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Jennerich AL. An Approach to Caring for Patients and Family of Patients Dying in the ICU. Chest 2024; 166:127-135. [PMID: 38354905 DOI: 10.1016/j.chest.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
TOPIC IMPORTANCE Death is common in the ICU and often occurs after a decision to withhold or withdraw life-sustaining therapies. Care of the dying is a core skill for ICU clinicians, requiring expert communication, primarily with family of critically ill patients. REVIEW FINDINGS Limited high-quality evidence supports specific practices related to the care of dying patients in the ICU; thus, many of the recommendations that exist are based on expert opinion. Value exists in sharing a practical approach to caring for patients during the dying process, including topics to be addressed with family members, rationales for recommended care, and strategies for implementing comfort measures only. Through dedicated preparation and planning, clinicians can help family members navigate this intense experience. SUMMARY After a decision had been made to discontinue life-sustaining therapies, family members need to be given a clear description of comfort measures only and provided with additional detail about what it entails, including therapies or interventions to be discontinued, monitoring during the dying process, and common features of the dying process. Order sets can be a valuable resource for ensuring that adequate analgesia and sedation are available and the care plan is enacted properly. To achieve a good death for patients, a collaborative effort among members of the care team is essential.
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Affiliation(s)
- Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
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2
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Reifarth E, Böll B, Kochanek M, Garcia Borrega J. Communication strategies for expressing empathy during family-clinician conversations in the intensive care unit: A mixed methods study. Intensive Crit Care Nurs 2024; 81:103601. [PMID: 38101211 DOI: 10.1016/j.iccn.2023.103601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/19/2023] [Accepted: 11/23/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVES To explore communication strategies intensive care clinicians and patients' family members prefer for expressing empathy during family-clinician conversations. RESEARCH METHODOLOGY/DESIGN Mixed-methods survey study. SETTING Two medical ICUs of a German academic tertiary care hospital. MAIN OUTCOME MEASURES Using a self-developed online survey with closed and open-ended questions with free-text options, the participants' preferences of communication strategies for expressing empathy were investigated. Quantifiable similarities and differences were determined by statistical analysis. Qualitative themes were derived at by directed content analysis. FINDINGS The responses of 94 family members, 42 nurses, and 28 physicians were analysed (response rate: 45.3 %). Four communication strategies were deduced: (1) reassuring the families that the intensive care unit team will not abandon neither them nor the patient, (2) acknowledging emotions and offering support, (3) saying that the families are welcome and cared for in the intensive care unit, (4) providing understandable information. In comparison, the families considered an expression of nonabandonment as more empathic than the physicians did (p =.031,r = 0.240), and those expressions focussing solely on the family members' well-being (p =.012,r = 0.228) or comprising evaluative wording ("good", "normal") (p =.017,r = 0.242) as less empathic than the nurses did. Unanimously advocated nonverbal communication strategies included to listen attentively and to avoid interrupting as well as being approachable and honest. CONCLUSION The participants' preferences supported expert recommendations and highlighted that it is not only important what the clinicians say but also how they say it. Further research is needed to elucidate ways of successfully expressing empathy during family-clinician conversations in the intensive care unit. IMPLICATIONS FOR CLINICAL PRACTICE Intensive care unit clinicians are encouraged to practice active listening and to express their caring and nonabandonment. It is further suggested to reflect on and adjust pertinent nonverbal behaviours and relational aspects of their communication, as applicable.
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Affiliation(s)
- Eyleen Reifarth
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany.
| | - Boris Böll
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Jorge Garcia Borrega
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
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3
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Geurtzen R, Wilkinson DJC. Incorporating parental values in complex paediatric and perinatal decisions. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:225-235. [PMID: 38219752 DOI: 10.1016/s2352-4642(23)00267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024]
Abstract
Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.
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Affiliation(s)
- Rosa Geurtzen
- Amalia Children's Hospital, Radboud Institute of Healthcare Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Dominic J C Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; Oxford Newborn Care Unit, John Radcliffe Hospital, Oxford University, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore
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4
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Pjesivac I, Eldredge SA, Dalton ED, Miller LE. Between the Facts and a Hard Place: Trust Judgments and Affective Responses in Information-Seeking Processes During Early COVID-19. HEALTH COMMUNICATION 2024; 39:518-528. [PMID: 36721308 DOI: 10.1080/10410236.2023.2171561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
This study examined the formation of trust judgments of information sources about COVID-19 and the role played by emotions in this information seeking process. Twenty-seven in-depth interviews with Americans revealed that both trust and affective responses were present in information seeking of health messages, thus discovering the applicability of Risk Information Seeking and Processing (RISP) model's propositions during pandemics. Using qualitative methods to assess RISP variables in a new context (COVID-19), the study proposes modifications to the existing model. It also extends the socio-psychological traditions on which the RISP model was based, by finding that when evaluating information sources during pandemics, under conditions of high issue relevance, individuals' peripheral evaluation of messages might precede systematic evaluation and might be used as a selection criteria for further elaboration. Finally, the assessments of source credibility as a peripheral cue in this study expand current theoretical understandings by including compassion as a possible new dimension.
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Affiliation(s)
| | | | | | - Laura E Miller
- School of Communication Studies, University of Tennessee
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5
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Renckens SC, Pasman HR, Jorna Z, Klop HT, Perron CD, van Zuylen L, Steegers MAH, Ten Tusscher BL, van Mol MMC, Vloet LCM, Onwuteaka-Philipsen BD. Varying (preferred) levels of involvement in treatment decision-making in the intensive care unit before and during the COVID-19 pandemic: a mixed-methods study among relatives. BMC Med Inform Decis Mak 2024; 24:46. [PMID: 38347583 PMCID: PMC10863197 DOI: 10.1186/s12911-024-02429-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/16/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND In the intensive care unit (ICU) relatives play a crucial role as surrogate decision-makers, since most patients cannot communicate due to their illness and treatment. Their level of involvement in decision-making can affect their psychological well-being. During the COVID-19 pandemic, relatives' involvement probably changed. We aim to investigate relatives' involvement in decision-making in the ICU before and during the pandemic and their experiences and preferences in this regard. METHODS A mixed-methods study among relatives of ICU patients admitted to an ICU before or during the COVID-19 pandemic. Relatives in six ICUs completed a questionnaire (n = 329), including two items on decision-making. These were analysed using descriptive statistics and logistic regression analyses. Subsequently, relatives (n = 24) were interviewed about their experiences and preferences regarding decision-making. Thematic analysis was used for analysing the qualitative data. RESULTS Nearly 55% of the relatives indicated they were at least occasionally asked to be involved in important treatment decisions and of these relatives 97.1% reported to have had enough time to discuss questions and concerns when important decisions were to be made. During the first COVID-19 wave relatives were significantly less likely to be involved in decision-making compared to relatives from pre-COVID-19. The interviews showed that involvement varied from being informed about an already made decision to deliberation about the best treatment option. Preferences for involvement also varied, with some relatives preferring no involvement due to a perceived lack of expertise and others preferring an active role as the patient's advocate. Discussing a patient's quality of life was appreciated by relatives, and according to relatives healthcare professionals also found this valuable. In some cases the preferred and actual involvement was in discordance, preferring either a larger or a smaller role. CONCLUSIONS As treatment alignment with a patient's values and preferences and accordance between preferred and actual involvement in decision-making is very important, we suggest that the treatment decision-making process should start with discussions about a patient's quality of life, followed by tailoring the process to relatives' preferences as much as possible. Healthcare professionals should be aware of relatives' heterogeneous and possibly changing preferences regarding the decision-making process.
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Affiliation(s)
- Sophie C Renckens
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands.
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands.
| | - H Roeline Pasman
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Zina Jorna
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Hanna T Klop
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Viaa University of Applied Sciences, Zwolle, The Netherlands
| | - Chantal du Perron
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, location VU Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Birkitt L Ten Tusscher
- Department of Intensive Care Medicine, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Margo M C van Mol
- Erasmus MC, Department of Intensive Care Medicine Adults, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Foundation Family and patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
| | - Lilian C M Vloet
- Foundation Family and patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
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6
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Ledin ER, Eriksson A, Mattsson J. "What choice do you have knowing your child can't breathe?!": Adaptation to Parenthood for Children Who Have Received a Tracheostomy. SAGE Open Nurs 2024; 10:23779608241245502. [PMID: 38601012 PMCID: PMC11005490 DOI: 10.1177/23779608241245502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/22/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024] Open
Abstract
Introduction A growing number of parents are navigating parenthood influenced by medical complexity and technological dependency as the group of children with long-term tracheostomy grows. However, little is known regarding the parental experiences of parenthood for this heterogeneous group of children now surviving through infancy and intensive care. Objective This study aimed to analyze how parents of children who have received a tracheostomy adapted to parenthood. Methods Interviews were conducted and analyzed following a constructivist grounded theory approach. Ten parents of seven children living with a tracheostomy in Sweden were recruited via the long-term intensive care unit (ICU). Results The core variable of parenthood "Stuck in survival" was explained by two categories and six subcategories. The category "Unaddressed previous history" describes the experiences from being in the ICU environment and how the parents are not able, due to insufficient time and resources, to address these stressful experiences. The category "Falling through the cracks of a rigid system" describes how the parents found themselves and their children to be continuously ill-fitted in a medical system impossible to adapt to their needs and situation. Parents placed the starting point of parenthood with the birth of the child, whilst the tracheotomy only constituted a turning point and would lead to the loss of any previously held expectations regarding parenthood. Conclusion This study identified a previously undescribed period prior to tracheostomy placement, which may have long-lasting effects on these families. The care provided in ICUs following the birth of a child who will require tracheostomy may not be tailored or adapted to accommodate the needs of these families leading to long-lasting effects on parenthood.
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Affiliation(s)
- Ellinor Rydhamn Ledin
- Department of Ergonomics - CBH, KTH Royal Institute of Technology, Huddinge, Sweden
- Department of Health Sciences, Swedish Red Cross University, Huddinge, Sweden
| | - Andrea Eriksson
- Department of Ergonomics - CBH, KTH Royal Institute of Technology, Huddinge, Sweden
| | - Janet Mattsson
- Department of Nursing and Health Sciences, University of South-Eastern Norway, Campus Vestfold, Norway
- Department of Nursing and Integrated Health Sciences, Kristianstad University, Kristianstad, Sweden
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7
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Reifarth E, Böll B, Kochanek M, Garcia Borrega J. Communication strategies for effective family-clinician conversations in the intensive care unit: A mixed methods study. Intensive Crit Care Nurs 2023; 79:103497. [PMID: 37542801 DOI: 10.1016/j.iccn.2023.103497] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/12/2023] [Accepted: 07/16/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES To explore the perspectives of intensive care patients' family members and clinicians on conveying information during family-clinician conversations. SETTING Two medical intensive care units of a German academic tertiary care hospital. RESEARCH METHODOLOGY AND DESIGN This study followed a mixed methods design using a digital survey on family-clinician conversations with open- and closed-ended questions, metric scales, and free-text options. Quantitative analysis was performed to determine similarities and differences. Qualitative directed content analysis was conducted to code all free-text responses into themes. FINDINGS The responses of 100 family members, 42 nurses, and 28 physicians were analysed (response rate: 47%). All groups preferred face-to-face communication, the ask-tell-ask method, recipient design, and explaining medical terminology. The groups further commented on empathic communication by advocating the acknowledgement of the large amount of information. Qualitative themes highlighting the importance of bedside manners and written information were unique to the family members. Closed-ended questions were identified as potential trouble sources. Two communication strategies were rated as more suitable by the family members than by the physicians: being offered to choose between a summary or a detailed report at the beginning (p =.012;r = 0.288) and receiving a summary and having all questions answered at the end of a conversation (p =.023;r = 0.240). CONCLUSION The shared preferences supported existing expert recommendations, the differing preferences corroborated the importance of relational aspects of communication and additional written information. More research is needed on empathic communication aspects. IMPLICATIONS FOR CLINICAL PRACTICE To facilitate understanding, the clinicians may apply recipient design and the ask-tell-ask method, explain medical terminology, summarise important information, and proactively elicit questions. They may use empathic phrasing, demonstrate a respectful demeanour, and reflect on their current use of closed-ended questions and on the relational messages of their communication.
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Affiliation(s)
- Eyleen Reifarth
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany.
| | - Boris Böll
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany.
| | - Matthias Kochanek
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany.
| | - Jorge Garcia Borrega
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany.
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8
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Jöbges S, Meier S. [News in intensive care unit communication]. Dtsch Med Wochenschr 2023; 148:1443-1447. [PMID: 37918429 DOI: 10.1055/a-1947-9612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Current publications on the topic of communication in intensive care units (ITS) are shaped by the experiences of the COVID19 pandemic and the restrictions on personal contact and communication experienced during this time. Virtual, computer-based and telemedical concepts have grown out of this situation with limited contact and communication possibilities with patients and their relatives, but also between the individual service providers in the health system. It can also be assumed that artificial intelligence will increasingly be an issue in communication in intensive care units in the coming years. However, the significance, consequences and risks of the use of these new possibilities remain to be seen.
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Affiliation(s)
- Susanne Jöbges
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charite, Universitätsmedizin Berlin
| | - Stefan Meier
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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Prins S, Linn AJ, van Kaam AHLC, van de Loo M, van Woensel JBM, van Heerde M, Dijk PH, Kneyber MCJ, de Hoog M, Simons SHP, Akkermans AA, Smets EMA, de Vos MA. Diversity of Parent Emotions and Physician Responses During End-of-Life Conversations. Pediatrics 2023; 152:e2022061050. [PMID: 37575087 DOI: 10.1542/peds.2022-061050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To provide support to parents of critically ill children, it is important that physicians adequately respond to parents' emotions. In this study, we investigated emotions expressed by parents, physicians' responses to these expressions, and parents' emotions after the physicians' responses in conversations in which crucial decisions regarding the child's life-sustaining treatment had to be made. METHODS Forty-nine audio-recorded conversations between parents of 12 critically ill children and physicians working in the neonatal and pediatric intensive care units of 3 Dutch university medical centers were coded and analyzed by using a qualitative inductive approach. RESULTS Forty-six physicians and 22 parents of 12 children participated. In all 49 conversations, parents expressed a broad range of emotions, often intertwining, including anxiety, anger, devotion, grief, relief, hope, and guilt. Both implicit and explicit expressions of anxiety were prevalent. Physicians predominantly responded to parental emotions with cognition-oriented approaches, thereby limiting opportunities for parents. This appeared to intensify parents' expressions of anger and protectiveness, although their anxiety remained under the surface. In response to more tangible emotional expressions, for instance, grief when the child's death was imminent, physicians provided parents helpful support in both affect- and cognition-oriented ways. CONCLUSIONS Our findings illustrate the diversity of emotions expressed by parents during end-of-life conversations. Moreover, they offer insight into the more and less helpful ways in which physicians may respond to these emotions. More training is needed to help physicians in recognizing parents' emotions, particularly implicit expressions of anxiety, and to choose helpful combinations of responses.
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Affiliation(s)
- Sanne Prins
- Department of Pediatrics, Emma Children's Hospital
| | - Annemiek J Linn
- Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Moniek van de Loo
- Department of Pediatrics, Division of Neonatology, Emma Children's Hospital
| | - Job B M van Woensel
- Department of Pediatrics, Division of Pediatric Intensive Care, Emma Children's Hospital
| | - Marc van Heerde
- Department of Pediatrics, Division of Pediatric Intensive Care, Emma Children's Hospital
| | | | - Martin C J Kneyber
- Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Sinno H P Simons
- Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aranka A Akkermans
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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10
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Antolovich G, McDougall R. 'Doctor, isn't there anything else you can do?': The ethics of information sharing with parents in paediatric care. J Paediatr Child Health 2023; 59:1017-1020. [PMID: 37533338 DOI: 10.1111/jpc.16465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/13/2023] [Accepted: 06/29/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Giuliana Antolovich
- Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Rosalind McDougall
- Centre for Health Equity, Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
- Clinical Ethics Unit, Department of Surgery-Austin Precinct, Austin Health, Melbourne, Victoria, Australia
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11
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Akkermans A, Prins S, Spijkers AS, Wagemans J, Labrie NHM, Willems DL, Schultz MJ, Cherpanath TGV, van Woensel JBM, van Heerde M, van Kaam AH, van de Loo M, Stiggelbout A, Smets EMA, de Vos MA. Argumentation in end-of-life conversations with families in Dutch intensive care units: a qualitative observational study. Intensive Care Med 2023; 49:421-433. [PMID: 37004524 PMCID: PMC10119246 DOI: 10.1007/s00134-023-07027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/01/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE In intensive care units (ICUs), decisions about the continuation or discontinuation of life-sustaining treatment (LST) are made on a daily basis. Professional guidelines recommend an open exchange of standpoints and underlying arguments between doctors and families to arrive at the most appropriate decision. Yet, it is still largely unknown how doctors and families argue in real-life conversations. This study aimed to (1) identify which arguments doctors and families use in support of standpoints to continue or discontinue LST, (2) investigate how doctors and families structure their arguments, and (3) explore how their argumentative practices unfold during conversations. METHOD A qualitative inductive thematic analysis of 101 audio-recorded conversations between doctors and families. RESULTS Seventy-one doctors and the families of 36 patients from the neonatal, pediatric, and adult ICU (respectively, N-ICU, P-ICU, and A-ICU) of a large university-based hospital participated. In almost all conversations, doctors were the first to argue and families followed, thereby either countering the doctor's line of argumentation or substantiating it. Arguments put forward by doctors and families fell under one of ten main types. The types of arguments presented by families largely overlapped with those presented by doctors. A real exchange of arguments occurred in a minority of conversations and was generally quite brief in the sense that not all possible arguments were presented and then discussed together. CONCLUSION This study offers a detailed insight in the argumentation practices of doctors and families, which can help doctors to have a sharper eye for the arguments put forward by doctors and families and to offer room for true deliberation.
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Affiliation(s)
- Aranka Akkermans
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Sanne Prins
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Amber S Spijkers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jean Wagemans
- Department of Speech Communication, Argumentation Theory, and Rhetoric, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon H M Labrie
- Department of Language, Literature and Communication, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dick L Willems
- Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas G V Cherpanath
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc van Heerde
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne Stiggelbout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Mirjam A de Vos
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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12
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Edwards JD. A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity. Semin Pediatr Neurol 2023; 45:101037. [PMID: 37003634 DOI: 10.1016/j.spen.2023.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 04/03/2023]
Abstract
Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.
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Affiliation(s)
- Jeffrey D Edwards
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY..
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Gupta D, October TW, Wolfe AHJ. Characteristics of Prognostic Statements During Family Conferences of Critically Ill Children. Pediatr Crit Care Med 2023; 24:34-40. [PMID: 36594798 DOI: 10.1097/pcc.0000000000003116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Discussion of prognosis is an essential component of decision-making family conferences in critical care. We do not know how clinicians convey prognosis to families of critically ill children. We, therefore, aimed to evaluate the frequency of prognostic statements and the message and meaning conveyed through each statement during PICU family conferences. DESIGN Retrospective, mixed-methods study. SETTING PICU of a single quaternary medical center. PATIENTS Critically ill children and their families participating in PICU family conferences of critical medical decision-making. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 72 transcripts from audio-recorded PICU family conferences to identify prognostic statements. Descriptive, thematic content analysis was used to elucidate the message and meaning of each prognostic statement. Prognosis was not discussed in 26% (19/72) of family conferences. Of the other (53/72) conferences where prognostic statements were made, 60% (67/112) of statements conveyed a message (i.e., prognostic medical information) and a meaning (i.e., anticipated impact on patient/family). "Messages" of prognostic statements fell within eight themes: uncertain recovery, delayed recovery, progressive decline, escalation of support, attributable complications, no progress, irreversible, and probability of death. "Meanings" of prognostic statements fell within six themes: restoration of health, activities of daily living, additional equipment, prolonged care needs, brain dysfunction, and death. Broadly, clinicians discussed prognostic information in three categories: loss of Time (i.e., prolonged care needs), Function (i.e., additional medical equipment), or Cure (i.e., death). CONCLUSIONS Nearly in half of discussions (32/72, 44%) where families were asked to make critical medical decisions, clinicians did not provide a prognostic statement including a message and meaning. When discussed, prognostic information was conveyed in three categories: loss of time, function, or cure. Providing families context in this framework, particularly in times of uncertainty, may improve the family's ability to make informed, value-driven medical decisions for their child.
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Affiliation(s)
- Divya Gupta
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Tessie W October
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Amy H J Wolfe
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Giabicani M, Arditty L, Mamzer MF, Fournel I, Ecarnot F, Meunier-Beillard N, Bruneel F, Weiss E, Spranzi M, Rigaud JP, Quenot JP. Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs. PLoS One 2023; 18:e0284756. [PMID: 37098023 PMCID: PMC10128920 DOI: 10.1371/journal.pone.0284756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. METHODS Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. RESULTS Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts. CONCLUSION Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
| | - Laure Arditty
- Service de Réanimation, Centre Hospitalier Intercommunal des Alpes du Sud, Gap, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Isabelle Fournel
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besançon, France
- EA3920, Université de Bourgogne-Franche Comté, Besançon, France
| | - Nicolas Meunier-Beillard
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
| | - Marta Spranzi
- Center for Clinical Ethics, AP-HP, Paris and Université de Versailles Saint-Quentin en Yvelines, Versailles, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, CH de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, CHU de Caen, Caen, France
| | - Jean-Pierre Quenot
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Mackintosh K, McConnell P. Parent and medical team disagreements in the UK: universal lessons in the origins and resolution in conflict. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:47. [PMID: 37386545 DOI: 10.1186/s44158-022-00075-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/24/2022] [Indexed: 07/01/2023]
Abstract
In recent decades, there has been an increase in life expectancy in children with life-limiting conditions. Ideally, parents and clinicians would work together to ensure the best care for these children. Several cases have appeared in the media in recent years where conflict has risen between parents and healthcare professionals acting in the 'best interests' of children, which have resulted in court action. However, the legislation itself promotes conflict. Similar laws exist across Europe based on Article 24 of the UN Convention on the Rights of the Child.The aim of the Children's Act 1989 in the UK was to place the 'child's welfare' as the 'paramount consideration'. It has prevented draconian care and supervision orders, which can only be made if the child is at risk of 'significant harm'. This threshold does not apply to healthcare teams. Healthcare decisions are based on 'best interests', which are not explicitly defined. This sets the threshold for progression to court action much lower, and due to a lack of definitive definition of what 'best interests' are, this has unfortunately escalated conflict rather than resolve it.Healthcare institutions have been criticised for not utilising alternative approaches first, such as mediation. We propose an alternative approach based on collaboration, reasonableness and the threshold of significant harm, which we have explored in this review.Conflict management frameworks are a tool that can be used to recognise early signs of conflict and develop strategies to prevent escalation at ward level. They can be tailored to individual institutions and utilise content-oriented and empathetic communication strategies through designated clinicians. They should offer guidance on when to refer to the courts.Parental wishes should be assessed on whether they represent significant harm or not. If not, they cannot simply be wrong. Acknowledgement of the 'reasonableness' of parental requests can be a key factor which is diffusing conflict. Therefore, setting the threshold for state intervention at 'significant harm' rather than 'best interests' would help to reduce the number of these cases progressing to courts.
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Affiliation(s)
- Karen Mackintosh
- Anaesthetic Department, Royal Alexandra Hospital, Corsebar Road, Paisley, Scotland, PA2 9PN.
| | - Paul McConnell
- Anaesthetic Department, Royal Alexandra Hospital, Corsebar Road, Paisley, Scotland, PA2 9PN
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