Withholding or withdrawing therapy in intensive care units: an analysis of collaboration among healthcare professionals

Nurses' experiences of ethical and legal issues in post-resuscitation care: A qualitative content analysis

BACKGROUND

Cardiopulmonary resuscitation and subsequent care are subject to various ethical and legal issues. Few studies have addressed ethical and legal issues in post-resuscitation care.

OBJECTIVE

To explore nurses' experiences of ethical and legal issues in post-resuscitation care.

RESEARCH DESIGN

This qualitative study adopted an exploratory descriptive qualitative design using conventional content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

In-depth, semi-structured interviews were conducted in three educational hospital centers in northwestern Iran. Using purposive sampling, 17 nurses participated. Data were analyzed by conventional content analysis.

ETHICAL CONSIDERATIONS

The study was approved by Research Ethics Committees at Tabriz University of Medical Sciences. Participation was voluntary and written informed consent was obtained. For each interview, the ethical principles including data confidentiality and social distance were respected.

FINDINGS

Five main categories emerged: Pressure to provide unprincipled care, unprofessional interactions, ignoring the patient, falsifying documents, and specific ethical challenges. Pressures in the post-resuscitation period can cause nurses to provide care that is not consistent with guidelines, and to avoid communicating with physicians, patients and their families. Patients can also be labeled negatively, with early judgments made about their condition. Medical records can be written in a way to indicate that all necessary care has been provided. Disclosure, withdrawing, and withholding of therapy were also specific important ethical challenges in the field of post-resuscitation care.

CONCLUSION

There are many ethical and legal issues in post-resuscitation care. Developing evidence-based guidelines and training staff to provide ethical care can help to reduce these challenges.

What is appropriate care? A qualitative study into the perceptions of healthcare professionals in Flemish university hospital intensive care units

Aim

This study examines when healthcare professionals consider intensive care as appropriate care.

Background

Despite attempts to conceptualize appropriate care in prior research, there is a lack of insight into its meaning and implementation in practice. This is an important issue because healthcare professionals as well as patients and relatives report inappropriate care in the intensive care unit (ICU) on a regular basis.

Methods

A qualitative study was designed, based on principles of grounded theory. Seventeen semi-structured interviews were conducted with nurses, doctors and doctors in training from three Flemish university hospitals. Analyses followed the Quagol method; insights were gained by means of the constant comparative method.

Results

Healthcare professionals described appropriate care as socially sustainable care, high-quality care, patient-oriented care, dignified care and meaningful care. They considered it important that care is not only proportional to the expected survival and quality of life of the patient and in line with the patient's or relatives' wishes, but also that the pursuit of the care goals is proportional to the patient's suffering.Although healthcare professionals indicated the same elements of appropriate care, they were defined and interpreted in individual and therefore different ways. This diversity lies at the basis of fields of tension and frustrations among healthcare professionals.

Conclusion

Appropriate care is defined and interpreted in individual and therefore different ways. In order to decide which type of care is appropriate for a specific patient, a process of open and constructive communication in a team is recommended.

Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center

BACKGROUND

Commentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave.

METHODS

We performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave.

RESULTS

Nurses perceived the ethical climate for decision-making as less favorable than physicians (p < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/Pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p ≤ 0.05) and also demonstrated lower moral distress scores (both p < 0.05) and lower "intention to leave" scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = -0.58, p < 0.001); moral distress and "intention to leave" was positively correlated (r = 0.52, p < 0.001); and ethical climate and "intention to leave" were negatively correlated (r = -0.50, p < 0.001).

CONCLUSIONS

Significant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care.

Attitudes of health science students towards death in Spain

BACKGROUND

Health science students in Spain should be trained to manage the process of death and dying.

AIM

To compare the perceptions, attitudes and fears of death from a sample of these students.

METHODS

This descriptive, cross-sectional and multi-centre study comprised 411 students studying degrees in medicine, nursing and physiotherapy. The variables used were the hospice-related death self-efficacy scale by Robbins and the Collet-Lester fear of death scale.

FINDINGS

The total score obtained on the death self-efficacy scale was 74.43/110, which is considered moderate to high self-efficacy for facing death. Facing the death of a friend at a young age obtained the lowest score (3.85±2.809). Regarding the Collet-Lester scale, the lowest score was 'fear of one's own death' (3.58±0.983) with a value of p=0.81.

CONCLUSION

The health science students who participated in this study displayed high levels of fear and anxiety towards death.

Withholding and withdrawal of life-sustaining treatments in intensive care units in Lebanon: a cross-sectional survey of intensivists and interviews of professional societies, legal and religious leaders

Background

Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU).

Methods

A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders.

Results

Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect” (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate).

Conclusion

Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.

From Awareness to Prognosis: Ethical Implications of Uncovering Hidden Awareness in Behaviorally Nonresponsive Patients

Long-term patient outcomes after severe brain injury are highly variable, and reliable prognostic indicators are urgently needed to guide treatment decisions. Functional neuroimaging is a highly sensitive method of uncovering covert cognition and awareness in patients with prolonged disorders of consciousness, and there has been increased interest in using it as a research tool in acutely brain injured patients. When covert awareness is detected in a research context, this may impact surrogate decisionmaking-including decisions about life-sustaining treatment-even though the prognostic value of covert consciousness is currently unknown. This paper provides guidance to clinicians and families in incorporating individual research results of unknown prognostic value into surrogate decisionmaking, focusing on three potential issues: (1) Surrogate decisionmakers may misinterpret results; (2) Results may create false hope about the prospects of recovery; (3) There may be disagreement about the meaningfulness or relevance of results, and appropriateness of continued care.

Perceptions of Ethical Decision-Making Climate Among Clinicians Working in European and U.S. ICUs: Differences Between Nurses and Physicians

OBJECTIVES

To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses' and physicians' rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses.

DESIGN

Prospective observational study.

SETTING

A total of 68 adult ICUs in 13 European countries and the United States.

SUBJECTS

ICU physicians and nurses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses' involvement at end-of-life, average without nurses' involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions.

CONCLUSIONS

Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.

Ethical aspects of time in intensive care decision making

The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting.

Influence of nurse's involvement on practices during end-of-life decisions within stroke units

OBJECTIVES

Decision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions.

PATIENTS AND METHODS

This secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision.

RESULTS

Among the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03).

CONCLUSION

The involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.

Withholding and Withdrawal of Treatments: Differences in Perceptions between Intensivists, Oncologists, and Prosecutors in Brazil

Background: Legal concerns have been implicated in the occurrence of variability in decisions of limitations of medical treatment (LOMT) before death. Objective: We aimed to assess differences in perceptions between physicians and prosecutors toward LOMT. Measurements: We sent a survey to intensivists, oncologists, and prosecutors from Brazil, from February 2018 to May 2018. Respondents rated the degree of agreement with withholding or withdrawal of therapies in four different vignettes portraying a patient with terminal lung cancer. We measured the difference in agreement between respondents. Results: There were 748 respondents, with 522 (69.8%) intensivists, 106 (14.2%) oncologists, and 120 (16%) prosecutors. Most respondents agreed with withhold of chemotherapy (95.2%), withhold of mechanical ventilation (MV) (90.2%), and withdrawal of MV (78.4%), but most (75%) disagreed with withdrawal of MV without surrogate's consent. Prosecutors were less likely than intensivists and oncologists to agree with withhold of chemotherapy (95.7% vs. 99.2% vs. 100%, respectively, p < 0.001) and withhold of MV (82.4% vs. 98.3% vs. 97.9%, respectively, p < 0.001), whereas intensivists were more likely to agree with withdrawal of MV than oncologists (87.1% vs. 76.1%, p = 0.002). Moreover, prosecutors were more likely to agree with withholding of active cancer treatment than with withholding of MV [difference (95% confidence interval, CI) = 13.2% (5.2 to 21.6), p = 0.001], whereas physicians were more likely to agree with withholding than with withdrawal of MV [difference (95% CI) = 10.9% (7.8 to 14), p < 0.001]. Conclusions: This study found differences and agreements in perceptions toward LOMT between prosecutors, intensivists, and oncologists, which may inform the discourse aimed at improving end-of-life decisions.

Ethical dilemmas in clinical practice: a perspective on the results of an electronic survey of veterinary anaesthetists

Medical progress has greatly advanced our ability to manage animals with critical and terminal diseases. We now have the ability to sustain life even in the most dire of circumstances. However, the preservation of life may not be synonymous with providing 'quality of life', and worse, could cause unnecessary suffering. Using the results of an electronic survey, we aim to outline and give examples of ethical dilemmas faced by veterinary anaesthetists dealing with critically ill animals, how the impact of these dilemmas could be mitigated, and what thought processes underlie decision-making in such situations.

Seeing the Patient and Family Through: Nurses and Physicians Experiences With Withdrawal of Life-Sustaining Therapy in the ICU

Withdrawal of life-sustaining therapy at the end of life is a complex phenomenon. Intensive care nurses and physicians are faced with caring for patients and supporting families, as these difficult decisions are made. The purpose of this study was to explore and describe the experience of critical care nurses and physicians participating in the process of withdrawal of life-sustaining therapy. A hermeneutic phenomenological approach was used to guide this qualitative investigation. Interviews were conducted with critical care nurses and physicians from 2 medical centers. An inductive approach to data analysis was used to understand similarities between the nurses and the physicians’ experiences. Methodological rigor was established, and data saturation was achieved. The main categories that were inductively derived from the data analysis included from novice to expert, ensuring ethical care, uncertainty to certainty, facilitating the process, and preparing and supporting families. The categories aided in understanding the experiences of nurses and physicians, as they worked individually and together to see patients and families through the entire illness experience, withdrawal of life-sustaining therapy decision-making process and dying process. Understanding the perspectives of health-care providers involved in the withdrawal of life-sustaining therapy process will help other health-care providers who are striving to provide quality care to the dying and to their families.

Cuidado humanizado en pacientes con limitación del esfuerzo terapéutico en cuidados intensivos, desafíos para enfermería

En las unidades de cuidados intensivos (UCI) el equipo de salud utiliza todas las medidas posibles para preservar la vida de sus pacientes. No obstante, cuando las terapias son fútiles, se decide limitar el esfuerzo terapéutico (LET). Este artículo tiene como objetivo describir los factores que pueden llevar a enfermería a deshumanizar sus cuidados en pacientes en LET en UCI. Revisión de la literatura en bases de datos, con las palabras clave: critical care, intensive care unit, limitation of therapeutic effort, end of life care, humanized/human care, nursing. Los hallazgos fueron agrupados en seis categorías que pueden influir en la deshumanización del cuidado en UCI. Se concluye que en el cuidado humanizado se destacan los roles de enfermería como defensora de los intereses del paciente y como agente comunicador.

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose

Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.

Methods

In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.

Results

Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.

Conclusion

Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.

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.

The impact of healthcare professionals' personality and religious beliefs on the decisions to forego life sustaining treatments: an observational, multicentre, cross-sectional study in Greek intensive care units

OBJECTIVES

To assess the opinion of intensive care unit (ICU) personnel and the impact of their personality and religious beliefs on decisions to forego life-sustaining treatments (DFLSTs).

SETTING

Cross-sectional, observational, national study in 18 multidisciplinary Greek ICUs, with >6 beds, between June and December 2015.

PARTICIPANTS

149 doctors and 320 nurses who voluntarily and anonymously answered the End-of-Life (EoL) attitudes, Personality (EPQ) and Religion (SpREUK) questionnaires. Multivariate analysis was used to detect the impact of personality and religious beliefs on the DFLSTs.

RESULTS

The participation rate was 65.7%. Significant differences in DFLSTs between doctors and nurses were identified. 71.4% of doctors and 59.8% of nurses stated that the family was not properly informed about DFLST and the main reason was the family's inability to understand medical details. 51% of doctors expressed fear of litigation and 47% of them declared that this concern influenced the information given to family and nursing staff. 7.5% of the nurses considered DFLSTs dangerous, criminal or illegal. Multivariate logistic regression identified that to be a nurse and to have a high neuroticism score were independent predictors for preferring the term 'passive euthanasia' over 'futile care' (OR 4.41, 95% CI 2.21 to 8.82, p<0.001, and OR 1.59, 95% CI 1.03 to 2.72, p<0.05, respectively). Furthermore, to be a nurse and to have a high-trust religious profile were related to unwillingness to withdraw mechanical ventilation. Fear of litigation and non-disclosure of the information to the family in case of DFLST were associated with a psychoticism personality trait (OR 2.45, 95% CI 1.25 to 4.80, p<0.05).

CONCLUSION

We demonstrate that fear of litigation is a major barrier to properly informing a patient's relatives and nursing staff. Furthermore, aspects of personality and religious beliefs influence the attitudes of ICU personnel when making decisions to forego life-sustaining treatments.

Limitation of therapeutic effort experienced by intensive care nurses

Background:

Nurses who practice limitation of therapeutic effort become fully involved in emotionally charged situations, which can affect them significantly on an emotional and professional level.

Objectives:

To describe the experience of intensive care nurses practicing limitation of therapeutic effort.

Method:

A qualitative, phenomenological study was performed within the intensive care units of the Madrid Hospitals Health Service. Purposeful and snowball sampling methods were used, and data collection methods included semi-structured and unstructured interviews, researcher field notes, and participants’ personal letters. The Giorgi proposal for data analysis was used on the data.

Ethical considerations:

This study was approved by the Ethical Research Committee of the relevant hospital and by the Ethics Committee of the Rey Juan Carlos University and was guided by the ethical principles of voluntary enrollment, anonymity, privacy, and confidentiality.

Results:

In total, 22 nurses participated and 3 themes were identified regarding the nurses’ experiences when faced with limitation of therapeutic effort: (a) experiencing relief, (b) accepting the medical decision, and (c) implementing limitation of therapeutic effort.

Conclusion:

Nurses felt that, although they were burdened with the responsibility of implementing limitation of therapeutic effort, they were being left out of the final decision-making process regarding the same.

Clinical Nurse Participation at Family Conferences in the Pediatric Intensive Care Unit

BACKGROUND

Clinical nurses attend family conferences in the intensive care unit, but their role during these meetings is not yet fully understood.

OBJECTIVES

To assess perceived and observed contributions of the clinical nurse during family conferences.

METHODS

Prospective cross-sectional survey and review of 40 audio-recorded family conferences conducted in the 44-bed pediatric intensive care unit of an urban pediatric hospital.

RESULTS

Survey responses from 47 nurses were examined. Most nurses thought it important to attend family conferences, but identified workload as a barrier to attendance. They perceived their roles as gaining firsthand knowledge of the discussion and providing a unique perspective regarding patient care, emotional support, and advocacy. Audio recordings revealed that bedside nurses attended 20 (50%) of 40 family conferences and spoke in 5 (25%) of the 20. Nurses verbally contributed 4.6% to the overall speech at the family conference, mostly providing information on patient care.

CONCLUSIONS

The clinical nurse is often absent or silent during family conferences in the intensive care unit, despite the important roles they want to play in these settings. Strategies to improve both the physical and verbal participation of clinical nurses during the family conference are suggested, especially in the context of previous research demonstrating the need for more attention in family conferences to social-emotional support and patient advocacy.

[Perspective of intensive care nursing staff on the limitation of life support treatment]

OBJECTIVE

To determine the perspective of intensive care nursing staff on the limitation of life support treatment (LLST) in the Intensive Care Units.

METHOD

An exploratory qualitative study was carried out by applying the theory of Strauss and Corbin as the analysis tool. Constructivist paradigm.

POPULATION

Nursing staff from three Intensive Care Units of Hospital Universitari de Bellvitge. Convenience sampling to reach theoretical saturation of data. Data collection through semi-structured interview recorded prior to informed consent. Rigor and quality criteria (reliability, credibility, transferability), and authenticity criteria: reflexivity. Demographic data was analysed using Excel.

RESULTS

A total of 28 interviews were conducted. The mean age of the nurses was 35.6 years, with a mean seniority of 11.46 years of working in ICU. A minority of nurses (21.46%) had received basic training in bioethics. The large majority (85.7%) believe that LLST is not a common practice due to therapeutic cruelty and poor management with it. There is a correlation with the technical concepts; but among the main ethical problems is the decision to apply LLST. Nurses recognise that the decision on applying LLST depends on medical consensus with relatives, and they believe that their opinion is not considered. Their objective is trying to avoid suffering, and assist in providing a dignified death and support to relatives.

CONCLUSIONS

There is still a paternalistic pattern between the doctor and patient relationship, where the doctor makes the decision and then agrees with the relatives to apply LLST. Organ failure and poor prognosis are the most important criteria for applying LLST. It is necessary to develop a guide for applying LLST, emphasising the involvement of nurses, patients, and their relatives.

Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

PURPOSE

The effect of capacity strain in an ICU on the timing of end-of-life decision-making is unknown. We sought to determine how changes in strain impact timing of new do-not-resuscitate (DNR) orders and of death.

METHODS

Retrospective cohort study of 9891 patients dying in the hospital following an ICU stay ≥72 h in Project IMPACT, 2001-2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression.

RESULTS

Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p = 0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p < 0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p < 0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p = 0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65 % of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy.

CONCLUSIONS

Strains in ICU capacity are associated with end-of-life decision-making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.

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.

Great variation between ICU physicians in the approach to making end-of-life decisions

INTRODUCTION

End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting.

METHODS

The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities.

RESULTS

In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%.

CONCLUSION

There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training.

Avenues of action in ethically complex situations: a critical incident study

OBJECTIVES

The aims of this study were to explore nurse leaders' experiences with ethically difficult situations, perceptions about risk factors, and specific actions for ethical conflicts.

BACKGROUND

Research indicates that nurses are reluctant to bring ethical concerns to nurse leaders for fear of creating trouble, and yet, nurse leaders are key figures in supporting ethics-minded clinicians and cultures.

METHODS

The critical incident technique was used to collect descriptions from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and counted.

RESULTS

End-of-life situations accounted for the majority of incidents. Most situations had 3 to 4 ethical issues. Healthcare provider and system-level factors were perceived to increase the likelihood of ethical conflicts more often than family and patient factors. Respondents were more likely to identify leader actions that address specific situations rather than specify system-level actions addressing root causes of conflicts.

CONCLUSIONS

Findings can be used to help leaders create ethics competencies, policies, and education.

[Nurses' perception, experience and knowledge of palliative care in intensive care units]

BACKGROUND

Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients.

OBJECTIVE

To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients.

METHODOLOGY

A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed.

RESULTS

Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses.

CONCLUSION

This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making.

End-of-life care in the intensive care unit: a patient-based questionnaire of intensive care unit staff perception and relatives' psychological response

BACKGROUND

Communication is a hallmark of end-of-life care in the intensive care unit. It may influence the impact of end-of-life care on patients' relatives. We aimed to assess end-of-life care and communication from the perspective of intensive care unit staff and relate it to relatives' psychological symptoms.

DESIGN

Prospective observational study based on consecutive patients with severe sepsis receiving end-of-life care; trial registration NCT01247792.

SETTING/PARTICIPANTS

Four interdisciplinary intensive care units of a German University hospital. Responsible health personnel (attendings, residents and nurses) were questioned on the day of the first end-of-life decision (to withdraw or withhold life-supporting therapies) and after patients had died or were discharged. Relatives were interviewed by phone after 90 days.

RESULTS

Overall, 145 patients, 610 caregiver responses (92% response) and 84 relative interviews (70% response) were analysed. Most (86%) end-of-life decisions were initiated by attendings and only 2% by nurses; 41% of nurses did not know enough about end-of-life decisions to communicate with relatives. Discomfort with end-of-life decisions was low. Relatives reported high satisfaction with decision-making and care, 87% thought their degree of involvement had been just right. However, 51%, 48% or 33% of relatives had symptoms of post-traumatic stress disorder, anxiety or depression, respectively. Predictors for depression and post-traumatic stress disorder were patient age and relatives' gender. Relatives' satisfaction with medical care and communication predicted less anxiety (p = 0.025).

CONCLUSION

Communication should be improved within the intensive care unit caregiver team to strengthen the involvement of nurses in end-of-life care. Improved communication between caregivers and the family might lessen relatives' long-term anxiety.

Causes and consequences of disproportionate care in intensive care medicine

PURPOSE OF REVIEW

Increased use of advanced life-sustaining measures in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities and/or a poor quality of life has become a worrying trend over the last decade. This can lead to futile, disproportionate or inappropriate care in the ICU. This review summarizes the causes and consequences of disproportionate care in the ICU.

RECENT FINDINGS

Disproportionate care seems to be common in European and North American ICUs. The initiation and prolongation of disproportionate care can be related to hospital facilities, healthcare providers, the patient and his/her representatives and society. This can have serious consequences for patients, their relatives, physicians, nurses and society.

SUMMARY

Disproportionate care is common in western ICUs. It can lead to violation of basic bioethical principles, suffering of patients and relatives and compassion fatigue and moral distress in healthcare providers. Avoiding inappropriate use of ICU resources and disproportionate care in the ICU should have high priority for ICU managers but also for every healthcare provider taking care of patients at the bedside.

Ethical decision making in intensive care units: a burnout risk factor? Results from a multicentre study conducted with physicians and nurses

BACKGROUND

Ethical decision making in intensive care is a demanding task. The need to proceed to ethical decision is considered to be a stress factor that may lead to burnout. The aim of this study is to explore the ethical problems that may increase burnout levels among physicians and nurses working in Portuguese intensive care units (ICUs). A quantitative, multicentre, correlational study was conducted among 300 professionals.

RESULTS

The most crucial ethical decisions made by professionals working in ICU were related to communication, withholding or withdrawing treatments and terminal sedation. A positive relation was found between ethical decision making and burnout in nurses, namely, between burnout and the need to withdraw treatments (p=0.032), to withhold treatments (p=0.002) and to proceed to terminal sedation (p=0.005). This did not apply to physicians. Emotional exhaustion was the burnout subdimension most affected by the ethical decision. The nurses' lack of involvement in ethical decision making was identified as a risk factor. Nevertheless, in comparison with nurses (6%), it was the physicians (34%) who more keenly felt the need to proceed to ethical decisions in ICU.

CONCLUSIONS

Ethical problems were reported at different levels by physicians and nurses. The type of ethical decisions made by nurses working in Portuguese ICUs had an impact on burnout levels. This did not apply to physicians. This study highlights the need for education in the field of ethics in ICUs and the need to foster inter-disciplinary discussion so as to encourage ethical team deliberation in order to prevent burnout.

Challenges in end-of-life decisions in the intensive care unit: an ethical perspective

When making end-of-life decisions in intensive care units (ICUs), different staff groups have different roles in the decision-making process and may not always assess the situation in the same way. The aim of this study was to examine the challenges Danish nurses, intensivists, and primary physicians experience with end-of-life decisions in ICUs and how these challenges affect the decision-making process. Interviews with nurses, intensivists, and primary physicians were conducted, and data is discussed from an ethical perspective. All three groups found that the main challenges were associated with interdisciplinary collaboration and future perspectives for the patient. Most of these challenges were connected with ethical issues. The challenges included different assessments of treatment potential, changes and postponements of withholding and withdrawing therapy orders, how and when to identify patients' wishes, and suffering caused by the treatment. To improve end-of-life decision-making in the ICU, these challenges need to be addressed by interdisciplinary teams.

Intensive care nurses’ involvement in the end-of-life process – perspectives of relatives

In this article, we report findings from a qualitative study that explored how the relatives of intensive care unit patients experienced the nurses’ role and relationship with them in the end-of-life decision-making processes. In all, 27 relatives of 21 deceased patients were interviewed about their experiences in this challenging ethical issue. The findings reveal that despite bedside experiences of care, compassion and comfort, the nurses were perceived as vague and evasive in their communication, and the relatives missed a long-term perspective in the dialogue. Few experienced that nurses participated in meetings with doctors and relatives. The ethical consequences imply increased loneliness and uncertainty, and the experience that the relatives themselves have the responsibility of obtaining information and understanding their role in the decision-making process. The relatives therefore felt that the nurses could have been more involved in the process.

End-of-life practices in Danish ICUs: development and validation of a questionnaire

Background

Practices for withholding or withdrawing therapy vary according to professional, cultural and religious differences. No Danish-validated questionnaire examining withholding and withdrawing practices exists, thus the aim of this study was to develop and validate a questionnaire for surveying the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the ICU.

Methods

A questionnaire was developed on the basis of literature, focus group interviews with intensive care nurses and intensivists, and individual interviews with primary physicians. The questionnaire was validated in the following 3 phases: a qualitative test with 17 participants; a quantitative pilot test with 60 participants; and a survey with 776 participants. The validation process included tests for face and content validity (by interviewing participants in the qualitative part of the pilot study), reliability (by assessing the distribution of responses within the individual response categories), agreement (by conducting a test-retest, evaluated by paired analyses), known groups’ validity (as a surrogate test for responsiveness, by comparing two ICUs with a known difference in end-of-life practices), floor and ceiling effect, and missing data.

Results

Face and content validity were assessed as good by the participants in the qualitative pilot test; all considered the questions relevant and none of the participants found areas lacking. Almost all response categories were used by the participants, thus demonstrating the questionnaires ability to distinguish between different respondents, agreement was fair (the average test-retest agreement for the Likert scale responses was 0.54 (weighted kappa; range, 0.25-0.73), and known groups’ validity was proved by finding significant differences in level of satisfaction with interdisciplinary collaboration and in experiences of withdrawal decisions being unnecessarily postponed. Floor and ceiling effect was in accordance with other questionnaires, and missing data was limited to a range of 0-7% for all questions.

Conclusions

The validation showed good and fair areas of validity of the questionnaire. The questionnaire is considered a useful tool to assess the perceptions of collaboration and other aspects of withholding and withdrawing therapy practices in Danish ICUs amongst nurses, intensivists, and primary physicians.

Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland

Although currently there are many different recommendations and strategies in the therapy of odontoid fractures in the elderly, there are still no generally accepted guidelines for a structured and standardised treatment. Moreover, the current opinion of spine surgeons regarding the optimal treatment of odontoid fractures Type II of the elderly is unknown. In order to have an objective insight into the diverging strategies for the management of Anderson Type II odontoid fractures and form a basis for future comparisons, this study investigated the current concepts and preferences of orthopaedic, neuro- and trauma surgeons. Spine surgeons from 34 medical schools and 8 hospitals in Germany, 4 university hospitals in Austria and 5 in Switzerland were invited to participate in an online survey using a 12-item 1-sided questionnaire. A total of 44 interviewees from 34 medical institutions participated in the survey, consisting of trauma (50%), orthopaedic (20.5%) and neurosurgeons (27.3%). Out of these, 70.5% treated 1-20 fractures per year; 63.6% favoured the anterior screw fixation as therapy for Type II odontoid fractures, the open posterior Magerl transarticular C1/C2 fusion, the posterior Harms C1/C2 fusion, and conservative immobilisation by cervical orthosis was preferred by 9.1% in each case. 59.1% preferred the anterior odontoid screw fixation as an appropriate treatment of Anderson Type II odontoid fractures in the elderly. 79.5% chose cervical orthosis for postsurgical treatment. Following operative treatment, nonunion rates were reported to be <10% and <20% by 40.9% and 70% of the surgeons, respectively. 56.8% reported changing from primary conservative to secondary operative treatment in <10% of cases. The most favoured technique in revision surgery of nonunions was the open posterior Magerl transarticular fusion technique, chosen by 38.6% of respondents. 18.2% preferred the posterior Harms C1/C2 fusion technique, 11.4% the percutaneous posterior Magerl technique and the anterior odontoid screw fixation in each case. This study discovered major variations in the treatment of Anderson Type II odontoid fractures in the elderly in terms of indication for conservative and operative treatment between several treatment centres in 3 European countries. Difficulty and complexity in formulating general guidelines based on multicenter studies is conceivable.