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Divatia JV, Chawla R, Kapadia F, Myatra SN, Rajagopalan R, Amin P, Khilnani P, Prayag S, Todi SK, Uttam R. Guidelines for end-of-life and palliative care in Indian intensive care to units: ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2020. [DOI: 10.5005/ijccm-17-s1-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Kanmani TR, Thimmappur RM, Birudu R, Reddy N K, Raj P. Burden and Psychological Distress of Intensive Care Unit Caregivers of Traumatic Brain Injury Patients. Indian J Crit Care Med 2019; 23:220-223. [PMID: 31160838 PMCID: PMC6535995 DOI: 10.5005/jp-journals-10071-23164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Aim Admission to Intensive Care Unit (ICU) is a stressful event and unforeseen crisis for the caregivers. Burden and psychosocial distress among caregivers in the ICU were unexplored. Therefore, the current study was aimed to assess the caregivers’ burden and psychological distress among caregivers of traumatic brain injury (TBI) patients at emergency ICU during hospitalization. Materials and Methods A total of 60 caregivers recruited by using purposive sampling method with descriptive research design. Consent was obtained. Interview schedule of family for depression, anxiety, stress scale (DAS-21) were administered. The data were analyzed by using SPSS. Descriptive statistics and independent burden t-test were used. Results Results revealed that male caregivers (75%) and female caregivers (25%) took part in the study. Caregivers' mean age was found to be 35.22±11.29 years. Most of the TBI survivors admitted in ICU had severe injury (8.30±3.63). Mean scores showed that caregivers had experienced financial burden (6.28±2.36), severe depression (12.15±4.84), and a moderate level of anxiety (12.85±5.20). Independent t-test showed significant difference in caregiving burden between male and female caregivers at ICU (Male = 18.43±4.83; Female = 14.29±4.83; t = 2.16; p <0.035). Overall, caregivers experienced higher family burden and severe psychological distress at ICU. Conclusion There is an immediate need to assess psychological distress and family burden of caregivers at ICU and provide timely psychosocial intervention. How to cite this article Kanmani TR, Thimmappur RM, Birudu R, Reddy KN, Raj P. Burden and Psychological Distress of Intensive Care Unit Caregivers of Traumatic Brain Injury Patients. Indian J Crit Care Med 2019;23(5):220-223.
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Affiliation(s)
- Thiruchengodu Raju Kanmani
- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Ramappa M Thimmappur
- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Raju Birudu
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Krishna Reddy N
- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Prabhu Raj
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Salins N, Gursahani R, Mathur R, Iyer S, Macaden S, Simha N, Mani RK, Rajagopal MR. Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the End of Life: The Indian Council of Medical Research Commission Report. Indian J Crit Care Med 2018; 22:249-262. [PMID: 29743764 PMCID: PMC5930529 DOI: 10.4103/ijccm.ijccm_165_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indian hospitals, in general, lack policies on the limitation of inappropriate life-sustaining interventions at the end of life. To facilitate discussion, preparation of guidelines and framing of laws, terminologies relating to the treatment limitation, and providing palliative care at the end-of-life care (EOLC) need to be defined and brought up to date. METHODOLOGY This consensus document on terminologies and definitions of terminologies was prepared under the aegis of the Indian Council of Medical Research. The consensus statement was created using Nominal Group and Delphi Method. RESULTS Twenty-five definitions related to the limitations of treatment and providing palliative care at the end of life were created by reviewing existing international documents and suitably modifying it to the Indian sociocultural context by achieving national consensus. Twenty-five terminologies defined within the scope of this document are (1) terminal illness, (2) actively dying, (3) life-sustaining treatment, (4) potentially inappropriate treatment, (5) cardiopulmonary resuscitation (CPR), (6) do not attempt CPR, (7) withholding life-sustaining treatment, (8) withdrawing life-sustaining treatment, (9) euthanasia (10) active shortening of the dying process, (11) physician-assisted suicide, (12) palliative care, (13) EOLC, (14) palliative sedation, (15) double effect, (16) death, (17) best interests, (18) health-care decision-making capacity, (19) shared decision-making, (20) advance directives, (21) surrogates, (22) autonomy, (23) beneficence, (24) nonmaleficence, and (25) justice.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, India
| | - Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India
| | - Roli Mathur
- ICMR Bioethics Unit, National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
| | - Stanley Macaden
- Palliative Care Program of the Christian Medical Association of India, India
- Coordinator of the Palliative Care Program of Christian Medical Association of India and Honorary Palliative Medicine Consultant at Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Nagesh Simha
- Medical Director, Karunashraya Hospice, Bengaluru, Karnataka, India
| | - Raj Kumar Mani
- CEO and Chairman, Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India
| | - M. R. Rajagopal
- Chairman of Pallium India and Director of Trivandrum Institute of Palliative Sciences, Pallium, India
- Trivandrum Institute of Palliative Sciences, Thiruvananthapuram, Kerala, India
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Sengupta J, Chatterjee SC. Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life care. J Crit Care 2016; 39:11-17. [PMID: 28104546 DOI: 10.1016/j.jcrc.2016.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/07/2016] [Accepted: 12/18/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE This study critically examines the available policy guidelines on integration of palliative and end-of-life care in Indian intensive care units to appraise their congruence with Indian reality. MATERIALS AND METHODS Six position statements and guidelines issued by the Indian Society for Critical Care Medicine and the Indian Association of Palliative Care from 2005 till 2015 were examined. The present study reflects upon the recommendations suggested by these texts. RESULT Although the policy documents conform to the universally set norms of introducing palliative and end-of-life care in intensive care units, they hardly suit Indian reality. The study illustrates local complexities that are not addressed by the policy documents. This include difficulties faced by intensivists and physicians in arriving at a consensus decision, challenges in death prognostication, hurdles in providing compassionate care, providing "culture-specific" religious and spiritual care, barriers in effective communication, limitations of documenting end-of-life decisions, and ambiguities in defining modalities of palliative care. Moreover, the policy documents largely dismiss special needs of elderly patients. CONCLUSION The article suggests the need to reexamine policies in terms of their attainability and congruence with Indian reality.
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Affiliation(s)
- Jaydeep Sengupta
- Department of Humanities & Social Sciences, Indian Institute of Technology Kharagpur, West Bengal 721302, India.
| | - Suhita Chopra Chatterjee
- Department of Humanities & Social Sciences, Indian Institute of Technology Kharagpur, West Bengal 721302, India
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Chikhladze N, Janberidze E, Velijanashvili M, Chkhartishvili N, Jintcharadze M, Verne J, Kordzaia D. Mismatch between physicians and family members views on communications about patients with chronic incurable diseases receiving care in critical and intensive care settings in Georgia: a quantitative observational survey. BMC Palliat Care 2016; 15:63. [PMID: 27449224 PMCID: PMC4957836 DOI: 10.1186/s12904-016-0135-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 07/08/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Physicians working in critical and intensive care settings encounter death of chronic incurable patients on a daily basis; however they have scant skills on how to communicate with the patients and their family members. The aim of the present survey is to examine communication of critical and intensive care physicians with patients' family members receiving treatment due to chronic incurable diseases/conditions and to compare the views of families with physicians working in critical and intensive care settings. METHODS The survey was conducted in four cities of Georgia (Tbilisi, Kutaisi, Batumi and Telavi) in 2014. Physicians working in critical and intensive care settings and family members were asked to fill in separate questionnaires, covering various aspects of communication including patients' prognosis, ways of death occurrence, treatment plans and religion. Participants ranked their responses on a scale ranging from "0" to "10", where "0" represented "never" and "10"-"always". After data collection, responses were recoded into three categories: 0-3 = never/rarely, 4-7 = somewhat and 8-10 = often/always. Differences were tested using Pearson's chi-square or Fisher's exact test as appropriate. P value of < 0.05 was considered as significant. RESULTS Sixty-five physicians and 59 patients' family members participated in this cross-sectional study. Majority of their responses was statistically significantly different. Only one quarter (23.7 %) of family members of patients receiving medical aid in critical and intensive care settings were satisfied with the communication level. In contrast, 78.5 % of physicians considered their communication with families as positive (p < 0.0001). CONCLUSIONS The survey revealed the mismatch between the views on communication of critical and intensive care settings physicians and family members of the patients with chronic incurable diseases receiving care in critical and intensive care settings. In order to provide the best care for chronic incurable patients and their family members, physicians working in critical and intensive care settings must have relevant clinical knowledge and ability to provide effective communication. Present results reflect important potential targets for educational interventions including critical and intensive care physicians training through online modules.
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Affiliation(s)
- Nana Chikhladze
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Elene Janberidze
- Department of Gerontology and Palliative Care, of Al. Natishvili Institute of Morphology, TSU, Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Mariam Velijanashvili
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Nikoloz Chkhartishvili
- Georgian National Association for Palliative Care, Tbilisi, Georgia
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | | | - Dimitri Kordzaia
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Department of Gerontology and Palliative Care, of Al. Natishvili Institute of Morphology, TSU, Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
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Rafii F, Nikbakht Nasrabadi A, Karim MA. End-of-life care provision: experiences of intensive care nurses in Iraq. Nurs Crit Care 2015; 21:105-12. [PMID: 26487503 DOI: 10.1111/nicc.12219] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/22/2015] [Accepted: 08/25/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nurses play a key role in providing care for the critically ill in the intensive care unit (ICU). The physical, psychological, emotional and spiritual intimate care given by Kurdish nurses allows them to develop a therapeutic relationship with terminally ill patients in the ICU. AIMS This study sought to explore the meaning of caring for terminally ill patients from the perspective of Kurdish ICU nurses. DESIGN Van Manen's (1990) hermeneutic phenomenological design was adopted. METHOD The data were collected through in-depth semi-structured interviews with a purposive sample of 10 nurses working in ICUs. Interviews were transcribed and finally analysed according to Van Manen's method. RESULTS Four major themes including emotional labour, death as a positive dimension, optimistic rather than futile care and working within constraints emerged. CONCLUSIONS Kurdish nurses in their caring encounters with terminally ill patients experienced a range of feelings from emotional strain to being optimistic while working within limited resources in the ICU. Further research is needed to explore the experiences of nurses with other cultures of caring for terminally ill patients in ICUs. RELEVANCE TO PRACTICE End-of-life care in ICU is emotionally challenging, therefore, nurses in this setting require psychological and spiritual support to ensure optimal care provision.
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Affiliation(s)
- Forough Rafii
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, International Campus (IUMS-IC), Tehran, Iran
| | - Alireza Nikbakht Nasrabadi
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, International Campus (TUMS-IC), Tehran, Iran
| | - Muaf Abdulla Karim
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, International Campus (TUMS-IC), Tehran, Iran
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Schimmer C, Hamouda K, Oezkur M, Sommer SP, Leistner M, Leyh R. [End-of-life decisions and practices in critically ill patients in the cardiac intensive care unit. A nationwide survey]. Med Klin Intensivmed Notfmed 2015; 111:92-7. [PMID: 26065385 DOI: 10.1007/s00063-015-0045-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 04/04/2014] [Accepted: 04/03/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ethical and medical criteria in the decision-making process of withholding or withdrawal of life support therapy in critically ill patients present a great challenge in intensive care medicine. OBJECTIVES The purpose of this work was to assess medical and ethical criteria that influence the decision-making process for changing the aim of therapy in critically ill cardiac surgery patients. MATERIALS AND METHODS A questionnaire was distributed to all German cardiac surgery centers (n = 79). All clinical directors, intensive care unit (ICU) consultants and ICU head nurses were asked to complete questionnaires (n = 237). RESULTS In all, 86 of 237 (36.3 %) questionnaires were returned. Medical reasons which influence the decision-making process for changing the aim of therapy were cranial computed tomography (cCT) with poor prognosis (91.9 %), multi-organ failure (70.9 %), and failure of assist device therapy (69.8 %). Concerning ethical reasons, poor expected quality of life (48.8 %) and the presumed patient's wishes (40.7 %) were reported. There was a significant difference regarding the perception of the three different professional groups concerning medical and ethical criteria as well as the involvement in the decision-making process. CONCLUSION In critically ill cardiac surgery patients, medical reasons which influence the decision-making process for changing the aim of therapy included cCT with poor prognosis, multi-organ failure, and failure of assist device therapy. Further studies are mandatory in order to be able to provide adequate answers to this difficult topic.
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Affiliation(s)
- C Schimmer
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - K Hamouda
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - M Oezkur
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - S-P Sommer
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - M Leistner
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - R Leyh
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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Affiliation(s)
- Raj Kumar Mani
- Department of Pulmonology, Critical Care and Sleep Medicine, Saket City Hospital, Mandir Marg, Saket, New Delhi, India
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Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, Kulkarni P, Simha S, Mani RK. End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014; 18:615-35. [PMID: 25249748 PMCID: PMC4166879 DOI: 10.4103/0972-5229.140155] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE The purpose was to develop an end-of-life care (EOLC) policy for patients who are dying with an advanced life limiting illness and to develop practical procedural guidelines for limiting inappropriate therapeutic medical interventions and improve the quality of care of the dying within an ethical framework and through a professional and family/patient consensus process. EVIDENCE The Indian Society of Critical Care Medicine (ISCCM) published its first guidelines on EOLC in 2005 [1] which was later revised in 2012.[2] Since these publications, there has been an exponential increase in empirical information and discussion on the subject. The literature reviewed observational studies, surveys, randomized controlled studies, as well as guidelines and recommendations, for education and quality improvement published across the world. The search terms were: EOLC; do not resuscitate directives; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care; EOLC in India; cultural variations. Indian Association of Palliative Care (IAPC) also recently published its consensus position statement on EOLC policy for the dying.[3]. METHOD An expert committee of members of the ISCCM and IAPC was formed to make a joint EOLC policy for the dying patients. Proposals from the chair were discussed, debated, and recommendations were formulated through a consensus process. The members extensively reviewed national and international established ethical principles and current procedural practices. This joint EOLC policy has incorporated the sociocultural, ethical, and legal perspectives, while taking into account the needs and situation unique to India.
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Affiliation(s)
- Sheila Nainan Myatra
- From: Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Shivakumar Iyer
- Department of Critical Care, Bharati Vidyapeeth, University Medical College, Pune, Maharashtra, India
| | - Stanley C. Macaden
- Palliative Care Program of Christian Medical Association of India, Bangalore, Karnataka, India
| | - Jigeeshu V. Divatia
- From: Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Maryann Muckaden
- Department of Palliative Medicine, Tata Memorial Hospital, Pune, Maharashtra, India
| | | | | | - Raj Kumar Mani
- Department of Pulmonology, Critical Care and Sleep Medicine, Saket City Hospital, New Delhi, India
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Higginson IJ, Koffman J, Hopkins P, Prentice W, Burman R, Leonard S, Rumble C, Noble J, Dampier O, Bernal W, Hall S, Morgan M, Shipman C. Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty. BMC Med 2013; 11:213. [PMID: 24083470 PMCID: PMC3850793 DOI: 10.1186/1741-7015-11-213] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 08/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are widespread concerns about communication and support for patients and families, especially when they face clinical uncertainty, a situation most marked in intensive care units (ICUs). Therefore, we aimed to develop and evaluate an interventional tool to improve communication and palliative care, using the ICU as an example of where this is difficult. METHODS Our design was a phase I-II study following the Medical Research Council Guidance for the Development and Evaluation of Complex Interventions and the (Methods of Researching End-of-life Care (MORECare) statement. In two ICUs, with over 1900 admissions annually, phase I modeled a new intervention comprising implementation training and an assessment tool. We conducted a literature review, qualitative interviews, and focus groups with 40 staff and 13 family members. This resulted in the new tool, the Psychosocial Assessment and Communication Evaluation (PACE). Phase II evaluated the feasibility and effects of PACE, using observation, record audit, and surveys of staff and family members. Qualitative data were analyzed using the framework approach. The statistical tests used on quantitative data were t-tests (for normally distributed characteristics), the χ2 or Fisher's exact test (for non-normally distributed characteristics) and the Mann-Whitney U-test (for experience assessments) to compare the characteristics and experience for cases with and without PACE recorded. RESULTS PACE provides individualized assessments of all patients entering the ICU. It is completed within 24 to 48 hours of admission, and covers five aspects (key relationships, social details and needs, patient preferences, communication and information status, and other concerns), followed by recording of an ongoing communication evaluation. Implementation is supported by a training program with specialist palliative care. A post-implementation survey of 95 ICU staff found that 89% rated PACE assessment as very or generally useful. Of 213 family members, 165 (78%) responded to their survey, and two-thirds had PACE completed. Those for whom PACE was completed reported significantly higher satisfaction with symptom control, and the honesty and consistency of information from staff (Mann-Whitney U-test ranged from 616 to 1247, P-values ranged from 0.041 to 0.010) compared with those who did not. CONCLUSIONS PACE is a feasible interventional tool that has the potential to improve communication, information consistency, and family perceptions of symptom control.
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Affiliation(s)
- Irene J Higginson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, School of Medicine, Bessemer Road, Denmark Hill, London SE5 9PJ, UK.
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Mani RK, Amin P, Chawla R, Divatia JV, Kapadia F, Khilnani P, Myatra SN, Prayag S, Rajagopalan R, Todi SK, Uttam R. Guidelines for end-of-life and palliative care in Indian intensive care units' ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2012. [PMID: 23188961 PMCID: PMC3506078 DOI: 10.4103/0972-5229.102112] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- R K Mani
- Committee for the Development of Guidelines for limiting life-prolonging interventions and providing palliative care towards the end-of-life: Indian Society of Critical Care Medicine
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Kongsuwan W, Chaipetch O, Matchim Y. Thai Buddhist families' perspective of a peaceful death in ICUs. Nurs Crit Care 2012; 17:151-9. [PMID: 22497919 DOI: 10.1111/j.1478-5153.2012.00495.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To describe the concept of a peaceful death in intensive care units (ICUs) from the perspective of Thai Buddhist family members. METHODS This descriptive qualitative study was based on data generated from individual in-depth interviews of nine Thai Buddhist family members from the southern region of Thailand whose loved ones died in adult ICUs. Colaizzi's phenomenological approach was used to analyse the data. Rigour for the study was established by Lincoln and Guga's guidelines for qualitative research studies. FINDINGS Five core qualities emerged that made-up the concept of a peaceful death as described by Thai Buddhist family members who cared for their loved ones while they were dying in ICUs. These core qualities were 'knowing death was impending, preparing for a peaceful state of mind, not suffering, being with family members and not alone, and family members were not mourning'. CONCLUSION Thai Buddhist family members described what they meant by a peaceful death. 'This was: preparing for a peaceful state of mind in knowing that one's impending death is not a situation of suffering or being alone, but rather a time of being with family members who are not yet mourning one's death.' The findings support that family members should participate in promoting a peaceful death for their loved ones dying in ICUs. IMPLICATIONS FOR PRACTICE The five core qualities of a peaceful death reported in this study could be used as a framework for nurses to create nursing practice interventions for quality end-of-life care for Thai Buddhists.
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Affiliation(s)
- Waraporn Kongsuwan
- Medical Nursing Department, Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand.
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Montagnini M, Smith H, Balistrieri T. Assessment of Self-Perceived End-of-Life Care Competencies of Intensive Care Unit Providers. J Palliat Med 2012; 15:29-36. [DOI: 10.1089/jpm.2011.0265] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marcos Montagnini
- Division of Geriatric Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Geriatrics Research and Education Clinical Center (GRECC), VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Heather Smith
- Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
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Schimmer C, Gorski A, Özkur M, Sommer SP, Hamouda K, Hain J, Aleksic I, Leyh R. Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey. Interact Cardiovasc Thorac Surg 2011; 14:294-9. [PMID: 22194277 DOI: 10.1093/icvts/ivr119] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the decision-making process of withholding and/or withdrawal (WH/WD) of life-sustaining treatment in cardiac intensive care units (ICUs) in Germany. METHODS A questionnaire regarding 16 medical and 6 ethical questions of WH/WD of life-sustaining treatment was distributed to the clinical director, senior ICU physician and head nurses of all German heart surgery centres (n = 237 questionnaires). Furthermore, we present a literature survey using the key words 'End-of-life care AND withholding/withdrawal of life support therapy AND intensive care unit'. RESULTS We received replies from 86 of 237 (36.3%) contacted persons. Concerning medical reasons, cranial computed tomography (CCT) with poor prognosis (91.9%), multi-organ failure (70.9%) and failure of assist device therapy (69.8%) were the three most frequently cited medical reasons for WH/WD life-sustaining treatment. Overall, 32.6% of persons answered that ethical aspects influence their decision-making processes. Poor expected quality of life (48.8%), the patient's willingness to limit medical care (40.7%) and the families' choice (27.9%) were the top three reported ethical reasons. There was a significant difference regarding the perception of the three involved professional groups concerning the decision-making parameters: multi-organ failure (P = 0.018), failure of assist device therapy (P = 0.001), cardiac index (P = 0.009), poor expected quality of life (P = 0.009), the patient's willingness to limit medical care (P = 0.002), intraoperative course (P = 0.054), opinion of family members (P = 0.032) and whether decision-making process are done collaboratively (clinical director, 45.7%; ICU physician, 52%; and head of nursing staff, 26.9%). Palliation medication in patients after WH/WD of life-support consisted of morphine (92%) and benzodiazepines (88%). CONCLUSIONS This survey is a step towards creating standards of end-of-life care in cardiac ICUs, which may contribute to build consensus and avoid conflicts among caregivers, patients and families at each step of the decision-making process.
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Affiliation(s)
- Christoph Schimmer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany.
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Gálvez González M, Ríos Gallego F, Fernández Vargas L, del Águila Hidalgo B, Muñumel Alameda G, Fernández Luque C. [The end of life in the intensive care unit from the nursing perspective: a phenomenological study]. ENFERMERIA INTENSIVA 2011; 22:13-21. [PMID: 21315638 DOI: 10.1016/j.enfi.2010.11.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 11/02/2010] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Intensive Care Units do not adapt to the social and health reality regarding the phenomenon of death and this results in a high degree of dissatisfaction among professional, relatives and patients. The special characteristics of these units give the nursing staff a main roll as carers of critical dying patients. The principal aim of this study is to know the nursing staffs' experiences and attitudes towards the phenomenon of death in the intensive care units. PARTICIPANTS AND METHOD A descriptive qualitative study of phenomenological character was performed. Constant comparison and progressive incorporation of participants was made, using intentional sampling up to data saturation (n=16). The data collection technique used was a semi-structured in-depth interview, which were recorded and literally transcribed. The data collected was verified by the informants and analyzed according to the steps proposed by Taylor-Bogdan. RESULTS The analysis shows 5 thematic categories: death and beliefs, emotional work, environmental factors, decision-making management of death in intensive care units and relationships with relatives. CONCLUSIONS The management model of death in intensive care units focuses on medical intervention and overlooks the opinions of the nurses, relatives and patients. This study shows the contributions that can be provided by the nursing staff in decision making and in the care of the dying patients in these wards.
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Affiliation(s)
- M Gálvez González
- Centro de salud Torrequebrada, Distrito Sanitario Costa del Sol, Málaga, Spain.
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16
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Benbenishty J, Weissman C, Sprung CL, Brodsky-Israeli M, Weiss Y. Characteristics of patients receiving vasopressors. Heart Lung 2011; 40:247-52. [DOI: 10.1016/j.hrtlng.2010.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Revised: 04/12/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
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17
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Guay D, Michaud C, Mathieu L. De « bons soins » palliatifs aux soins intensifs : une perspective infirmière. Rech Soins Infirm 2011. [DOI: 10.3917/rsi.105.0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Kongsuwan W, Keller K, Touhy T, Schoenhofer S. Thai Buddhist intensive care unit nurses' perspective of a peaceful death: an empirical study. Int J Palliat Nurs 2010; 16:241-7. [PMID: 20679972 DOI: 10.12968/ijpn.2010.16.5.48145] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To describe the concept of a peaceful death from Thai Buddhist intensive care unit (ICU) nurses' perspectives. METHOD A descriptive qualitative study of data generated from individual in-depth interviews of ten intensive care nurses who practiced in adult ICUs in the southern region of Thailand. Content analysis was used to analyse the data. FINDINGS Four core qualities of a peaceful death emerged as described by Thai Buddhist nurses who practised in the ICUs. These core qualities are: peaceful mind; no suffering; family's acceptance of patient's death; and being with others and not alone. CONCLUSION Thai Buddhist nurses described a peaceful death as 'a situation in which persons who are dying have peace of mind, and do not show signs and symptoms of suffering. Peaceful death occurs when family members declare acceptance of their loved one's dying and eventual death. Such a death is witnessed by relatives and friends and the dying person is not alone.' The findings encourage nurses to be with, and provide palliative care for, dying patients and families.
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Affiliation(s)
- Waraporn Kongsuwan
- Faculty of Nursing, Prince of Songkhla University, Hat Yai, Songkhla, Thailand.
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19
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Gerstel E, Engelberg RA, Koepsell T, Curtis JR. Duration of withdrawal of life support in the intensive care unit and association with family satisfaction. Am J Respir Crit Care Med 2008; 178:798-804. [PMID: 18703787 DOI: 10.1164/rccm.200711-1617oc] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Most deaths in the intensive care unit (ICU) involve withholding or withdrawing multiple life-sustaining therapies, but little is known about how to proceed practically and how this process affects family satisfaction. OBJECTIVES To examine the duration of life-support withdrawal and its association with overall family satisfaction with care in the ICU. METHODS We studied family members of 584 patients who died in an ICU at 1 of 14 hospitals after withdrawal of life support and for whom complete medical chart and family questionnaires were available. MEASUREMENTS AND MAIN RESULTS Data concerning six life-sustaining interventions administered during the last 5 days of life were collected. Families were asked to rate their satisfaction with care using the Family Satisfaction in the ICU questionnaire. For nearly half of the patients (271/584), withdrawal of all life-sustaining interventions took more than 1 day. Patients with a prolonged (>1 d) life-support withdrawal were younger, stayed longer in the ICU, had more life-sustaining interventions, had less often a diagnosis of cancer, and had more decision makers involved. Among patients with longer ICU stays, a longer duration in life-support withdrawal was associated with an increase in family satisfaction with care (P = 0.037). Extubation before death was associated with higher family satisfaction with care (P = 0.009). CONCLUSIONS Withdrawal of life support is a complex process that depends on patient and family characteristics. Stuttering withdrawal is a frequent phenomenon that seems to be associated with family satisfaction. Extubation before death should be encouraged if possible.
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Affiliation(s)
- Eric Gerstel
- Departments of Internal Medicine and Critical Care, Geneva University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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20
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Glavan BJ, Engelberg RA, Downey L, Curtis JR. Using the medical record to evaluate the quality of end-of-life care in the intensive care unit. Crit Care Med 2008; 36:1138-46. [PMID: 18379239 PMCID: PMC2735216 DOI: 10.1097/ccm.0b013e318168f301] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
RATIONALE We investigated whether proposed "quality markers" within the medical record are associated with family assessment of the quality of dying and death in the intensive care unit (ICU). OBJECTIVE To identify chart-based markers that could be used as measures for improving the quality of end-of-life care. DESIGN A multicenter study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hrs of being transferred from an ICU. SETTING ICUs at ten hospitals in the northwest United States. PATIENTS Overall, 356 patients who died in the ICU or within 24 hrs of transfer from an ICU. MEASUREMENTS The 22-item family assessed Quality of Dying and Death (QODD-22) questionnaire and a single item rating of the overall quality of dying and death (QODD-1). ANALYSIS The associations of chart-based quality markers with QODD scores were tested using Mann-Whitney U tests, Kruskal-Wallis tests, or Spearman's rank-correlation coefficients as appropriate. RESULTS Higher QODD-22 scores were associated with documentation of a living will (p = .03), absence of cardiopulmonary resuscitation performed in the last hour of life (p = .01), withdrawal of tube feeding (p = .04), family presence at time of death (p = .02), and discussion of the patient's wish to withdraw life support during a family conference (p < .001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p < or = .05). CONCLUSIONS We identified chart-based variables associated with higher QODD scores. These QODD scores could serve as targets for measuring and improving the quality of end-of-life care in the ICU.
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Affiliation(s)
- Bradford J Glavan
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
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21
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Michalsen A. Care for dying patients – German legislation. Intensive Care Med 2007; 33:1823-6. [PMID: 17634924 DOI: 10.1007/s00134-007-0780-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Accepted: 06/22/2007] [Indexed: 11/26/2022]
Abstract
Caring for dying patients appears to be one of the most difficult challenges in modern medicine. Apart from respective medical standards, such care is influenced by legal stipulations, economic resources, societal values, and ethical principles. In Germany, legal provisions prohibit actively hastening a patient's death. Although passive and indirect means of assistance to die are permitted for terminally ill patients, they appear to be implemented only with hesitation. Probably, the authority of advance directives needs further clarification. More importantly, however, physicians' deficits in knowledge as well as their conceptual and psycho-emotional barriers need comprehensive improvement in order to foster end-of-life care.
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Affiliation(s)
- Andrej Michalsen
- Department of Anaesthesiology and Intensive Care Medicine, Uberlingen Hospital, 88662, Uberlingen/See, Germany.
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22
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Wall RJ, Curtis JR, Cooke CR, Engelberg RA. Family satisfaction in the ICU: differences between families of survivors and nonsurvivors. Chest 2007; 132:1425-33. [PMID: 17573519 DOI: 10.1378/chest.07-0419] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We previously noted that the families of patients dying in the ICU reported higher satisfaction with their ICU experience than the families of survivors. However, the reasons for this finding were unclear. In the current study, we sought to confirm these findings and identify specific aspects of care that were rated more highly by the family members of patients dying in the ICU compared to family members of ICU survivors. METHODS A total of 539 family members with a patient in the ICU were surveyed. Family satisfaction was measured using the 24-item family satisfaction in the ICU questionnaire. Ordinal logistic regression identified which components of family satisfaction were associated with the patient's outcome (ie, whether the patient lived or died). RESULTS A total of 51% of respondents had a loved one die in the ICU. Overall, the families of patients dying in the ICU were more satisfied with their ICU experience than were families of ICU survivors, and the largest differences were noted for care aspects directly affecting family members. Significant differences were found for inclusion in decision making, communication, emotional support, respect and compassion shown to family, and consideration of family needs (p<0.01). CONCLUSIONS The families of patients dying in the ICU were more satisfied with their ICU experience than were the families of ICU survivors. The reasons for this difference were higher ratings on family-centered aspects of care. These findings suggest that efforts to improve the support of ICU family members should focus not only on the families of dying patients but also on the families of patients who survive their ICU stay.
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Affiliation(s)
- Richard J Wall
- Department of Medicine, University of Washington, Seattle, WA 98104, USA.
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23
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Wall RJ, Engelberg RA, Gries CJ, Glavan B, Curtis JR. Spiritual care of families in the intensive care unit. Crit Care Med 2007; 35:1084-90. [PMID: 17334245 DOI: 10.1097/01.ccm.0000259382.36414.06] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is growing recognition of the importance of spiritual care as a quality domain for critically ill patients and their families, but there is a paucity of research to guide quality improvement in this area. Our goals were to: 1) determine whether intensive care unit (ICU) family members who rate an item about their spiritual care are different from family members who skip the item or rate the item as "not applicable" and 2) identify potential determinants of higher family satisfaction with spiritual care in the ICU. DESIGN Cross-sectional study, using data from a cluster randomized trial aimed at improving end-of-life care in the ICU. SETTING ICUs in ten Seattle-area hospitals. SUBJECTS A total of 356 family members of patients dying during an ICU stay or within 24 hrs of ICU discharge. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Family members were surveyed about spiritual care in the ICU. Chart abstractors obtained clinical variables including end-of-life care processes and family conference data. The 259 of 356 family members (73%) who rated their spiritual care were slightly younger than family members who did not rate this aspect of care (p = .001). Multiple regression revealed family members were more satisfied with spiritual care if a pastor or spiritual advisor was involved in the last 24 hrs of the patient's life (p = .007). In addition, there was a strong association between satisfaction with spiritual care and satisfaction with the total ICU experience (p < .001). Ratings of spiritual care were not associated with any other demographic or clinical variables. CONCLUSIONS These findings suggest that for patients dying in the ICU, clinicians should assess each family's spiritual needs and consult a spiritual advisor if desired by the family. Further research is needed to develop a comprehensive approach to ICU care that meets not only physical and psychosocial but also spiritual needs of patients and their families.
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Affiliation(s)
- Richard J Wall
- Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA, USA.
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24
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Cook D, Rocker G, Giacomini M, Sinuff T, Heyland D. Understanding and changing attitudes toward withdrawal and withholding of life support in the intensive care unit. Crit Care Med 2007; 34:S317-23. [PMID: 17057593 DOI: 10.1097/01.ccm.0000237042.11330.a9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A careful examination of our attitudes toward end-of-life care is critical to our understanding of where change is needed to improve patient outcomes. The objectives of our narrative review are 1) to review why the intensive care unit setting presents particular challenges for the delivery of optimal end-of-life care, 2) to outline how four different research methods can provide insights into our understanding of attitudes about withdrawal of life support, and 3) to suggest seven different approaches to changing prevailing attitudes toward withdrawal of life support in the intensive care unit. To better understand attitudes about end-of-life care in general and withdrawal of life support in particular, we reviewed four different sources of data: 1) decision support tools, 2) qualitative research, 3) surveys, and 4) observational studies. Understanding these attitudes offers valuable insights about strategies that may help to improve the care of dying patients and their families. There are several ways to change attitudes; the approaches we reviewed are 1) promoting social change professionally, 2) legitimizing end-of-life research, 3) determining what families of dying patients need, 4) initiating quality improvement locally, 5) evaluating the benefits and harms of new initiatives, 6) modeling quality end-of-life care for future clinicians, and 7) using narratives. Attitudes toward end-of-life care are influenced by many factors and change slowly. Our attitudes have social and personal origins; they are grounded in values that are collective and community based. Different research methods provide insights into attitudes toward death in the intensive care unit and withdrawal of life support in particular. Understanding these attitudes may offer valuable insights about strategies that should help improve the care for dying patients and their families.
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Affiliation(s)
- Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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25
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Guy V. Liver failure, life support, family support, and palliation: an inside story. J Crit Care 2006; 21:250-2. [PMID: 16990092 DOI: 10.1016/j.jcrc.2005.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Accepted: 10/10/2005] [Indexed: 01/29/2023]
Abstract
My sister was admitted to the intensive-care-unit (ICU) five months before she died. At the time of admission her life-support wishes were not discussed with her. During her time in the ICU, we, the family, were given hope that she may survive. As with most families, we wanted my sister to live. During her progression from ICU to step-down unit to ward unit, the plan of care was not discussed, and goals were not set. Many medical teams were involved in my sister's care, and many looked at individual body parts instead of the whole person. I am a Registered Nurse at the same hospital where my sister was being cared for. Through many family meetings I was regarded as a medical professional, not as a sister. Knowing the medical system yet going through this as a family member has given me the opportunity to gain insight into what should have happened. If code status had been discussed we would have known my sisters wishes. If relevant literature pertaining to her disease and her slim chance of recovery had been brought to our attention, my sister could have died at home as she wished, and perhaps could have lived her final days in comfort.
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26
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Rocker G. Life-support limitation in the pre-hospital setting. Intensive Care Med 2006; 32:1464-6. [PMID: 16896860 DOI: 10.1007/s00134-006-0293-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Accepted: 06/21/2006] [Indexed: 11/26/2022]
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Kompanje EJO. 'Death rattle' after withdrawal of mechanical ventilation: practical and ethical considerations. Intensive Crit Care Nurs 2006; 22:214-9. [PMID: 16551501 DOI: 10.1016/j.iccn.2005.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Revised: 05/23/2005] [Accepted: 06/13/2005] [Indexed: 11/20/2022]
Abstract
The noise produced by oscillatory movements of secretions in oropharynx, hypopharynx and trachea during inspiration and expiration in unconscious terminal patients is often described as 'the death rattle'. The reported incidence of death rattle in terminally ill patients varied between six and 92%. It is most commonly reported in patients dying from pulmonary malignancies, primary brain tumours or brain metastases, and predicts death within 48 hours in 75% of the patients. Clinical studies demonstrate that hyoscine hydrobromide is effective at improving symptoms. After withdrawal of artificial ventilation on the intensive care unit, excessive respiratory secretions resulting in rattling breathing, during the last hours of life, is not uncommon. Physicians and nurses experience considerable difficulties and frustrations in treating the death rattle. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient. This article provides practical and ethical considerations in the management of this near-death symptom. The fact that relatives were relieved in almost all cases, in which a positive effect was obtained, makes treatment in anticipation of death rattle an ethical demand. In practice, injectable scopolamine is the reference drug for symptomatic treatment of death rattle.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care and Department of Medical Ethics, Erasmus MC University Medical Center, Room V-208, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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29
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Kompanje EJO. "The death rattle" in the intensive care unit after withdrawal of mechanical ventilation in neurological patients. Neurocrit Care 2006; 3:107-10. [PMID: 16174877 DOI: 10.1385/ncc:3:2:107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The noise produced by oscillatory movements of secretions in the oropharynx, hypopharynx, and trachea during inspiration and expiration in unconscious terminal patients is often described as "the death rattle." The secretions are produced by the salivary glands and bronchial mucosa. These patients are usually too weak to expectorate or swallow the migrating secretions. Sputum usually only accumulates in these areas if there is a significant impairment of the cough reflex, as in deep coma or near death. Reported incidence of death rattle in terminal patients varied between 6 and 92%. Death rattle was most commonly reported in patients dying from pulmonary malignancies, primary brain tumors, or brain metastases, and predicts death within 48 hours in 75% of the patients. After withdrawal of artificial ventilation from the intensive care unit, excessive respiratory secretion resulting in a rattling breathing during the last hours of life is not uncommon, especially not in pulmonary and neurological patients. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care and Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Giannini A. ICU physicians, end-of-life care, and the law. Intensive Care Med 2005; 31:1725; author reply 1726. [PMID: 16283168 DOI: 10.1007/s00134-005-2843-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2005] [Indexed: 11/26/2022]
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31
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Rocker GM, Cook DJ, O'Callaghan CJ, Pichora D, Dodek PM, Conrad W, Kutsogiannis DJ, Heyland DK. Canadian nurses' and respiratory therapists' perspectives on withdrawal of life support in the intensive care unit. J Crit Care 2005; 20:59-65. [PMID: 16015517 DOI: 10.1016/j.jcrc.2004.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe perspectives of nurses (RNs) and respiratory therapists (RTs) related to end-of-life care for critically ill patients. METHODS For patients who had life support withdrawn in 4 Canadian university-affiliated ICUs, RNs and RTs reported their comfort level with decision making and process for 14 aspects of end-of-life care. RESULTS Ninety-eight patients had life support withdrawn. Responses were received from 96 (98.0%) bedside RNs and 73 (74.5%) RTs. Most RNs (85/94, 90.4%) and RTs (50/73, 68.5%) were very comfortable with decisions to withhold cardiopulmonary resuscitation or to withdraw life support (83/94, 88.3% of RNs and 56/73, 76.7% of RTs). Most RNs (range 71.3%-80.65%) and RTs (60.0%-70.8%) were very comfortable with ventilation/oxygen withdrawal and sedation. Among paired responses for 72 (73.5%) of 98 patients, RTs rated less favorably than RNs ( P < .05): the quality of the physician explanation of the life support withdrawal process, the availability of the physician, the peacefulness of the dying process, and the amount of privacy for families. Suggested improvements included earlier and more inclusive discussions, clearer plans, and better preparation of families and the ICU team for patients' deaths. CONCLUSIONS Most RNs and RTs were comfortable with decision making and the process of life support withdrawal, but they suggested several ways to improve end-of-life care.
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Affiliation(s)
- Graeme M Rocker
- Department of Medicine, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia.
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