Transcending the silos: toward an interdisciplinary approach to end-of-life care in the ICU

Healthcare Professionals' Attitudes towards and Knowledge and Understanding of Paediatric Palliative Medicine (PPM) and Its Meaning within the Paediatric Intensive Care Unit (PICU): A Summative Content Analysis in a Tertiary Children's Hospital in Scotland-"An In Vitro Study"

Background: Paediatric palliative medicine (PPM) is a holistic approach to care for children and their families. Services are growing and developing worldwide but significant disparity in service provision remains. The Paediatric Supportive and Palliative Care Team (PSPCT) at the Royal Hospital for Children in Glasgow was established in 2019, but there is still no clear integrated role within the paediatric intensive care unit (PICU) at present. Through analysing the attitudes, meaning, knowledge and understanding of PPM in the PICU environment, we hoped to explore the experiences of those providing paediatric palliative care and to identify any barriers to or facilitators of integrated working to gain a better understanding of providing this care. Methods: This qualitative study used a survey composed of five open-ended and five closed questions. Sixteen out of a possible thirty-two responses (50%) were accrued from PICU healthcare professionals, including consultants (n = 19), advanced nurse practitioners (n = 4) and band-seven nurses (n = 9). The data were comprehensively studied and analysed by two coders using summative content analysis with assistance from data management software. Codes were further developed to form categories and subcategories. Results: Two categories were found: (1) the role of palliative care and (2) experiences of providing palliative care. A total of five subcategories were found, demonstrating that the PSPCT can enhance care in PICU through collaborative working. Barriers identified included staffing, funding and stigma around palliative care. Conclusions: This study shows that PICU professionals have a good understanding of the concepts of PPM and view it as an essential part of PICU work. Barriers related to resources and misperceptions of palliative care can be overcome through improved education, funding and staff retention, but this would require buy-in from policymakers. The perspective from our relatively small team increases generalizability to growing teams across the country.

Beyond technology, drips, and machines: Moral distress in PICU nurses caring for end-of-life patients

Moral distress is an experience of profound moral compromise with deeply impactful and potentially long-term consequences to the individual. Critical care areas are fraught with ethical issues, and end-of-life care has been associated with numerous incidences of moral distress among nurses. One such area where the dichotomy of life and death seems to be at its sharpest is in the pediatric intensive care unit. The purpose of this study was to understand the moral distress experiences of pediatric intensive care nurses when caring for pediatric patients at the end of life. A secondary analysis was undertaken of seven transcripts from registered nurses across six Canadian pediatric intensive care units and produced three themes: under prioritization of child patient dignity, burden of insider knowledge, and environmental constraints on nursing roles and responsibilities. When caring for patients at the end of life, nurses experienced moral distress when a dignified death was not realized. Furthermore, despite interprofessional collaboration efforts in Canada, the concept of silo mentality persists and contributes to moral distress. Organizational involvement is needed to address moral distress in pediatric intensive care nurses both to achieve a dignified death for child patients and in addressing silo mentality.

Expanding the 3 Wishes Project for compassionate end-of-life care: a qualitative evaluation of local adaptations

BACKGROUND

The 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs.

METHODS

Using the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program.

RESULTS

Beyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose.

CONCLUSIONS

The successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other.

TRIAL REGISTRATION

NCT04147169 , retrospectively registered with clinicaltrials.gov on October 31, 2019.

Interprofessional Shared Decision-Making in the ICU: A Systematic Review and Recommendations From an Expert Panel

OBJECTIVES

There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.

DATA SOURCES

We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.

STUDY SELECTION

Three authors screened titles and abstracts in duplicate.

DATA SYNTHESIS

Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.

CONCLUSIONS

Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

A Team Disclosure of Error Educational Activity: Objective Outcomes

Medical errors can involve multiple team members. Few curricula are being developed to provide instruction on disclosing medical errors that include simulation training with interprofessional team disclosure. To explore more objective evidence for the value of an educational activity on team disclosure of errors, faculty developed and assessed the effectiveness of a multimodal educational activity for learning team-based disclosure of a medical error. This study employed a methodological triangulation research design. Participants (N = 458) included students enrolled in academic programs at three separate institutions. The activity allowed students to practice team communication while: (1) discussing a medical error within the team; (2) planning for the disclosure of the error; and (3) conducting the disclosure. Faculty assessed individual student's change in knowledge and, using a rubric, rated the performance of the student teams during a simulation with a standardized family member (SFM). Students had a high level of preexisting knowledge and demonstrated the greatest knowledge gains in questions regarding the approach to disclosure (P < .001) and timing of an apology (P < .001). Both SFMs and individual students rated the team error disclosure behavior highly (rho = 0.54; P < .001). Most participants (more than 80%) felt the activity was worth their time and that they were more comfortable with disclosing a medical error as a result of having completed the activity. This activity for interprofessional simulation of team-based disclosure of a medical error was effective for teaching students about and how to perform this type of important disclosure.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool

Background

Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU).

Objectives

To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates.

Methods

Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups.

Results

Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner.

Conclusions

The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study)

PURPOSE

The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives.

METHODS

This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff.

RESULTS

We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group.

CONCLUSIONS

Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01818895.

Pediatric End-of-life Care Barriers and Facilitators: Perception of Nursing Professionals in Jordan

Introduction:

End-of-life care is a critical issue for pediatric population with terminal illness to ensure the best possible quality of care for them and their families. A survey was conducted to identify the barriers and facilitators to provide pediatric end-of-life care.

Methods:

A descriptive cross-sectional study was conducted at three tertiary centers providing end-of-life care in Jordan. Two hundred critical care nurses were surveyed (response rate 93%).

Results:

Nurses reported moderate level of experience in all areas of delivering pediatric end-of-life care. The highest scoring of barriers respectively were patients-families barriers having deal with angry family member; health-care professional barriers multiple physicians, involved with one patient, who differ in opinion about the direction care, and where plan of care should go; and organizational barriers not available support person for the family. The highest scoring of facilitators respectively were of patients families facilitators having family members accept that the patient is dying; health-care professional-facilitators having a physician agrees about the direction of care, and organizational facilitators providing family members adequate time to be alone with the pediatric after he or she has died.

Conclusion:

Nurses perceived that patient-family, health-care professionals, and organizational related barriers and facilitators were had the most influence in providing of pediatric end-of-life care. Findings highlighted the need for additional education and support for pediatric staff, across professions, in providing pediatric end-of-life care. A pediatric end-of-life care team should be developed to assist in improving patients’ quality of care and increasing the awareness for the need for a standardized tool to evaluate the nursing competency level concerning pediatric end-of-life care.

A culture of avoidance: voices from inside ethically difficult clinical situations

BACKGROUND

Healthcare providers experience many ethical challenges while caring for and making treatment decisions with patients and their families.

OBJECTIVES

The purpose of this ethnographic study was to examine the challenges and circumstances that surround ethically difficult situations in oncology practice.

METHODS

The authors conducted six focus groups with 30 oncology nurses in the United States and interviewed 12 key informants, such as clinical ethicists, oncologists, and nurse administrators.

FINDINGS

The authors found that many healthcare providers remain silent about ethical concerns until a precipitating crisis occurs and ethical questions can no longer be avoided. Patients, families, nurses, and physicians tended to delay or defer conversations about prognosis and end-of-life treatment options. Individual, interactional, and system-level factors perpetuated the culture of avoidance. These included the intellectual and emotional toll of addressing ethics, differences in moral perspectives, fear of harming relationships, lack of continuity in care, emphasis on efficiency, and lack of shared decision making. This information is critical for any proactive and system-level effort aimed at mitigating ethical conflicts and their frequent companions-moral distress and burnout.

Breaking down the silos to decrease internal diversions and patient flow delays

Hospitals strive to admit patients to the units where caregiver competencies align with the patient's condition. When the hospital's census peaks, internal diversions and the associated risks increase, which are intensified when silos exist, as segregated care negatively impacts collaboration and patient safety. In this study, a 600+-bed academic, tertiary care specialty hospital experienced an increase in internal diversions. Within the neuroscience service line, emergent neuroscience transfers from outside hospitals had been declined or internally diverted because of capacity limitations. Formalized processes for improving collaboration between health care providers related to capacity issues were required to decrease internal diversions and improve patient flow and patient safety. A pilot project was conducted on neuroscience units during a process improvement initiative. A hospital-wide internal diversion plan was developed, identifying primary and secondary placement options for all patients requiring hospitalization to support patient flow and patient safety. Forecasting tools were developed to provide units' leadership with current information on expected admissions. Daily capacity huddles were instituted to increase collaboration between patient care units. The interventions trialed during the pilot decreased internal diversions and improved patient flow. The improved collaboration resulted in an 80% decrease in declinations of emergent intensive care unit transfers from outside hospitals due to capacity limitations and a 50% decrease in the number of these patients being internally diverted to alternate intensive care units. The interventions implemented minimized internal diversions and improved patient flow. The transparency of the patient placement process led to an increased collaboration between all participants.

ICU physicians' and nurses' perceptions of terminal extubation and terminal weaning: a self-questionnaire study

PURPOSE

Terminal extubation (TE) and terminal weaning (TW) are the methods available for withdrawing mechanical ventilation. Perceptions of TE and TW by intensive care unit (ICU) staff may influence bedside practices and the feasibility of studies comparing these methods.

METHODS

From January to June 2013, 5 nurses and 5 physicians in each of 46 (out of 70, 65.7 %) French ICUs completed an anonymous self-questionnaire. Clusters of staff members defined by perceptions of TE and TW were identified by exploratory analysis. Denominators for computing percentages were total numbers of responses to each item; cases with missing data were excluded for the relevant item.

RESULTS

Of the 451 (98 %) participants (225 nurses and 226 physicians), 37 (8.4 %) had never or almost never performed TW and 138 (31.3 %) had never or almost never performed TE. A moral difference between TW and TE was perceived by 205 (45.8 %) participants. The exploratory analysis identified three clusters defined by personal beliefs about TW and TE: 21.2 % of participants preferred TW, 18.1 % preferred TE, and 60.7 % had no preference. A preference for TW seemed chiefly related to unfavorable perceptions or insufficient knowledge of TE. Staff members who preferred TE and those with no preference perceived TE as providing a more natural dying process with less ambiguity.

CONCLUSION

Nearly two-fifths of ICU nurses and physicians in participating ICUs preferred TW or TE. This finding suggests both a need for shared decision-making and training before performing TE or TW and a high risk of poor compliance with randomly allocated TW or TE.

Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study

STUDY OBJECTIVE

We explored physicians' perceptions of and attitudes toward triage and end-of-life decisions for elderly critically ill patients at the emergency department (ED)-ICU interface.

METHODS

This was a qualitative study with thematic analysis of data collected through semistructured interviews (15 emergency physicians and 9 ICU physicians) and nonparticipant observations (324 hours, 8 units, in 2 hospitals in France).

RESULTS

Six themes emerged: (1) Physicians revealed a representation of elderly patients that comprised both negative and positive stereotypes, and expressed the concept of physiologic age. (2) These age-related factors influenced physicians' decisionmaking in resuscitate/not resuscitate situations. (3) Three main communication patterns framed the decisions: interdisciplinary decisions, decisions by 2 physicians on their own, and unilateral decisions by 1 physician; however, some physicians avoided decisions, facing uncertainty and conflicts. (4) Conflicts and communication gaps occurred at the ED-ICU interface and upstream of the ED-ICU interface. (5) End-of-life decisions were perceived as more complex in the ED, in the absence of family or of information about elderly patients' end-of-life preferences, and when there was conflict with relatives, time pressure, and a lack of training in end-of-life decisionmaking. (6) During decisionmaking, patients' safety and quality of care were potentially compromised by delayed or denied intensive care and lack of palliative care.

CONCLUSION

These qualitative findings highlight the cognitive heuristics and biases, interphysician conflicts, and communication gaps influencing physicians' triage and end-of-life decisions for elderly critically ill patients at the ED-ICU interface and suggest strategies to improve these decisions.

Bridging gaps to promote networked care between teams and groups in health delivery systems: a systematic review of non-health literature

OBJECTIVES

To assess non-health literature, identify key strategies in promoting more networked teams and groups, apply external ideas to healthcare, and build a model based on these strategies.

DESIGN

A systematic review of the literature outside of healthcare.

METHOD

Searches guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) of ABI/INFORM Global, CINAHL, IBSS, MEDLINE and Psychinfo databases following a mind-mapping exercise generating key terms centred on the core construct of gaps across organisational social structures that uncovered 842 empirical articles of which 116 met the inclusion criteria. Data extraction and content analysis via data mining techniques were performed on these articles.

RESULTS

The research involved subjects in 40 countries, with 32 studies enrolling participants in multiple countries. There were 40 studies conducted wholly or partly in the USA, 46 wholly or partly in continental Europe, 29 wholly or partly in Asia and 12 wholly or partly in Russia or Russian federated countries. Methods employed included 30 mixed or triangulated social science study designs, 39 qualitative studies, 13 experimental studies and 34 questionnaire-based studies, where the latter was mostly to gather data for social network analyses. Four recurring factors underpin a model for promoting networked behaviours and fortifying cross-group cooperation: appreciating the characteristics and nature of gaps between groups; using the leverage of boundary-spanners to bridge two or more groups; applying various mechanisms to stimulate interactive relationships; and mobilising those who can exert positive external influences to promote connections while minimising the impact of those who exacerbate divides.

CONCLUSIONS

The literature assessed is rich and varied. An evidence-oriented model and strategies for promoting more networked systems are now available for application to healthcare. While caution needs to be exercised in translating outside ideas and studies, drawing on non-health ideas is useful in providing insights into other sectors.

Management strategies to effect change in intensive care units: lessons from the world of business. Part III. Effectively effecting and sustaining change

Reaping the optimal rewards from any quality improvement project mandates sustainability after the initial implementation. In Part III of this three-part ATS Seminars series, we discuss strategies to create a culture for change, improve cooperation and interaction between multidisciplinary teams of clinicians, and position the intensive care unit (ICU) optimally within the hospital environment. Coaches are used throughout other industries to help professionals assess and continually improve upon their practice; use of this strategy is as of yet infrequent in health care, but would be easily transferable and potentially beneficial to ICU managers and clinicians alike. Similarly, activities focused on improving teamwork are commonplace outside of health care. Simulation training and classroom education about key components of successful team functioning are known to result in improvements. In addition to creating an ICU environment in which individuals and teams of clinicians perform well, ICU managers must position the ICU to function well within the hospital system. It is important to move away from the notion of a standalone ("siloed") ICU to one that is well integrated into the rest of the institution. Creating a "pull-system" (in which participants are active in searching out needed resources and admitting patients) can help ICU managers both provide better care for the critically ill and strengthen relationships with non-ICU staff. Although not necessary, there is potential upside to creating a unified critical care service to assist with achieving these ends.

Improving patient care through the prism of psychology: application of Maslow's hierarchy to sedation, delirium, and early mobility in the intensive care unit

The intensive care unit (ICU) is not only a place where lives are saved; it is also a site of harm and iatrogenic injury for millions of people treated in this setting globally every year. Increasingly, hospitals admit only the sickest patients, and although the overall number of hospital beds remains stable in the United States, the percentage of that total devoted to ICU beds is rising. These 2 realities engender a demographic imperative to address patient safety in the critical care setting. This article addresses the medical community's resistance to adopting a culture of safety in critical care with regard to issues surrounding sedation, delirium, and early mobility. Although there is currently much research and quality improvement in this area, most of what we know from these data and published guidelines has not become reality in the day-to-day management of ICU patients. This article is not intended to provide a comprehensive review of the literature but rather a framework to rethink our currently outdated culture of critical care by employing Maslow's hierarchy of needs, along with a few novel analogies. Application of Maslow's hierarchy will help propel health care professionals toward comprehensive care of the whole person not merely for survival but toward restoration of pre-illness function of mind, body, and spirit.

Comparison of APACHE III, APACHE IV, SAPS 3, and MPM0III and influence of resuscitation status on model performance

BACKGROUND

There are few comparisons among the most recent versions of the major adult ICU prognostic systems (APACHE [Acute Physiology and Chronic Health Evaluation] IV, Simplified Acute Physiology Score [SAPS] 3, Mortality Probability Model [MPM]0III). Only MPM0III includes resuscitation status as a predictor.

METHODS

We assessed the discrimination, calibration, and overall performance of the models in 2,596 patients in three ICUs at our tertiary referral center in 2006. For APACHE and SAPS, the analyses were repeated with and without inclusion of resuscitation status as a predictor variable.

RESULTS

Of the 2,596 patients studied, 283 (10.9%) died before hospital discharge. The areas under the curve (95% CI) of the models for prediction of hospital mortality were 0.868 (0.854-0.880), 0.861 (0.847-0.874), 0.801 (0.785-0.816), and 0.721 (0.704-0.738) for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. The Hosmer-Lemeshow statistics for the models were 33.7, 31.0, 36.6, and 21.8 for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. Each of the Hosmer-Lemeshow statistics generated P values < .05, indicating poor calibration. Brier scores for the models were 0.0771, 0.0749, 0.0890, and 0.0932, respectively. There were no significant differences between the discriminative ability or the calibration of APACHE or SAPS with and without “do not resuscitate” status.

CONCLUSIONS

APACHE III and IV had similar discriminatory capability and both were better than SAPS 3, which was better than MPM0III. The calibrations of the models studied were poor. Overall, models with more predictor variables performed better than those with fewer. The addition of resuscitation status did not improve APACHE III or IV or SAPS 3 prediction.

Comparing clinician ratings of the quality of palliative care in the intensive care unit

OBJECTIVE

There are numerous challenges to successfully integrating palliative care in the intensive care unit. Our primary goal was to describe and compare the quality of palliative care delivered in an intensive care unit as rated by physicians and nurses working in that intensive care unit.

DESIGN

Multisite study using self-report questionnaires.

SETTING

Thirteen hospitals throughout the United States.

PARTICIPANTS

Convenience sample of 188 physicians working in critical care (attending physicians, critical care fellows, resident physicians) and 289 critical care nurses.

MEASUREMENTS AND MAIN RESULTS

Clinicians provided overall ratings of the care delivered by either nurses or physicians in their intensive care unit for each of seven domains of intensive care unit palliative care using a 0-10 scale (0 indicating the worst possible and 10 indicating the best possible care). Analyses included descriptive statistics to characterize measurement characteristics of the ten items, paired Wilcoxon tests comparing item ratings for the domain of symptom management with all other item ratings, and regression analyses assessing differences in ratings within and between clinical disciplines. We used p < .001 to denote statistical significance to address multiple comparisons. The ten items demonstrated good content validity with few missing responses or ceiling or floor effects. Items receiving the lowest ratings assessed spiritual support for families, emotional support for intensive care unit clinicians, and palliative-care education for intensive care unit clinicians. All but two items were rated significantly lower than the item assessing symptom management (p < .001). Nurses rated nursing care significantly higher (p < .001) than physicians rated physician care in five domains. In addition, although nurses and physicians gave comparable ratings to palliative care delivered by nurses, nurses' and physicians' ratings of physician care were significantly different with nurse ratings of this care lower than physician ratings on all but one domain.

CONCLUSION

Our study supports the content validity of the ten overall rating items and supports the need for improvement in several aspects of palliative care, including spiritual support for families, emotional support for clinicians, and clinician education about palliative care in the intensive care unit. Furthermore, our findings provide some preliminary support for surveying intensive care unit clinicians as one way to assess the quality of palliative care in the intensive care unit.

The end-of-life family meeting in intensive care part I: Indications, outcomes, and family needs

This is a three-part article that reviews the literature on end-of-life family meetings in intensive care, focused on situations when the patient cannot participate. Family meetings in end-of-life care, especially when conducted prophylactically or proactively, have been shown to be effective procedures for improving family and staff satisfaction and even reducing resource utilization. The first part of the article outlines the family needs that should be addressed in such meetings, including clinician availability, consistent information sharing (especially of prognosis), empathic communication and support, facilitation of bereavement, and trust. The second part addresses family-centered, shared decision making and sources of conflict, as well as related communication and negotiation skills and how to end the meeting. Families and clinicians differ in 1) their understanding of the patient's condition and prognosis; 2) the emotional impact of the illness, particularly the personal meaning of pursuing recovery or limiting supports; and 3) their views of how to make decisions about life-prolonging treatments. The final part draws on the previous two sections to present a structured format and guide for communication skills in conflictual meetings. Ten steps for a humane and effective meeting are suggested, illustrated with sample conversations.

Moral obligations of nurses and physicians in neonatal end-of-life care

The aim of this study was to explore the obligations of nurses and physicians in providing end-of-life care. Nineteen nurses and 11 physicians from a single newborn intensive care unit participated. Using content analysis, an overarching obligation of creating the best possible experience for infants and parents was identified, within which two categories of obligations (decision making and the end of life itself) emerged. Obligations in decision making included talking to parents and timing withdrawal. End-of-life obligations included providing options, preparing parents, being with, advocating, creating peace and normalcy, and providing comfort. Nurses and physicians perceived obligations in both categories, although nurse obligations centered on the end of life while physician obligations focused on decision making. The findings demonstrate that, although the ultimate goal is shared by both disciplines, the paths to achieving that goal are often different. This has important implications for collaboration, communication, and improving the end of life.

A web-based team-oriented medical error communication assessment tool: development, preliminary reliability, validity, and user ratings

BACKGROUND

Multiple-choice exams are not well suited for assessing communication skills. Standardized patient assessments are costly and patient and peer assessments are often biased. Web-based assessment using video content offers the possibility of reliable, valid, and cost-efficient means for measuring complex communication skills, including interprofessional communication.

DESCRIPTION

We report development of the Web-based Team-Oriented Medical Error Communication Assessment Tool, which uses videotaped cases for assessing skills in error disclosure and team communication. Steps in development included (a) defining communication behaviors, (b) creating scenarios, (c) developing scripts, (d) filming video with professional actors, and (e) writing assessment questions targeting team communication during planning and error disclosure.

EVALUATION

Using valid data from 78 participants in the intervention group, coefficient alpha estimates of internal consistency were calculated based on the Likert-scale questions and ranged from α=.79 to α=.89 for each set of 7 Likert-type discussion/planning items and from α=.70 to α=.86 for each set of 8 Likert-type disclosure items. The preliminary test-retest Pearson correlation based on the scores of the intervention group was r=.59 for discussion/planning and r=.25 for error disclosure sections, respectively. Content validity was established through reliance on empirically driven published principles of effective disclosure as well as integration of expert views across all aspects of the development process. In addition, data from 122 medicine and surgical physicians and nurses showed high ratings for video quality (4.3 of 5.0), acting (4.3), and case content (4.5).

CONCLUSIONS

Web assessment of communication skills appears promising. Physicians and nurses across specialties respond favorably to the tool.

Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial

RATIONALE

Because of high mortality, end-of-life care is an important component of intensive care.

OBJECTIVES

We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care.

METHODS

We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics.

MEASUREMENTS AND MAIN RESULTS

All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81).

CONCLUSIONS

We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

End-of-life communication in the intensive care unit

OBJECTIVE

Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life (EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current research and recommendations for ICU EOL communication.

DESIGN

For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent bibliographies and cross-referenced known EOL ICU communication researchers.

RESULTS

Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency.

CONCLUSIONS

Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality of ICU palliative care and EOL communication.

Supporting hope and prognostic information: nurses' perspectives on their role when patients have life-limiting prognoses

CONTEXT

Clinicians often feel challenged by the need to deliver difficult prognostic information to patients with a life-limiting illness while, at the same time, support their hopes. Few studies have examined nurses' perspectives on their roles in meeting these patient and family needs.

OBJECTIVES

Our objectives were to 1) describe nurses' perspectives on meeting patients' needs for hope and illness information and 2) offer insights for interventions designed to improve communication about end-of-life care for patients and their families.

METHODS

Using experienced interviewers, we conducted one-on-one, semistructured interviews with 22 nurses caring for patients with advanced chronic obstructive pulmonary disease or cancer. Interviews were analyzed using a limited application of grounded theory.

RESULTS

Three themes emerged: 1) Nurses support patients' hopes by understanding individual aspects of these hopes, focusing on patient's quality of life, and building trust with patients; 2) Nurses provide prognostic information by assessing what the patient knows and following their lead. Nurses report doing these two activities independently; and 3) Nurses identify activities associated with the provision of prognostic information that required collaboration with physicians. Important barriers that complicate effective discussion of prognosis with patients and families were identified.

CONCLUSIONS

Nurses describe behaviors that are useful when meeting patients' and families' needs for hope and which they are comfortable implementing in practice, without collaboration with other clinicians. By contrast, most behaviors related to meeting patients' and families' needs regarding prognostic information are completed collaboratively with physicians. These findings provide insight for the development of interdisciplinary interventions targeting communication around end-of-life care.

Conflicts in the ICU: perspectives of administrators and clinicians

PURPOSE

The purpose of this study is to understand conflicts in the ICU setting as experienced by clinicians and administrators and explore methods currently used to resolve such conflicts when there may be discordance between clinicians and families, caregivers or administration.

METHODS

Qualitative case study methodology using semi-structured interviews was used. The sample included community and academic health science centres in 16 hospitals from across the province of Ontario, Canada. A total of 42 participants including hospital administrators and ICU clinicians were interviewed. Participants were sampled purposively to ensure representation.

RESULTS

The most common source of conflict in the ICU is a result of disagreement about the goals of treatment. Such conflicts arise between the ICU and referring teams (inter-team), among members of the ICU team (intra-team), and between the ICU team and patients' family/substitute decision-maker (SDM). Inter- and intra-team conflicts often contribute to conflicts between the ICU team and families. Various themes were identified as contributing factors that may influence conflict resolution practices as well as the various consequences and challenges of conflict situations. Limitations of current conflict resolution policies were revealed as well as suggested strategies to improve practice.

CONCLUSIONS

There is considerable variability in dealing with conflicts in the ICU. Greater attention is needed at a systems level to support a culture aimed at prevention and resolution of conflicts to avoid increased sources of anxiety, stress and burnout.

Conscientious objection: a potential neonatal nursing response to care orders that cause suffering at the end of life? Study of a concept

This article is an exploratory effort meant to solicit and provoke dialog. Conscientious objection is proposed as a potential response to the moral distress experienced by neonatal nurses. The most commonly reported cause of distress for all nurses is following orders to support patients at the end of their lives with advanced technology when palliative or comfort care would be more humane. Nurses report that they feel they are harming patients or causing suffering when they could be comforting instead. We examined the literature on moral distress, futility, and the concept of conscientious objection from the perspective of the nurse's potential response to performing advanced technologic interventions for the dying patient. We created a small pilot study to engage in clinical verification of the use of our concept of conscientious objection. Data from 66 neonatal intensive care and pediatric intensive care unit nurses who responded in a one-month period are reported here. Interest in conscientious objection to care that causes harm or suffering was very high. This article reports the analysis of conscientious objection use in neonatal care.

Family presence and environmental factors at the time of a patient's death in an ICU

BACKGROUND

In an intensive care unit (ICU), privacy and proximity are reported to be important needs of dying patients and their family members. It is assumed that good communication between the ICU team and families about end-of-life decisions improves the possibilities of meeting families' needs, thus guaranteeing a dignified and peaceful death in accordance with end-of-life care guidelines. The aim of this study was to explore the circumstances under which patients die in Swedish ICUs by reporting on the presence of family and whether patients die in private or shared rooms. An additional aim was to investigate the frequency of end-of-life decisions and whether nurses and family members were informed about such decisions.

METHODS

A questionnaire based on the research questions was completed when a patient died in the 10 ICUs included in the study. Data were collected on 192 deaths.

RESULTS

Forty per cent of the patients died without a next of kin at the bedside and 46% of deaths occurred in a shared room. This number decreased to 37% if a family member was present. Patients without a family member at their bedside received less analgesics and sedatives. There was a significant relationship between family presence, expected death and end-of-life decisions.

CONCLUSIONS

The results indicate the necessity of improving the ICU environment to promote the need for proximity and privacy for dying patients and their families. The study also highlights the risk of underestimating the needs of patients without a next of kin at their bedside at the time of death.

Identifying and overcoming the barriers to high-quality palliative care in the intensive care unit

Initiatives to improve end-of-life care in intensive care units face several important barriers. These include inflated expectations for critical care therapies, which are shared by many clinicians and many patients and families; preoccupation with an unattainable level of prognostic certainty, delaying attention to palliative needs; and fragmentation of the healthcare team into separate "silos" of disciplines and specialties. The article reviews these barriers and relevant empirical evidence. Specific strategies to improve intensive care unit palliative care, including consultation by palliative care specialists, and palliative care quality measurement are discussed.

Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward

Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.