A good death

Human flourishing, the goals of medicine and integration of palliative care considerations into intensive care decision-making

Aristotle's ethical system was guided by his vision of human flourishing (also, but potentially misleadingly, translated as happiness). For Aristotle, human flourishing was a rich holistic concept about a life lived well until its ending. Both living a long life and dying well were integral to the Aristotelian ideal of human flourishing. Using Aristotle's concept of human flourishing to inform the goals of medicine has the potential to provide guidance to clinical decision-makers regarding the provision of burdensome treatments, such as intensive care treatment, where pursuing a chance of survival must be balanced against the risk of exposing patients to a negative dying experience. By conceptually uniting potentially competing goals of medicine, such as prolonging life and the promotion of peaceful deaths, Aristotle's understanding of human flourishing creates an argument for the integration of palliative care considerations into intensive care decision-making and for advanced care planning with healthy patients.

The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences

OBJECTIVES

To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members.

DESIGN

A constructivist qualitative study.

SETTING

One hospitals intensive care unit in Southeast China.

METHODS

Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis.

FINDINGS

A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members.

CONCLUSION

The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.¹.

Transferring home to die from critical care units: A scoping review of international practices

PURPOSE

To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

MATERIALS AND METHODS

A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019.

RESULTS

Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes.

CONCLUSIONS

Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.

Doctors' and nurses' views and experience of transferring patients from critical care home to die: a qualitative exploratory study

BACKGROUND

Dying patients would prefer to die at home, and therefore a goal of end-of-life care is to offer choice regarding where patients die. However, whether it is feasible to offer this option to patients within critical care units and whether teams are willing to consider this option has gained limited exploration internationally.

AIM

To examine current experiences of, practices in and views towards transferring patients in critical care settings home to die.

DESIGN

Exploratory two-stage qualitative study

SETTING/PARTICIPANTS

Six focus groups were held with doctors and nurses from four intensive care units across two large hospital sites in England, general practitioners and community nurses from one community service in the south of England and members of a Patient and Public Forum. A further 15 nurses and 6 consultants from critical care units across the United Kingdom participated in follow-on telephone interviews.

FINDINGS

The practice of transferring critically ill patients home to die is a rare event in the United Kingdom, despite the positive view of health care professionals. Challenges to service provision include patient care needs, uncertain time to death and the view that transfer to community services is a complex, highly time-dependent undertaking.

CONCLUSION

There are evidenced individual and policy drivers promoting high-quality care for all adults approaching the end of life encompassing preferred place of death. While there is evidence of this choice being honoured and delivered for some of the critical care population, it remains debatable whether this will become a conventional practice in end of life in this setting.

A national survey exploring views and experience of health professionals about transferring patients from critical care home to die

BACKGROUND

Transferring critically ill patients home to die is poorly explored in the literature to date. This practice is rare, and there is a need to understand health care professionals' (HCP) experience and views.

OBJECTIVES

To examine (1) HCPs' experience of transferring patients home to die from critical care, (2) HCPs' views about transfer and (3) characteristics of patients, HCPs would hypothetically consider transferring home to die.

DESIGN

A national study developing a web-based survey, which was sent to the lead doctors and nurses in critical care units.

SETTING/PARTICIPANTS

Lead doctors and senior nurses (756 individuals) working in 409 critical care units across the United Kingdom were invited to participate in the survey.

RESULTS

In total, 180 (23.8%) completed surveys were received. A total of 65 (36.1%) respondents had been actively involved in transferring patients home to die and 28 (15.5%) had been involved in discussions that did not lead to transfer. Respondents were supportive of the idea of transfer home to die (88.8%). Patients identified by respondents as unsuitable for transfer included unstable patients (61.8%), intubated and ventilated patients (68.5%) and patients receiving inotropes (65.7%). There were statistically significant differences in views between those with and without experience and between doctors and nurses. Nurses and those with experience tended to have more positive views.

CONCLUSION

While transferring patients home to die is supported in critical care, its frequency in practice remains low. Patient stability and level of intervention are important factors in decision-making in this area. Views held about this practice are influenced by previous experience and the professional role held.

Pattern of end-of-life decisions in two Tunisian intensive care units: the role of culture and intensivists' training

PURPOSE

End-of-life (EOL) decisions are not well studied in developing countries. We report EOL decision patterns in two Tunisian intensive care units [ICUs, medical (MICU) and surgical (SICU)] belonging to the same teaching hospital.

METHODS

Consecutive deaths that occurred in participating ICUs over 2 years were analysed. End-of-life decisions were prospectively recorded by the senior attending physicians, while subject's characteristics were retrospectively collected.

RESULTS

Deaths occurred in 326 of 1,733 ICU-admitted patients (median age: 64 years; median SAPS II at admission = 36). Overall, a decision for full support was taken in 69%, while decisions to withhold or withdraw life support were held in 22.1 and 8.9% of deaths, respectively. The rate of end-of-life decisions was similar in the MICU and the SICU. In no instance was there MV withdrawal during ICU stay. Discharging patients to die at home was observed only in the MICU (10 out of the 20 patients with a withdrawal decision). Two factors were independently associated with WH or WD decisions: a severe and ultimately fatal underlying disease was positively associated with such decisions (OR = 2.4, 95% CI: 1.3-4.36; p = 0.003), while having an independent functional status before the ICU was associated with a decreased rate of physician decisions of WH or WD (OR = 0.32, 95% CI: 0.15-0.67; p = 0.002).

CONCLUSION

Withholding and withdrawing life support are common in medical and surgical ICUs of a Tunisian hospital. Withholding is more frequent than withdrawing life support. These decisions appear to be effected by functional status and underlying conditions.

The Going Home Initiative: Getting Critical Care Patients Home With Hospice

Although considerable effort is being directed at providing patients and their families with a “good death,” most patients in intensive care units, if given the choice, would prefer to die at home. With little guidance from the literature, the palliative care committee of an intensive care unit developed guidelines to get patients home from the intensive care unit to die. In the past few years, the unit has transferred many patients home with hospice care, much to the delight of their families. Although several obstacles to achieving this goal exist, the unit has achieved success in a small-scale implementation of its Going Home Initiative.

Instrument development measuring critical care nurses' attitudes and behaviors with end-of-life care

BACKGROUND

Although critical care nurses are expected to focus on providing life-sustaining measures, many intensive care patients actually receive end-of-life care.

OBJECTIVES

The aim of this study was to develop an instrument to measure nursing attitudes and behaviors regarding end-of-life care.

METHOD

Phase 1 was focused on item development from a content analysis of the literature and qualitative interviews of critical care nurses. Phase 2 consisted of content validity assessment and pilot testing. Phase 3 included field testing, factor analysis, and reliability estimation.

RESULTS

The Values of Intensive Care Nurses for End-of-Life (n = 695) was found to have four factors: Self-appraisal, Appraisal of Others, Emotional Strain, and Moral Distress. Reliability estimates ([alpha]) were acceptable at .59-.78, but the interitem range (.12-.78) was wider than desirable. Test-retest reliability was deemed adequate based on Pearson's correlations (.68-.81) and intraclass correlation coefficients (.65-.79) but less so when considering [kappa] (.05-.30). The Behaviors of Intensive Care Nurses for End-of-Life (n = 682) was found to have two factors: Communication and Nursing Tasks. Reliability estimates were adequate when considering internal consistency ([alpha] = .67 and .78, respectively), item total correlations (.30-.61), and test-retest as judged by Pearson's and intraclass correlations (.77-.81) but not when [kappa] was considered (.02-.40). The interitem correlations (.20-.35) were also lower than desirable.

DISCUSSION

Both the Values of Intensive Care Nurses for End-of-Life and the Behaviors of Intensive Care Nurses for End-of-Life were found to have conceptually linked factors and acceptable internal consistency estimates ([alpha]). However, test-retest estimates were inconsistent, suggesting that further work needs to be done on the stability of these instruments.

End-of-life decisions in an Indian intensive care unit

BACKGROUND

There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs).

OBJECTIVE

To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making.

DESIGN

Retrospective, observational.

PATIENTS

Consecutive patients admitted to a 12-bed closed medical-surgical ICU.

EXCLUSIONS

Patients with EOLD discharged home or transferred to another hospital.

MEASUREMENTS AND RESULTS

Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group.

CONCLUSIONS

Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens.

Withdrawal of Intensive Care Treatment at Home – ‘a Good Death’

A patient with end-stage congestive cardiac failure and acute renal failure was admitted to the intensive care unit for inotropic support. Following no improvement with treatment, the focus of care shifted to the patient's comfort, palliative care and family support. She wished to die at home and therefore all efforts were made to fulfil her desire. This was achieved and she was discharged from the intensive care unit on inotropes and allowed to die in the comfort of her own home, with the withdrawal of treatment occurring only when the patient was ready.