers CR. Family members' informal roles in end-of-life decision making in adult intensive care units. Am J Crit Care 2012; 21:43-51. [PMID: 22210699 DOI: 10.4037/ajcc2012520] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process. OBJECTIVE To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units. METHODS Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit. PARTICIPANTS Health care clinicians, patients, and family members. RESULTS Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains. CONCLUSIONS These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.
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Affiliation(s)
- Jill R. Quinn
- Jill R. Quinn is an associate professor, Madeline Schmitt is a professor emerita, Sally A. Norton is an associate professor, Mary T. Dombeck is a professor, and Craig R. Sellers is an associate professor of clinical nursing at the University of Rochester School of Nursing in Rochester, New York. Judith Gedney Baggs is a distinguished professor at Oregon Health & Science University School of Nursing in Portland
| | - Madeline Schmitt
- Jill R. Quinn is an associate professor, Madeline Schmitt is a professor emerita, Sally A. Norton is an associate professor, Mary T. Dombeck is a professor, and Craig R. Sellers is an associate professor of clinical nursing at the University of Rochester School of Nursing in Rochester, New York. Judith Gedney Baggs is a distinguished professor at Oregon Health & Science University School of Nursing in Portland
| | - Judith Gedney Baggs
- Jill R. Quinn is an associate professor, Madeline Schmitt is a professor emerita, Sally A. Norton is an associate professor, Mary T. Dombeck is a professor, and Craig R. Sellers is an associate professor of clinical nursing at the University of Rochester School of Nursing in Rochester, New York. Judith Gedney Baggs is a distinguished professor at Oregon Health & Science University School of Nursing in Portland
| | - Sally A. Norton
- Jill R. Quinn is an associate professor, Madeline Schmitt is a professor emerita, Sally A. Norton is an associate professor, Mary T. Dombeck is a professor, and Craig R. Sellers is an associate professor of clinical nursing at the University of Rochester School of Nursing in Rochester, New York. Judith Gedney Baggs is a distinguished professor at Oregon Health & Science University School of Nursing in Portland
| | - Mary T. Dombeck
- Jill R. Quinn is an associate professor, Madeline Schmitt is a professor emerita, Sally A. Norton is an associate professor, Mary T. Dombeck is a professor, and Craig R. Sellers is an associate professor of clinical nursing at the University of Rochester School of Nursing in Rochester, New York. Judith Gedney Baggs is a distinguished professor at Oregon Health & Science University School of Nursing in Portland
| | - Craig R. Sellers
- Jill R. Quinn is an associate professor, Madeline Schmitt is a professor emerita, Sally A. Norton is an associate professor, Mary T. Dombeck is a professor, and Craig R. Sellers is an associate professor of clinical nursing at the University of Rochester School of Nursing in Rochester, New York. Judith Gedney Baggs is a distinguished professor at Oregon Health & Science University School of Nursing in Portland
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Epstein RM, Street RL. Shared mind: communication, decision making, and autonomy in serious illness. Ann Fam Med 2011; 9:454-61. [PMID: 21911765 PMCID: PMC3185482 DOI: 10.1370/afm.1301] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 06/08/2011] [Accepted: 06/23/2011] [Indexed: 12/30/2022] Open
Abstract
In the context of serious illness, individuals usually rely on others to help them think and feel their way through difficult decisions. To help us to understand why, when, and how individuals involve trusted others in sharing information, deliberation, and decision making, we offer the concept of shared mind-ways in which new ideas and perspectives can emerge through the sharing of thoughts, feelings, perceptions, meanings, and intentions among 2 or more people. We consider how shared mind manifests in relationships and organizations in general, building on studies of collaborative cognition, attunement, and sensemaking. Then, we explore how shared mind might be promoted through communication, when appropriate, and the implications of shared mind for decision making and patient autonomy. Next, we consider a continuum of patient-centered approaches to patient-clinician interactions. At one end of the continuum, an interactional approach promotes knowing the patient as a person, tailoring information, constructing preferences, achieving consensus, and promoting relational autonomy. At the other end, a transactional approach focuses on knowledge about the patient, information-as-commodity, negotiation, consent, and individual autonomy. Finally, we propose that autonomy and decision making should consider not only the individual perspectives of patients, their families, and members of the health care team, but also the perspectives that emerge from the interactions among them. By drawing attention to shared mind, clinicians can observe in what ways they can promote it through bidirectional sharing of information and engaging in shared deliberation.
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Affiliation(s)
- Ronald M Epstein
- Departments of Family Medicine, Psychiatry, and Oncology, School of Medicine & Dentistry, and the and School of Nursing, University of Rochester Medical Center, Rochester, New York, USA.
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Lind R, Lorem GF, Nortvedt P, Hevrøy O. Family members' experiences of "wait and see" as a communication strategy in end-of-life decisions. Intensive Care Med 2011; 37:1143-50. [PMID: 21626240 PMCID: PMC3126999 DOI: 10.1007/s00134-011-2253-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 04/01/2011] [Indexed: 11/02/2022]
Abstract
PURPOSE The aim of this study is to examine family members' experiences of end-of-life decision-making processes in Norwegian intensive care units (ICUs) to ascertain the degree to which they felt included in the decision-making process and whether they received necessary information. Were they asked about the patient's preferences, and how did they view their role as family members in the decision-making process? METHODS A constructivist interpretive approach to the grounded theory method of qualitative research was employed with interviews of 27 bereaved family members of former ICU patients 3-12 months after the patient's death. RESULTS The core finding is that relatives want a more active role in end-of-life decision-making in order to communicate the patient's wishes. However, many consider their role to be unclear, and few study participants experienced shared decision-making. The clinician's expression "wait and see" hides and delays the communication of honest and clear information. When physicians finally address their decision, there is no time for family participation. Our results also indicate that nurses should be more involved in family-physician communication. CONCLUSIONS Families are uncertain whether or how they can participate in the decision-making process. They need unambiguous communication and honest information to be able to take part in the decision-making process. We suggest that clinicians in Norwegian ICUs need more training in the knowledge and skills of effective communication with families of dying patients.
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Affiliation(s)
- Ranveig Lind
- Intensive Care Unit, University Hospital of Northern Norway, Opin-klin, Pb 6060, 9038 Tromsø, Norway
- Department of Care and Health Sciences, University of Tromsø, Tromsø, Norway
| | - Geir F. Lorem
- Department of Care and Health Sciences, University of Tromsø, Tromsø, Norway
| | - Per Nortvedt
- Section for Medical Ethics, University of Oslo, Oslo, Norway
| | - Olav Hevrøy
- Intensive Care Unit, Haukeland University Hospital, Bergen, Norway
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Bélanger E, Rodríguez C, Groleau D. Shared decision-making in palliative care: a systematic mixed studies review using narrative synthesis. Palliat Med 2011; 25:242-61. [PMID: 21273220 DOI: 10.1177/0269216310389348] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study is to synthesize knowledge about the process of shared decision-making (SDM) in palliative care. Medline, EMBASE, CINAHL, PsychInfo, Web of Science were searched with core concepts: shared decisions, patient participation in decision-making, and palliative care. Titles and abstracts were screened according to inclusion criteria (original research, adult patients, Western contexts, decision-making, palliative treatment or setting), yielding 37 articles for analysis. A narrative synthesis was created using the methods of thematic analysis, conceptual mapping, and critical reflection on the synthesis process. Results demonstrate that while a majority of patients want to participate in treatment decisions to some extent, most do not achieve their preferred levels of involvement because decisions are delayed and alternative treatment options are seldom discussed. The literature regarding the process of SDM itself remains scarce in palliative care. Further research is needed in order to better understand the longitudinal, interactive, and interdisciplinary process of decision-making in palliative care.
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Affiliation(s)
- Emmanuelle Bélanger
- Division of Social and Transcultural Psychiatry, McGill University, Montreal, Canada.
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26
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Development and Validation of a Scale for the End of Life Caregiving Appraisal. Asian Nurs Res (Korean Soc Nurs Sci) 2010; 4:1-9. [DOI: 10.1016/s1976-1317(10)60001-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 11/12/2009] [Accepted: 01/19/2010] [Indexed: 11/20/2022] Open
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Goodridge D, Duggleby W, Gjevre J, Rennie D. Exploring the quality of dying of patients with chronic obstructive pulmonary disease in the intensive care unit: a mixed methods study. Nurs Crit Care 2009; 14:51-60. [PMID: 19243521 DOI: 10.1111/j.1478-5153.2008.00313.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE FOR THE STUDY Improving the quality of end-of-life (EOL) care in critical care settings is a high priority. Patients with advanced chronic obstructive pulmonary disease (COPD) are frequently admitted to and die in critical care units. To date, there has been little research examining the quality of EOL care for this unique subpopulation of critical care patients. AIMS The aims of this study were (a) to examine critical care clinician perspectives on the quality of dying of patients with COPD and (b) to compare nurse ratings of the quality of dying and death between patients with COPD with those who died from other illnesses in critical care settings. DESIGN AND SAMPLE A sequential mixed method design was used. Three focus groups provided data describing the EOL care provided to patients with COPD dying in the intensive care unit (ICU). Nurses caring for patients who died in the ICU completed a previously validated, cross-sectional survey (Quality of Dying and Death) rating the quality of dying for 103 patients. DATA ANALYSIS Thematic analysis was used to analyse the focus group data. Total and item scores for 34 patients who had died in the ICU with COPD were compared with those for 69 patients who died from other causes. RESULTS Three primary themes emerged from the qualitative data are as follows: managing difficult symptoms, questioning the appropriateness of care and establishing care priorities. Ratings for the quality of dying were significantly lower for patients with COPD than for those who died from other causes on several survey items, including dyspnoea, anxiety and the belief that the patient had been kept alive too long. The qualitative data allowed for in-depth explication of the survey results. CONCLUSIONS Attention to the management of dyspnoea, anxiety and treatment decision-making are priority concerns when providing EOL care in the ICU to patients with COPD.
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Affiliation(s)
- Donna Goodridge
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Review Article: Goals of Care Toward the End of Life: A Structured Literature Review. Am J Hosp Palliat Care 2008; 25:501-11. [DOI: 10.1177/1049909108328256] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967—2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.
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Affiliation(s)
- Lauris C. Kaldjian
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center,
| | - Ann E. Curtis
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center
| | - Laura A. Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine
| | - Katrina T. Cannon
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center
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Clayton JM, Hancock K, Parker S, Butow PN, Walder S, Carrick S, Currow D, Ghersi D, Glare P, Hagerty R, Olver IN, Tattersall MHN. Sustaining hope when communicating with terminally ill patients and their families: a systematic review. Psychooncology 2008; 17:641-59. [DOI: 10.1002/pon.1288] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Wingate S, Wiegand DLM. End-of-Life Care in the Critical Care Unit for Patients With Heart Failure. Crit Care Nurse 2008. [DOI: 10.4037/ccn2008.28.2.84] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Sue Wingate
- Sue Wingate is a cardiology nurse practitioner at Kaiser Permanente Mid-Atlantic States, Silver Spring, Maryland
| | - Debra Lynn-McHale Wiegand
- Debra Lynn-McHale Wiegand is an assistant professor at the University of Maryland School of Nursing, Baltimore, Maryland and is a staff nurse in the surgical cardiac care unit at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania
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Goodridge D, Duggleby W, Gjevre J, Rennie D. Caring for critically ill patients with advanced COPD at the end of life: a qualitative study. Intensive Crit Care Nurs 2008; 24:162-70. [PMID: 18313923 DOI: 10.1016/j.iccn.2008.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Revised: 01/10/2008] [Accepted: 01/12/2008] [Indexed: 11/19/2022]
Abstract
Providing expert critical care for the high acuity patient with a diagnosis of COPD at the end of life is both complex and challenging. The purpose of this descriptive study was to examine intensive care unit (ICU) clinicians' perspectives on the obstacles to providing quality care for individuals with COPD who die within the critical care environment. Transcripts of three focus groups of ICU clinicians were analyzed using thematic analysis. The three themes of "managing difficult symptoms", "questioning the appropriateness of life-sustaining care" and "conflicting care priorities" were noted to be significant challenges in providing high quality end of life care to this population. Difficulties in palliating dyspnea and anxiety were associated with caregiver feelings of helplessness, empathy and fears about "killing the patient". A sense of futility, concerns about "torturing the patient" and questions about the patient/family's understanding of treatment pervaded much of the discourse about caring for people with advanced COPD in the ICU. The need to prioritize care to the most unstable ICU patients meant that patients with COPD did not always receive the attention clinicians felt they should ideally have. Organizational support must be made available for critical care clinicians to effectively deal with these issues.
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Affiliation(s)
- Donna Goodridge
- College of Nursing, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan S7T5E5, Canada.
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Clayton JM, Hancock KM, Butow PN, Tattersall MHN, Currow DC, Adler J, Aranda S, Auret K, Boyle F, Britton A, Chye R, Clark K, Davidson P, Davis JM, Girgis A, Graham S, Hardy J, Introna K, Kearsley J, Kerridge I, Kristjanson L, Martin P, McBride A, Meller A, Mitchell G, Moore A, Noble B, Olver I, Parker S, Peters M, Saul P, Stewart C, Swinburne L, Tobin B, Tuckwell K, Yates P. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust 2007; 186:S77-S105. [PMID: 17727340 DOI: 10.5694/j.1326-5377.2007.tb01100.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 03/18/2007] [Indexed: 11/17/2022]
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Hancock K, Clayton JM, Parker SM, Walder S, Butow PN, Carrick S, Currow D, Ghersi D, Glare P, Hagerty R, Tattersall MHN. Discrepant perceptions about end-of-life communication: a systematic review. J Pain Symptom Manage 2007; 34:190-200. [PMID: 17544247 DOI: 10.1016/j.jpainsymman.2006.11.009] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Revised: 11/08/2006] [Accepted: 11/11/2006] [Indexed: 12/12/2022]
Abstract
Little research has compared the perceptions of health professionals (HPs), patients, and caregivers about the communication of prognostic information. The objectives of this literature review were to determine 1) patient and caregiver perceptions of levels of information received about prognosis and end-of-life (EoL) issues regarding a life-limiting illness; 2) patient perceptions of and factors related to their understanding and awareness of prognosis; 3) HPs' perceptions of patients' wishes about disclosure of prognosis and factors related to their decision whether to disclose; and 4) concordance between HPs and patients/caregivers regarding the information given by HPs about prognostic and EoL issues. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO, Cochrane Register of Controlled Trials [Central]) up to November 2004. The reference lists of identified studies were hand searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Fifty-one studies were identified. There was a large discrepancy between patients/caregivers and HPs regarding the amount of information they believed had been given. Patients' understanding and awareness of information received conflicted with the HPs' perceptions of patients' understanding and awareness of the information that had been given. HPs tended to underestimate patients' need for information and overestimate patients' understanding and awareness of their prognosis and EoL issues. HPs need to repeatedly check patients' understanding and preferences for information.
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Affiliation(s)
- Karen Hancock
- Medical Psychology Research Unit, NHMRC Clinical Trials Centre, School of Psychology, University of Sydney, Camperdown, New South Wales, Australia
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Calvin AO, Kite-Powell DM, Hickey JV. The neuroscience ICU nurse's perceptions about end-of-life care. J Neurosci Nurs 2007; 39:143-50. [PMID: 17591410 DOI: 10.1097/01376517-200706000-00004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this qualitative descriptive study was to describe neuroscience intensive care unit (NICU) nurses' perceptions regarding their roles and responsibilities in the decision-making process during the change in intensity of care and end-of-life care for patients. Twelve NICU nurses agreed to a private moderately structured interview. Three major themes summarize the data: (1) providing guidance, (2) being positioned in the middle of the communication process, and (3) feeling the emotions of patients and families. The nurse caring for a patient at the end of life provides guidance from the middle or "hub" of the communication process between family members and physicians. The nurses in this study describe an array of feelings associated with this role. This research adds to the limited body of knowledge concerning critical care nurses' experiences with end-of-life care. Providing guidance and being in the middle of the communication process can be a lonely, challenging, yet rewarding position. Results of this study provide a basis for offering emotional support to NICU nurses who care for patients at the end of life.
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Affiliation(s)
- Amy O Calvin
- School of Nursing, University of Texas Health Science Center, Houston, TX, USA.
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Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007; 35:1530-5. [PMID: 17452930 DOI: 10.1097/01.ccm.0000266533.06543.0c] [Citation(s) in RCA: 280] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). DESIGN A prospective pre/post nonequivalent control group design was used for this performance improvement study. SETTING Seventeen-bed adult MICU. PATIENTS Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. INTERVENTIONS Palliative care consultations. MEASUREMENTS AND MAIN RESULTS Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. CONCLUSIONS Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.
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Affiliation(s)
- Sally A Norton
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA.
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Baggs JG, Norton SA, Schmitt MH, Dombeck MT, Sellers CR, Quinn JR. Intensive care unit cultures and end-of-life decision making. J Crit Care 2007; 22:159-68. [PMID: 17548028 PMCID: PMC2214829 DOI: 10.1016/j.jcrc.2006.09.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2006] [Revised: 07/23/2006] [Accepted: 09/26/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM. MATERIALS AND METHODS Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit. RESULTS The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM. CONCLUSIONS As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.
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Affiliation(s)
- Judith Gedney Baggs
- School of Nursing, Oregon Health and Science University, Portland, OR 97239-2941, USA.
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Pato Benari A, Fung TT, Edelstein S. Dietary Acculturation Process of Israeli Women Who Immigrated to the United States as Adults. Ecol Food Nutr 2007. [DOI: 10.1080/03670240601093326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
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Hsieh HF, Shannon SE, Curtis JR. Contradictions and communication strategies during end-of-life decision making in the intensive care unit. J Crit Care 2006; 21:294-304. [PMID: 17175415 DOI: 10.1016/j.jcrc.2006.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 04/27/2006] [Accepted: 06/14/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to identify inherent tensions that arose during family conferences in the intensive care unit, and the communication strategies clinicians used in response. MATERIALS AND METHODS We identified 51 clinician-family conferences in the intensive care unit from 4 hospitals in which the attending physician believed discussion of withdrawing life-sustaining treatments or delivery of bad news would occur. The communication between clinicians and family members was analyzed using a dialectic perspective. RESULTS The tension of choosing whether to "let the patient die now" versus to "not let the patient die now" was the central contradiction within the conferences. Under this overriding theme were 5 categories: killing or allowing to die; death as a benefit or a burden; honoring the patient's wishes or following the family's wishes; weighing contradictory versions of the patient's wishes; and choosing an individual family member as decision maker or the family as a unit as decision maker. In response to these contradictions, clinicians used 2 clusters of communication strategies: decision-centered strategies and information-seeking strategies. CONCLUSIONS This study offered insights into end-of-life decision making, prompting clinicians to be conscious of the contradictions that arise and to use specific strategies to address these contradictions in their communication with families.
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Affiliation(s)
- Hsiu-Fang Hsieh
- Department of Nursing, Fooyin University, Kaohsiung Hsien 831, Taiwan
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Abstract
For many patients with a life-threatening illness, modern hospitals prevent a good death. When aggressive treatment is selected for a disease process with a remote cure, nurses engage in patient care that is psychologically exhausting and ethically demoralizing. Nursing is well positioned to lead a paradigm shift regarding end-of-life care. The concept of good death is explored through sociology, Christian theology, medicine, and nursing. Of the many determinants for a good death, the ones that transcend the disciplines include making adequate preparations, experiencing no unpleasant symptoms, having someone by one's side, and being spiritually whole. Empirical indicators for measuring a good death are also explored.
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Affiliation(s)
- Daria L Kring
- Moses H. Cone Memorial Health System, Greensboro, NC, USA.
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Abstract
OBJECTIVE To enhance understanding of the phenomenon of family surrogate decision-making at the end of life (EOL) by means of a systematic review and synthesis of published research reports that address this phenomenon. METHODS Garrard's (1999) methods for conducting a systematic review of the literature were followed. Fifty-one studies focusing on family decision-making experiences, needs, and processes when assisting a dying family member were selected following electronic database searches and ancestry searches. RESULTS In studies using hypothetical scenarios to compare patients' choices and surrogates' predictions of those choices, surrogates demonstrated low to moderate predictive accuracy. Increased accuracy occurred in more extreme scenarios, under conditions of forced choice, and when the surrogate was specifically directed to use substituted judgment. In qualitative explorations of their perspectives, family members voiced their desire to be involved and to accept the moral responsibility attendant to being a surrogate. Quality of communication available with providers significantly influenced family satisfaction with decision-making and EOL care. Group or consensual decision-making involving multiple family members was preferred over individual surrogate decision-making. Surrogates experienced long-term physical and psychological outcomes from being decision-makers. SIGNIFICANCE OF RESULTS Functioning as a surrogate decision-maker typically places great moral, emotional, and cognitive demands on the family surrogate. Clinicians can provide improved care to both patients and families with better understanding of surrogates' needs and experiences.
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Affiliation(s)
- Mary Ann Meeker
- School of Nursing, University at Buffalo, the State University of New York, NY 14214-3079, USA.
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Affiliation(s)
- Mary Thelen
- Mary Thelen is the nurse educator for the critical care unit at Luther Midelfort Mayo Health System, Eau Claire, Wis. Her work experience includes 18 years as a critical care nurse in 2 midwestern community hospitals. She is a recent graduate of the master’s degree program in nursing education at the University of Wisconsin, Eau Claire and is a member of the Indianhead chapter of the American Association of Critical-Care Nurses
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Bern-Klug M, Gessert CE, Crenner CW, Buenaver M, Skirchak D. "Getting Everyone on the Same Page": Nursing Home Physicians' Perspectives on End-of-Life Care. J Palliat Med 2004; 7:533-44. [PMID: 15353097 DOI: 10.1089/jpm.2004.7.533] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To improve understanding of nursing home physicians' perspectives regarding end-of-life care, and to suggest directions for further research. METHODS An exploratory qualitative design based on interviews of 12 nursing home physicians, 10 of whom were medical directors. Medical students served as interviewers. SAMPLE A purposeful sampling strategy yielded interviews with 12 physicians. The sample was selected based on "intensity sampling," which seeks information-rich but not extreme cases. Ten of the 12 physicians were nursing home medical directors; all respondents practiced at least 4 years part-time or full-time in a nursing home setting. Respondents varied by age, gender, urban/rural location, and fellowship training (half the sample had completed a geriatrics fellowship). Seven physicians were affiliated with an academic medical center. RESULTS Four themes were identified in the analysis of the 12 interview transcripts: extensive familiarity with dying; consensus is integral to good end-of-life care; obstacles can interfere with consensus; and advance directives set the stage for conversations about end-of-life care. The importance of consensus, both in terms of prognosis and in developing a palliative care plan, emerged as the major finding. CONCLUSIONS For the 12 physicians in this study consensus about the resident's status and an appropriate care plan are important features of good end-of-life care. Further research is needed to determine if other members of the health care team (i.e., residents, family members, nursing staff, social worker, etc.) also value consensus highly. It will be important to determine what barriers to consensus other team members identify. Based on the understanding generated from this study, a refinement of the general Education for Physicians on End-of-Life Care (EPEC) model describing the relationship between curative and palliative care is proposed for nursing homes. The refinement underscores the points at which the team might consider revisiting consensus about the resident's status and care plan.
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Affiliation(s)
- Mercedes Bern-Klug
- School of Social Work, The University of Iowa, Iowa City, Iowa 52242, USA.
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Affiliation(s)
- Denice K Sheehan
- Palliative Care Program, the Breen School of Nursing, Ursuline College, Pepper Pike, OH, USA.
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Schwartz CE, Mazor K, Rogers J, Ma Y, Reed G. Validation of a New Measure of Concept of a Good Death. J Palliat Med 2003; 6:575-84. [PMID: 14516499 DOI: 10.1089/109662103768253687] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The concept of a good death is central to end-of-life care research. Despite its importance and the high interest in the topic, there are few measures currently available for use in clinical research. PURPOSE The present work describes the development and testing of a set of items intended to measure the importance of several components posited to be critical to the concept of a good death. It is intended for use with health care providers and lay people in the context of end-of-life care research and education. POPULATION Four cohorts (n = 596) were recruited to participate, representing two helping profession disciplines, nonhelping professionals, and a range of ages, specifically: (1) undergraduate medical students; (2) master's degree students in nursing; (3) graduate students from the life sciences; and (4) practicing hospice nurses. METHODS Participants completed self-report questionnaires at baseline and retest. Psychometric analyses included item frequency distributions, factor analysis, alpha reliability, intraclass correlation, and measures of association. RESULTS The new Concept of a Good Death measure demonstrated good item frequency distributions, acceptable internal consistency reliability, and test-retest stability. Its factor structure revealed that three distinct domains are measured, reflecting the psychosocial/spiritual, physical, and clinical aspects of a good death. An examination of patterns of correlations showed differential associations with death anxiety, spiritual beliefs and practices, anxious mood, and sociodemographic characteristics. CONCLUSIONS The new Concept of a Good Death instrument appears to measure three distinct factors which people consider important to a Good Death. Ratings of the importance of these factors are reliable and valid. The instrument has the advantage of being a brief, self-report index for use in end-of-life care research.
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Affiliation(s)
- Carolyn E Schwartz
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
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Abstract
Physicians and patients find it hard to communicate when treatment fails to cure or control cancer. Communication barriers include fear of "giving up," losing the medical team, and discussing death. The quality of physician-patient communication affects important outcomes including patient distress, coping, and quality of life, and physician burnout. Communication skills that can be taught, learned, and maintained for physicians at all levels of training, and effective educational programs have been described. Research on communication skills training should focus on the best method of delivery, the "dose-response" effect, and how to measure success of training in complex health care environments.
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Affiliation(s)
- Geoffrey H Gordon
- Division of General Medicine and Geriatrics, Oregon Health and Science University, L475, Portland, OR 97201, USA.
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Duhamel F, Dupuis F. Families in palliative care: exploring family and health-care professionals' beliefs. Int J Palliat Nurs 2003; 9:113-9. [PMID: 12682573 DOI: 10.12968/ijpn.2003.9.3.11481] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
At the terminal stage of a disease, health professionals are encouraged to extend the scope of their interventions to include the family. However, clinicians often feel powerless when confronted with the suffering that family members experience. According to Wright, suffering is intimately related to family beliefs. These beliefs suffuse their experience of the illness and determine their understanding of the disease, the choice of treatment and compliance with a programme of care. Moreover, clinicians' own beliefs affect their sense of control over the patient and his or her family's suffering. This article suggests interventions that target families' and clinicians' beliefs and attempt to ease the dying process in a context of palliative care. These interventions consist of: acknowledging and challenging health-care professionals' own beliefs; exploring and challenging constraining beliefs of the patient and the family; and supporting beliefs that offer hope. These interventions can empower health professionals and families in their efforts to alleviate suffering related to the terminal phase of an illness.
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Affiliation(s)
- Fabie Duhamel
- Faculté des sciences infirmières, Université de Montréal, Montréal, Québec, Canada
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Deatrick JA, Angst DB, Moore C. Parents' views of their children's participation in phase I oncology clinical trials. J Pediatr Oncol Nurs 2002; 19:114-21. [PMID: 12203190 DOI: 10.1177/104345420201900402] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Data from two descriptive studies regarding decision making in pediatric oncology were analyzed using qualitative, secondary analysis techniques to describe how parents view their children's participation in phase I oncology clinical trials. A conceptual framework on family management styles (defining, managing, and consequence themes) was used as an organizational framework to analyze the available parental data. Parents defined or viewed their situation in relationship to their choices and expectations, health care provider expectations, children's illness situation, and family and personal situations. These themes are contrasted to clinical, parental, and ethical perspectives from the literature to make recommendations for further research emphasizing the concerns of families.
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Affiliation(s)
- Janet A Deatrick
- International Center of Research for Women, Children, and Families, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA.
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Norton SA, Talerico KA. Facilitating end-of-life decision-making: strategies for communicating and assessing. J Gerontol Nurs 2000; 26:6-13. [PMID: 11883616 PMCID: PMC3732104 DOI: 10.3928/0098-9134-20000901-05] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
End-of-life decision-making is often a difficult process and one that many elderly patients and their families will undergo. The grounded theory study of nurses, physicians, and family members (n = 20) reported in this article examined provider behaviors that facilitated the process of decision-making near the end of patients' lives. According to participants, providers who are experienced and comfortable are more likely to engage in communication and assessment strategies that facilitate end-of-life decision-making. Communication strategies included: being clear, avoiding euphemisms, spelling out the goals and expectations of treatment, using words such as "death" and "dying," and being specific when using such words as "hope" and "better." Assessment strategies included: assessing patients' physical conditions and end-of-life wishes, patients' and family members' understandings of the disease and prognosis, and their expectations and goals. An important first step for improved care is making explicit the provider's communicating and assessing strategies that facilitate end-of-life decision-making.
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Affiliation(s)
- S A Norton
- School of Nursing, Oregon Health Sciences University, Portland 97201-3098, USA
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