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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024; 37:805-817. [PMID: 38609749 DOI: 10.1016/j.aucc.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: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Palmryd L, Rejnö Å, Alvariza A, Godskesen T. Critical care nurses' experiences of ethical challenges in end-of-life care. Nurs Ethics 2024:9697330241252975. [PMID: 38775348 DOI: 10.1177/09697330241252975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
BACKGROUND In Swedish intensive care units, nine percent of patients do not survive despite receiving advanced life-sustaining treatments. As these patients transition to end-of-life care, ethical considerations may become paramount. AIM To explore the ethical challenges that critical care nurses encounter when caring for patients at the end of life in an intensive care context. RESEARCH DESIGN The study used a qualitative approach with an interpretive descriptive design. RESEARCH CONTEXT AND PARTICIPANTS Twenty critical care nurses from eight intensive care units in an urban region in Sweden were interviewed, predominately women with a median age of fifty-one years. ETHICAL CONSIDERATIONS This study was approved by The Swedish Ethics Review Authority. FINDINGS Critical care nurses described encountering ethical challenges when life-sustaining treatments persisted to patients with minimal survival prospects and when administering pain-relieving medications that could inadvertently hasten patients' deaths. Challenges also arose when patients expressed a desire to withdraw life-sustaining treatments despite the possibility of recovery, or when family members wanted to shield patients from information about a poor prognosis; these wishes occasionally conflicted with healthcare guidelines. The critical care nurses also encountered ethical challenges when caring for potential organ donors, highlighting the balance between organ preservation and maintaining patient dignity. CONCLUSION Critical care nurses encountered ethical challenges when caring for patients at the end of life. They described issues ranging from life-sustaining treatments and administration of pain-relief, to patient preferences and organ donation considerations. Addressing these ethical challenges is essential for delivering compassionate person-centered care, and supporting family members during end-of-life care in an intensive care context.
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Affiliation(s)
- Lena Palmryd
- Marie Cederschiöld University
- Karolinska University Hospital
| | - Åsa Rejnö
- University West
- Skaraborg Hospital Skövde
- Skaraborg institute for Research and Development
| | | | - Tove Godskesen
- Nord University
- Uppsala University
- Marie Cederschiöld University
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Näppä U, Nässén E, Winqvist I. Palliative care in rural areas - collaboration between district nurses and doctors: an interview study. BMC Palliat Care 2023; 22:73. [PMID: 37322520 DOI: 10.1186/s12904-023-01190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Palliative care requires major nursing interventions as well as medical interventions; thus, both district nurses and doctors are vital to the palliative team. Sparsely populated rural areas are characterised by large geographic distances with the nurses and doctors located far away from each other. If collaboration does not work, this can create challenges for district nurses when managing patients' symptoms. The aim of this study was to describe district nurses' experiences of collaborating with doctors-in-charge during palliative home care in sparsely populated rural areas. METHOD Semi-structured interviews were conducted with 10 district nurses. Inductive content analysis was used to analyse the data. RESULTS The experiences of the district nurses are described under the overarching theme of Experiences of acting as the patient's advocate, which is divided into two categories: Feeling secure in oneself and the other person and Feeling alone when collaboration breaks down. CONCLUSION Consensus and coherence, or lack thereof, between district nurses and doctors affect how collaboration is experienced. Positive experiences are generated when the district nurse and the doctor share a holistic approach, while collaboration is experienced as dysfunctional when the doctor's decisions are not consistent with what the nurse judges to be beneficial to the patient. An understanding of how collaboration across long distances is experienced in rural areas is necessary to enhance collaboration.
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Affiliation(s)
- Ulla Näppä
- Department of Health Sciences, Mid Sweden University, Östersund, Sweden.
| | - Elin Nässén
- Department of Surgery, Östersund Hospital, Östersund, Sweden
| | - Idun Winqvist
- Department of Health Sciences, Mid Sweden University, Östersund, Sweden
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Jodaki K, Esmaeili M, Cheraghi MA, Mazaheri M. Striving to Keep a Clear Conscience by Going Above and Beyond: The Experiences of Intensive Care Unit Nurses. Crit Care Nurs Q 2023; 46:192-202. [PMID: 36823746 DOI: 10.1097/cnq.0000000000000452] [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: 02/25/2023]
Abstract
Working as a nurse in the critical care unit may involve ethical challenges including conflict of conscience. Literature provides very limited knowledge about intensive care unit (ICU) nurses' perception of conscience. Considering the influence of culture on the perception of conscience, it is important to study it in diverse contexts. This study aims were to explore the meaning of conscience and the impact of conscience on nurses' practice in the ICU. A qualitative research approach was used to answer the research question, and qualitative content analysis guided the study. A total of 17 interviews were conducted with ICU nurses. Data were collected through semistructured tools by using videoconferencing and face-to-face interviews. Data analysis resulted in the formation of 2 main categories and 7 subcategories. The main categories included understanding the conscience and unlimited efforts in caretaking as the path to a clear conscience. The category of understanding the conscience includes 3 subcategories of conscience as an intrinsic asset and internal observer, dynamicity of conscience, and conscience as the cornerstone of morality. Also, the category of unlimited efforts in caretaking as the path to a clear conscience consists of 4 subcategories including giving full attention to the patient, putting oneself in another's shoes, taking responsibility, and working beyond the job description. Conscience plays an essential role in providing the ethical care among ICU nurses. The ICU nurses felt that they need to go above and beyond to keep their conscience clear. Nurses expressed the importance of following the call of conscience at their workplace, which demanded unlimited efforts to achieve a clear conscience.
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Affiliation(s)
- Kurosh Jodaki
- School of Nursing & Midwifery, Iran University of Medical Sciences, Tehran, Iran (Dr Jodaki); Department of ICU, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran (Dr Esmaeili); Department of Nursing Management, School of Nursing and Midwifery, Tehran University of Medical Sciences and Health Sciences Phenomenology Association, Ministry of Health and Medical Education, Tehran, Iran (Dr Cheraghi); Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Department of Health Sciences, The Swedish Red Cross University College, Huddinge, Sweden (Dr Mazaheri)
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Huang J, Qi H, Zhu Y, Zhang M. Factors Influencing the Initiative Behavior of Intensive Care Unit Nurses toward End-of-Life Decision Making: A Cross-Sectional Study. J Palliat Med 2022; 25:1802-1809. [PMID: 35749724 DOI: 10.1089/jpm.2021.0640] [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] [Indexed: 01/04/2023] Open
Abstract
Background: Although the importance of intensive care unit (ICU) nurse initiative in end-of-life (EOL) decision making has been confirmed, there are few studies on the nurses' initiative in EOL situations. Objectives: To explore the role and mechanism of facilitators/barriers and perceived stress on the behavior of ICU nurses that initiate EOL decision making (i.e., initiative behavior). Design: This research adopted a cross-sectional descriptive design. Setting/Participants: A questionnaire composed of demographics, facilitators/barriers scale, perceived stress scale, and initiative behavior for EOL decision-making scale was used for registered ICU nurses in five tertiary general hospitals in Zhejiang Province, China. Results: The average score of the EOL decision initiative behavior was 5.54 on a range of 2-10. The results of correlation analysis indicated that the facilitators promote the initiative behavior, whereas the barriers interfere with initiative behavior. Facilitators/barriers in the EOL decision-making process significantly predicted the initiative behavior of ICU nurses in decision making (β = 0.698, p < 0.001). Facilitators/barriers had a significant indirect effect on the initiative behavior of ICU nurses through perceived stress. The 95% confidence interval was (-0.327 to -0.031), and the mediating effect of perceived stress accounted for 6.31% of the total effect. Conclusion: In the EOL context, the decision initiative of ICU nurses was at a medium level. Medical managers should implement intervention strategies based on the path that affects the initiative behavior of ICU nurses to reduce barriers and stress level in the decision-making process. That is, they should improve inter-team collaboration, nurse-patient communication, clarity of role responsibilities, and emotional support in dying situations to increase initiative and participation of ICU nurses in decision making.
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Affiliation(s)
- Jingying Huang
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Haiou Qi
- Nursing Department, and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Yiting Zhu
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Minyan Zhang
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
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Laurin AC, Martin P. Towards democratic institutions: Tronto's care ethics inspiring nursing actions in intensive care. Nurs Ethics 2022; 29:1578-1588. [PMID: 35726836 DOI: 10.1177/09697330221089093] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Care as a concept has long been central to the nursing discipline, and care ethics have consequently found their place in nursing ethics discussions. This paper briefly revisits how care and care ethics have been theorized and applied in the discipline of nursing, with an emphasis on Tronto's political view of care. Adding to the works of other nurse scholars, we consider that Tronto's care ethics is useful to understand caring practices in a sociopolitical context. We also contend that this vision can be used specifically to politicize nurses, by encouraging them to think critically about the context in which they work and how they can participate to change the status quo, notably by prompting the democratization of care in institutional settings. We illustrate this by demonstrating how moral distress that can occur with aggressive or futile treatments in the intensive care unit can be reduced if nurses are systematically included in the decision-making process. By showing some ways in which nursing political actions can begin to change the status quo as it pertains to futile treatments at the end of life, we can help empower nurses to strive to be included in political spaces and voice their concerns to have their professional needs met.
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Affiliation(s)
| | - Patrick Martin
- 4440Laval University, Quebec Heart and Lung Institute, Quebec, Canada
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7
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Paddley B, Espin S, Indar A, Rose D, Bookey-Bassett S. Communication of Code Status Escalation for Nurses and Physicians in the Intensive Care Unit: A Case Study. Can J Nurs Res 2022; 55:176-184. [PMID: 35538849 DOI: 10.1177/08445621221099117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Interprofessional teams working in the Intensive Care Unit (ICU) care for patients requiring varying degrees of life sustaining therapy. A patient's code status can help clinicians to understand the appropriate life support measures to deliver to patients in this setting. Members of the interprofessional team, such as physicians and nurses, can experience challenges related to communication when the code status is unclear. PURPOSE The purpose of this study was to explore how nurses and physicians in the ICU experience communication of code status escalations. METHODS A qualitative case study approach was used. Participants were physicians and nurses, working in the medical-surgical ICU of a large, urban academic hospital. Data were collected using semi-structured interviews, observations of health care rounds and a chart review. Data were analyzed using qualitative content analysis. RESULTS Thematic findings include: (1) engaging in an interprofessional discussion, (2) finding consistent documentation, (3) revisiting the code status, and (4) telling the patient story. The study findings also provide contextual information about participants' experiences of code status communication during the first wave (February 2020 to May 2020) of the COVID-19 pandemic. CONCLUSIONS The results of this study could inform standard communication frameworks or practices related to dissemination of code status decisions among members of the ICU team.
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Affiliation(s)
- Brianna Paddley
- Medical Surgical Intensive Care Unit, 10071St. Michael's Hospital, Toronto, Canada
| | - Sherry Espin
- Daphne Cockwell School of Nursing, 7984Ryerson University, Toronto, Canada
| | - Alyssa Indar
- Faculty of Health Sciences and Wellness, 10025Humber College, Toronto, Canada
| | - Don Rose
- Daphne Cockwell School of Nursing, 7984Ryerson University, Toronto, Canada
| | - Sue Bookey-Bassett
- Daphne Cockwell School of Nursing, 7984Ryerson University, Toronto, Canada
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8
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Relationship between End-of-Life Care Stress, Death Anxiety, and Self-Efficacy of Clinical Nurses in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031082. [PMID: 35162105 PMCID: PMC8833901 DOI: 10.3390/ijerph19031082] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 02/03/2023]
Abstract
In South Korea, the number of cancer patients continues to rise, indicating that nurses have greater access to end-of-life care in clinical settings. This study examined the relationship between the end-of-life care stress, death anxiety, and self-efficacy of clinical nurses in South Korea. A cross-sectional descriptive design was used. Participants were 124 nurses working in university hospitals. Data included the general characteristics of study participants, end-of-life care stress, death anxiety, and self-efficacy. Data were collected from February to March 2021. This study shows that the degrees of end-of-life care stress and death anxiety of clinical nurses in South Korea were higher than the median values. Married nurses had higher self-efficacy than unmarried, and there was a difference between bedside and administrative nurses’ self-efficacy. Nurses with no experience of end-of-life care nursing education had higher death anxiety than nurses with experience. The higher the end-of-life care stress of nurses, the higher the death anxiety. The study suggests that therapeutic and detailed educational programs to reduce end-of-life care stress and death anxiety of clinical nurses are needed, and experimental research to verify this. The results can contribute to countries as an additional and enriching reference.
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Hewitt J. End-of-life decisions, nurses, and the law. Aust Crit Care 2022; 35:1-2. [DOI: 10.1016/j.aucc.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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10
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Chan NPX, Chia JL, Ho CY, Ngiam LXL, Kuek JTY, Ahmad Kamal NHB, Hanifah Marican Abdurrahman AB, Ong YT, Chiam M, Lee ASI, Chin AMC, Mason S, Radha Krishna LK. Extending the Ring Theory of Personhood to the Care of Dying Patients in Intensive Care Units. Asian Bioeth Rev 2022; 14:71-86. [PMID: 34691261 PMCID: PMC8526529 DOI: 10.1007/s41649-021-00192-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022] Open
Abstract
It is evident, in the face of the COVID-19 pandemic that has physicians confronting death and dying at unprecedented levels along with growing data suggesting that physicians who care for dying patients face complex emotional, psychological and behavioural effects, that there is a need for their better understanding and the implementation of supportive measures. Taking into account data positing that effects of caring for dying patients may impact a physician's concept of personhood, or "what makes you, 'you'", we adopt Radha Krishna's Ring Theory of Personhood (RToP) to scrutinise the experiences of physicians working in intensive care units (ICU) using a fictional scenario that was inspired by real events. The impact of death and dying, its catalysts, internal constituents, external factors, dyssynchrony, and buffers, specific to ICU physicians, were identified and explored. Such a framework allows for ramifications to be considered holistically and facilitates the curation of strategies for conflict resolution. This evaluation of the RToP acknowledges the experience and wide-ranging effects it has on ICU physicians. As such, our findings provide insight into their specific needs and highlight the importance of support on a personal and organisational level. Although further research needs to be conducted, the RToP could serve as the basis for a longitudinal assessment tool supported by the use of portfolios or mentorship due to their provision of personalised, appropriate, specific, timely, accessible and long-term support.
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Affiliation(s)
- Natalie Pei Xin Chan
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Jeng Long Chia
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Chong Yao Ho
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Lisa Xin Ling Ngiam
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Joshua Tze Yin Kuek
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Nur Haidah Binte Ahmad Kamal
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Ahmad Bin Hanifah Marican Abdurrahman
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Min Chiam
- Division of Cancer Education , National Cancer Centre Singapore, Singapore
| | - Alexia Sze Inn Lee
- Division of Cancer Education , National Cancer Centre Singapore, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
- Cancer Research Centre, University of Liverpool, Liverpool, UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
- Division of Cancer Education , National Cancer Centre Singapore, Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
- Cancer Research Centre, University of Liverpool, Liverpool, UK
- Palliative Care Centre for Excellence in Research and Education (PalC), Singapore
- Centre for Biomedical Ethics, National University of Singapore , Singapore
- Duke-NUS Graduate Medical School, Singapore
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Palma A, Aliaga-Castillo V, Bascuñan L, Rojas V, Ihl F, Medel JN. An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile. Am J Crit Care 2022; 31:24-32. [PMID: 34972854 DOI: 10.4037/ajcc2022585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Deaths in the intensive care unit (ICU) represent an experience of suffering for patients, their families, and professionals. End-of-life (EOL) care has been added to the responsibilities of the ICU team, but the evidence supporting EOL care is scarce, and there are many barriers to implementing the clinical recommendations that do exist. OBJECTIVES To explore the experiences and perspectives of the various members of an ICU care team in Chile regarding the EOL care of their patients. METHODS A qualitative study was performed in the ICU of a high-complexity academic urban hospital. The study used purposive sampling with focus groups as a data collection method. A narrative analysis based on grounded theory was done. RESULTS Four discipline-specific focus groups were conducted; participants included 8 nurses, 6 nursing assistants, 8 junior physicians, and 6 senior physicians. The main themes that emerged in the analysis were emotional impact and barriers to carrying out EOL care. The main barriers identified were cultural difficulties related to decision-making, lack of interprofessional clinical practice, and lack of effective communication. Communication difficulties within the team were described along with lack of self-efficacy for family-centered communication. CONCLUSION These qualitative findings expose gaps in care that must be filled to achieve high-quality EOL care in the ICU. Significant emotional impact, barriers related to EOL decision-making, limited interprofessional clinical practice, and communication difficulties were the main findings cross-referenced.
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Affiliation(s)
- Alejandra Palma
- Alejandra Palma is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Verónica Aliaga-Castillo
- Verónica Aliaga-Castillo is a physical therapist, Departamento de Kinesiología, Facultad de Medicina, Univer sidad de Chile, Santiago, Chile
| | - Luz Bascuñan
- Luz Bascuñan is a psychologist, Departamento de Bioética y Humanidades Médicas, Facultad de Medicina, Universidad de Chile
| | - Verónica Rojas
- Verónica Rojas is a licensed nurse, Departamento de Medicina Interna Norte, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, and Proyecto Internacional de Investigación para la Humaniza ción de los Cuidados Intensivos (Proyecto HU-CI), España
| | - Fernando Ihl
- Fernando Ihl is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Juan Nicolás Medel
- Juan Nicolás Medel is a critical care physician, Departa mento de Medicina Interna Norte, Unidad de Pacientes Críti cos, Hospital Clínico Universidad de Chile
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Ćurković M, Brajković L, Jozepović A, Tonković D, Župan Ž, Karanović N, Borovečki A. End-of-Life Decisions in Intensive Care Units in Croatia-Pre COVID-19 Perspectives and Experiences From Nurses and Physicians. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:629-643. [PMID: 34554388 PMCID: PMC8459337 DOI: 10.1007/s11673-021-10128-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
Healthcare professionals working in intensive care units (ICUs) are often involved in end-of-life decision-making. No research has been done so far about these processes taking place in Croatian ICUs. The aim of this study was to investigate the perceptions, experiences, and challenges healthcare professionals face when dealing with end-of-life decisions in ICUs in Croatia. A qualitative study was performed using professionally homogenous focus groups of ICU nurses and physicians (45 in total) of diverse professional and clinical backgrounds at three research sites (Zagreb, Rijeka, Split). In total, six institutions at the tertiary level of healthcare were included. The constant comparative analysis method was used in the analysis of the data. Differences were found between the perceptions and experiences of nurses and physicians in relation to end-of-life decisions. Nurses' perceptions were more focused on the context and features of immediate care, while physicians' perceptions also included the wider sociocultural context. However, the critical issues these specific professional groups face when dealing with end-of-life decisions seem to overlap. A high variability of practices, both between individual practitioners and between different organizational units, was omnipresent. The lack of adequate legal, professional, and clinical guidelines was commonly expressed as one of the most critical source of difficulties.
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Affiliation(s)
- Marko Ćurković
- University Psychiatric Hospital Vrapče, Bolnička cesta 32, 10090, Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia
| | - Lovorka Brajković
- Department for Psychology, Faculty of Croatian Studies, University of Zagreb, Borongajska cesta 83d, 10000, Zagreb, Croatia
| | - Ana Jozepović
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia
| | - Dinko Tonković
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia
- Department of Anesthesiology, Reanimatology and Intensive care, University Hospital Center Zagreb, Kišpatićeva ulica 12, 10000, Zagreb, Croatia
| | - Željko Župan
- Department of Anesthesiology, University Hospital Center Rijeka, Krešimirova ulica 42, 51000, Rijeka, Croatia
- School of Medicine, University of Rijeka, Ulica Braće Branchetta 20/1, 51000, Rijeka, Croatia
| | - Nenad Karanović
- Department of Anesthesiology, University Hospital Center Split, Spinčićeva ulica 1, 21000, Split, Croatia
- School of Medicine, University of Split, Šoltanska ulica 2, 21000, Split, Croatia
| | - Ana Borovečki
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia.
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13
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Jensen HI, Halvorsen K, Jerpseth H, Fridh I, Lind R. Practice Recommendations for End-of-Life Care in the Intensive Care Unit. Crit Care Nurse 2021; 40:14-22. [PMID: 32476029 DOI: 10.4037/ccn2020834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices. CLINICAL RELEVANCE Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members. PURPOSE OF PAPER To provide recommendations for high-quality end-of-life care for patients and family members. CONTENT COVERED This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.
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Affiliation(s)
- Hanne Irene Jensen
- Hanne Irene Jensen is an associate professor at the Department of Anaesthesiology and Intensive Care, Vejle and Middelfart Hospitals, Vejle, Denmark, and the University of Southern Denmark, Odense, Denmark
| | - Kristin Halvorsen
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Heidi Jerpseth
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Isabell Fridh
- Isabell Fridh is an associate professor at the Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden
| | - Ranveig Lind
- Ranveig Lind is an associate professor at UiT, the Arctic University of Norway, and a research nurse in the intensive care unit at University Hospital of North Norway, Tromsø, Norway
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Abuhammad S, Muflih S, Alzoubi KH, Gharaibeh B. Nursing and PharmD Undergraduate Students' Attitude Toward the "Do Not Resuscitate" Order for Children with Terminally Ill Diseases. J Multidiscip Healthc 2021; 14:425-434. [PMID: 33658789 PMCID: PMC7917390 DOI: 10.2147/jmdh.s298384] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Nurses and Doctor of Pharmacy (pharmD) must communicate and properly documented the do not resuscitate orders for terminally ill children and their relatives. They also have to offer excellent care including more family support, assisting the child with terminally ill disease in passing on peacefully, and preventing unnecessary cardiopulmonary resuscitation. This research was aimed to survey attitudes of nursing and pharmD undergraduate students about the "do not resuscitate" order for children with terminally ill diseases. METHODS A cross-sectional correlational design was used to study the correlation between attitude toward DNR and demographic variables. More than 400 nursing and pharmD students from Jordan University of Science and Technology were recruited in this study. All the participating students were e-mailed information regarding the study, including the web survey link. RESULTS The results showed that there was a significant difference in perception toward do not resuscitate order between nursing and pharmD students (p ≤ 0.05). The pharmD students had more positive attitude toward do not resuscitate than the nursing students. Approximately, 60% of the nursing and pharmD students would disclose the need for the do not resuscitate order for children with terminally ill diseases Demographic variables were not associated with the perception toward do not resuscitate orders (p ≥ 0.05). CONCLUSION This study showed that Jordanian nursing and pharmD students are willing to learn more about different aspects of do not resuscitate orders for terminally ill children. Analyzing their responses to many items showed their misconception about do not resuscitate orders for terminally ill children.
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Affiliation(s)
- Sawsan Abuhammad
- Department of Maternal and Child Health, Jordan University of Science and Technology, Irbid, 22110, Jordan,Correspondence: Sawsan Abuhammad Email
| | - Suhaib Muflih
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Besher Gharaibeh
- Department of Adult Health, Jordan University of Science and Technology, Irbid, 22110, Jordan
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Kuek JTY, Ngiam LXL, Kamal NHA, Chia JL, Chan NPX, Abdurrahman ABHM, Ho CY, Tan LHE, Goh JL, Khoo MSQ, Ong YT, Chiam M, Chin AMC, Mason S, Krishna LKR. The impact of caring for dying patients in intensive care units on a physician's personhood: a systematic scoping review. Philos Ethics Humanit Med 2020; 15:12. [PMID: 33234133 PMCID: PMC7685911 DOI: 10.1186/s13010-020-00096-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/11/2020] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Supporting physicians in Intensive Care Units (ICU)s as they face dying patients at unprecedented levels due to the COVID-19 pandemic is critical. Amidst a dearth of such data and guided by evidence that nurses in ICUs experience personal, professional and existential issues in similar conditions, a systematic scoping review (SSR) is proposed to evaluate prevailing accounts of physicians facing dying patients in ICUs through the lens of Personhood. Such data would enhance understanding and guide the provision of better support for ICU physicians. METHODS An SSR adopts the Systematic Evidenced Based Approach (SEBA) to map prevailing accounts of caring for dying patients in ICUs. To enhance the transparency and reproducibility of this process, concurrent and independent use of tabulated summaries, thematic analysis and directed content analysis (Split Approach) is adopted. RESULTS Eight thousand three hundred fifty-eight abstracts were reviewed from four databases, 474 full-text articles were evaluated, 58 articles were included, and the Split Approach revealed six categories/themes centered around the Innate, Individual, Relational and Societal Rings of Personhood, conflicts in providing end of life care and coping mechanisms employed. CONCLUSION This SSR suggests that caring for dying patients in ICU impacts how physicians view their personhood. To resolve conflicts within individual concepts of personhood, physicians use prioritization, reframing and rely on accessible, personalized support from colleagues to steer coping strategies. An adapted form of the Ring Theory of Personhood is proposed to direct timely personalized, appropriate and holistic support.
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Affiliation(s)
- Joshua Tze Yin Kuek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Lisa Xin Ling Ngiam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Nur Haidah Ahmad Kamal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Jeng Long Chia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Natalie Pei Xin Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Ahmad Bin Hanifah Marican Abdurrahman
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Chong Yao Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Lorraine Hui En Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Jun Leng Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Michelle Shi Qing Khoo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Singapore, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK.
- Duke-NUS Graduate Medical School, Singapore, Singapore.
- Centre for Biomedical Ethics, National University of Singapore, Singapore, Singapore.
- PalC, The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore.
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Huang J, Yang L, Qi H, Zhu Y, Zhang M. Psychometric properties of the Chinese version of the End-of-Life Decision-Making and Staff Stress Questionnaire. Int J Clin Health Psychol 2020; 20:271-281. [PMID: 32994800 PMCID: PMC7501447 DOI: 10.1016/j.ijchp.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/03/2020] [Indexed: 11/18/2022] Open
Abstract
Background/objective The goal of this study is to establish a Chinese version of the End-of-Life Decision Making and Associated Staff Stress Questionnaire to assess its reliability and validity. Method A sample of 119 Intensive Care Unit physicians and 485 nurses in China completed the questionnaire, along with questionnaires assessing motional exhaustion subscale, Stress Overload Scale, and other variables associated with end-of-life decision. Results Seven factors obtained via exploratory factor analysis could explain 70.61% of the total variance. Confirmatory factor analysis demonstrated an acceptable model fit with Root Mean Square Error of Approximation (RMSEA) being .078 and Standardized Root Mean Square Residual (SRMR) being .066. Validity evidence based on relationships with other variables was provided by positive or negative correlations between the questionnaire subscales and emotional exhaustion, stress overload, and other variables associated with end-of-life decision. The average content validity index was .96. The Cronbach’s α and test–retest reliability was outstanding. Conclusions The Chinese version of the End-of-Life Decision Making and Associated Staff Stress Questionnaire is a reliable and valid instrument for measuring the facilitators and hinders to facilitate the end-of-life decision-making, communication and the associated pressure perceived by relevant Intensive Care Unit medical staff among the Chinese population.
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Affiliation(s)
- Jingying Huang
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, China
| | - Lili Yang
- Nursing Education Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, China
- Corresponding author at: Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 Qingchun East Road, Hangzhou, Zhejiang Province, 310016 China.
| | - Haiou Qi
- Nursing Education Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, China
| | - Yiting Zhu
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, China
| | - Minyan Zhang
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, China
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Choudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020; 24:404-408. [PMID: 32863631 PMCID: PMC7435104 DOI: 10.5005/jp-journals-10071-23454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Early initiation of end-of-life (EOL) care in terminally ill patients can reduce the administration of unnecessary medications, minimize laboratory and radiological investigations, and avoid procedures that can provoke untoward complications without substantial benefits. This retrospective observational study was performed to compare early vs late initiation of EOL care in terminally ill ICU patients after the recognition of treatment futility. Materials and methods The medical records of all patients who were considered to be terminally ill any time after ICU admission between January 2014 and December 2018 were extracted from the ICU database. The patients who were recognized for treatment futility were eligible for inclusion. The patients who were already on EOL care prior to the ICU admission or whose diagnosis was unconfirmed were excluded from the study. The treatment futility was a subjective decision jointly undertaken by the primary physician and the intensivist based upon the disease stage and the available therapeutic options. The commencement of EOL care after recognition of treatment futility was divided into (a) early group (EG)—within 48 hours of decision of treatment futility and (b) late group (LG)—after 48 hours of recognition of treatment futility. Both the groups were compared for (a) ICU mortality, (b) length of ICU stay, (c) number of antibiotic-free days, (d) number of ventilator-free days, (e) number of medical and/or surgical interventions (insertion of central lines, drains, IABP, etc.), (f) number of blood and radiological investigations, and (g) satisfaction level of family members. Results Out of 107 terminally ill patients with diagnosis of treatment futility, 64 patients (59.8%) underwent early initiation of EOL against delayed initiation in 43 (40.2%) patients (1.3 ± 0.4 days vs 5.1 ± 1.6 days; p = 0.01). The patients in the late initiation group were younger in age (49 ± 3.6 years vs 66 ± 5.3 years; p = 0.03). The number of antibiotic-free days was higher in the early initiation group (12 ± 5.2 days vs 6 ± 7.5; p = 0.02). The number of medical and surgical interventions was lesser in the early initiation group (3.0 ± 0.7 episodes vs 12 ± 3.9 episodes; p = 0.007). The late initiation of EOL was caused by prognostic dilemma (30.2%), reluctance of the family members (44.1%), ambivalence of the primary physician (18.6%), and hesitancy of the intensivist (6.9%). The satisfaction level of the family members was similar in both the groups. Conclusion We conclude that delayed initiation of EOL care in terminally ill ICU patients after recognition of treatment futility can increase the antibiotic usage and medical and/or surgical interventions with no effect on the satisfaction level of the family members. How to cite this article Choudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(6):404–408.
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Affiliation(s)
- Anirban H Choudhuri
- Department of Anesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ankit Sharma
- Department of Anesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Rajeev Uppal
- Department of Anesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Flannery L, Peters K, Ramjan LM. The differing perspectives of doctors and nurses in end-of-life decisions in the intensive care unit: A qualitative study. Aust Crit Care 2019; 33:311-316. [PMID: 31679985 DOI: 10.1016/j.aucc.2019.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 08/20/2019] [Accepted: 08/28/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND End-of-life (EOL) decision-making in the intensive care unit (ICU) can be emotionally challenging for both doctors and nurses, who are sometimes placed in difficult positions where they are required to make decisions on behalf of patients. With an ageing population and advances in medical technology, there is an increase in such decisions being made in ICUs. OBJECTIVES The objective of this study was to explore the perspectives of doctors and nurses involved in the EOL decision-making process in an ICU. METHODS This study used a qualitative methodology based on naturalistic inquiry. Intensive care nurses and doctors from a large Sydney metropolitan public hospital were purposively selected, and data saturation was reached after a total of eight nurses and four doctors were interviewed. Data were collected through semistructured interviews, either face-to-face or over the telephone. Interviews were then transcribed verbatim, and themes were identified and coded through a line-by-line analysis of each transcript (manual thematic analysis). FINDINGS The findings revealed two main themes: 'Doctors' and nurses' roles in decision-making' and 'Managing family expectations'. These themes highlighted key differences in decision-making processes, in that doctors tended to aim to meet the family's needs, while the nurses tended to advocate on behalf of the patient and what they interpreted as the patient's best interests. Furthermore, nurses tended to feel undervalued in decision-making during family conferences, when in reality, the doctors were making decisions based on all information obtained, primarily from nursing staff. CONCLUSIONS EOL decision-making is complex and affects doctors and nurses involved in different ways. More emphasis on interprofessional education and collaboration between the two disciplines may enhance future decision-making processes.
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Affiliation(s)
- Liz Flannery
- Western Sydney University, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Kath Peters
- Western Sydney University, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Lucie M Ramjan
- Western Sydney University, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW, 2751, Australia.
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Pettersson M, Höglund AT, Hedström M. Perspectives on the DNR decision process: A survey of nurses and physicians in hematology and oncology. PLoS One 2018; 13:e0206550. [PMID: 30462673 PMCID: PMC6248939 DOI: 10.1371/journal.pone.0206550] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/15/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION In cancer care, do-not-resuscitate (DNR) decisions are made frequently; i.e., decisions not to start the heart in the event of a cardiac arrest. A DNR decision can be a complex process involving nurses and physicians with a wide variety of experiences and perspectives. Previous studies have shown different perceptions of the DNR decision process among nurses and physicians, e.g. concerning patient involvement and information. DNR decisions have also been reported to be unclear and documentation inconsistent. OBJECTIVE The aim was to investigate how important and how likely to happen nurses and physicians considered various aspects of the DNR decision process, regarding participation, information and documentation, as well as which attributes they found most important in relation to DNR decisions. METHODS A descriptive correlational study using a web survey was conducted, including 132 nurses and 84 physicians working in hematology and oncology. RESULTS Almost half of the respondents reported it not likely that the patient would be involved in the decision on DNR, and 21% found it unimportant to inform patients of the DNR decision. Further, 57% reported that providing information to the patient was important, but only 21% stated that this was likely to happen. There were differences between nurses and physicians, especially regarding participation by and information to patients and relatives. The attributes deemed most important for both nurses and physicians pertained more to medical viewpoints than to ethical values, but a difference was found, as nurses chose patient autonomy as the most important value, while physicians rated non-maleficence as the most important value in relation to DNR decisions. CONCLUSION Nurses and physicians need to be able to talk openly about their different perspectives on DNR decisions, so that they can develop a deeper understanding of the decisions, especially in cases where they disagree. They should also be aware that what they think is important is not always likely to happen. The organization needs to support such discussions through providing an environment that allows ethical discussions on regular basis. Patients and relatives will also benefit from receiving the same information from all caregivers.
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Affiliation(s)
- Mona Pettersson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Anna T. Höglund
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Mariann Hedström
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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Willemse S, Smeets W, van Leeuwen E, Janssen L, Foudraine N. Spiritual Care in the ICU: Perspectives of Dutch Intensivists, ICU Nurses, and Spiritual Caregivers. JOURNAL OF RELIGION AND HEALTH 2018; 57:583-595. [PMID: 28801715 PMCID: PMC5854753 DOI: 10.1007/s10943-017-0457-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Since there are no scientific data available about the role of spiritual care (SC) in Dutch ICUs, the goal of this quantitative study was twofold: first, to map the role of SC as a part of daily adult ICU care in The Netherlands from the perspective of intensivists, ICU nurses, and spiritual caregivers and second, to identify similarities and differences among these three perspectives. This study is the quantitative part of a mixed methods approach. To conduct empirical quantitative cohort research, separate digital questionnaires were sent to three different participant groups in Dutch ICUs, namely intensivists, ICU nurses, and spiritual caregivers working in academic and general hospitals and one specialist oncology hospital. Overall, 487 participants of 85 hospitals (99 intensivists, 290 ICU nurses, and 98 spiritual caregivers) responded. The majority of all respondents (>70%) considered the positive effects of SC provision to patients and relatives: contribution to mental well-being, processing and channeling of emotions, and increased patient and family satisfaction. The three disciplines diverged in their perceptions of how SC is currently evolving in terms of information, assessment, and provision. Nationwide, SC is not implemented in daily ICU care. The majority of respondents, however, attached great importance to interdisciplinary collaboration. In their view SC contributes positively to the well-being of patients and relatives in the ICU. Further qualitative research into how patients and relatives experience SC in the ICU is required in order to implement and standardize SC as a scientifically based integral part of daily ICU care.
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Affiliation(s)
- Suzan Willemse
- Spiritual Care Department, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
| | - Wim Smeets
- Department of Spiritual and Pastoral Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, The Netherlands
| | - Evert van Leeuwen
- Department of Ethics, Philosophy and History of Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, The Netherlands
| | - Loes Janssen
- Department of Clinical Epidemiology, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
| | - Norbert Foudraine
- Department of Critical Care, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
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Baliza MF, Bousso RS, Poles K, Santos MRD, Silva L, Paganini MC. [Factors influencing Intensive Care Units nurses in end-of-life decisions]. Rev Esc Enferm USP 2016; 49:572-9. [PMID: 26353093 DOI: 10.1590/s0080-623420150000400006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To identify the factors that influence the Intensive Care Unit nurse in the decision-making process in end-of-life situations. METHOD Ethnographic case study, which used the theoretical framework of medical anthropology. Data were collected through semi-structured interviews with 10 nurses. RESULTS The inductive thematic analysis enabled us to identify four themes:The cultural context of the Intensive Care Unit: decision-making in situations of end-of-life; Beliefs and subjectivity of care in end-of-life situations; Professional experience and context characteristics of end-of-life care situations; and Humanization practices in end-of-life situations: the patient and family centered care. CONCLUSION Professional maturity, the ability to transmit information and the ability to negotiate are directly related to the inclusion of nurses in the decision-making process.
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Affiliation(s)
| | - Regina Szylit Bousso
- Departamento de Enfermagem Materno-Infantil e Psiquiátrica, Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, BR
| | - Kátia Poles
- Universidade Federal de São João Del-Rei, São João Del-Rei, MG, BR
| | | | - Lucía Silva
- Departamento de Enfermagem Materno-Infantil e Psiquiátrica, Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, BR
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Velarde-García JF, Luengo-González R, González-Hervias R, Cardenete-Reyes C, Alvarado-Zambrano G, Palacios-Ceña D. Facing death in the intensive care unit. A phenomenological study of nurses' experiences. Contemp Nurse 2016; 52:1-12. [PMID: 27225999 DOI: 10.1080/10376178.2016.1194725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Nurses may experience considerable emotional burden due to patient death, in part as they are generally the professionals who have the most contact with patients. OBJECTIVE To describe the lived experience of Spanish nurses working in intensive care units regarding how they face the death of their patients. METHODS A qualitative phenomenological study was performed. A purposeful sample was used. The data collection strategies used included in-depth unstructured and semi-structured interviews, field notes and personal documents. Afterwards, data were analyzed using the Giorgi proposal. RESULTS 22 nurses participated, with a mean age of 40.8 years and a mean work experience of 13.8 years. Three themes were identified: 1) dealing with expectations of recovery, 2) accepting the age of death, and 3) experiencing emotional attachment. CONCLUSIONS Nurses in intensive care units report a great emotional burden derived from patients death, Support programs for nurses should be organised within these units.
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Affiliation(s)
| | - Raquel Luengo-González
- a Department of Nursing , Spanish Red Cross , Avda. Reina Victoria n°28, Madrid 28003 , Spain
| | - Raquel González-Hervias
- a Department of Nursing , Spanish Red Cross , Avda. Reina Victoria n°28, Madrid 28003 , Spain
| | - César Cardenete-Reyes
- b Department of Nursing , Universidad Europea , Calle Tajo s/n, Villaviciosa de Odon, Madrid 28670 , Spain
| | - Gema Alvarado-Zambrano
- c Servicio Madrileño de Salud, Nursing Division , Hospital Universitario La Paz , Paseo de la Castellana, 261, Madrid 28046 , Spain
| | - Domingo Palacios-Ceña
- d Department of Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine , Universidad Rey Juan Carlos , Avenida Atenas s/n. 28922. Alcorcn, Madrid . Spain
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Flannery L, Ramjan LM, Peters K. End-of-life decisions in the Intensive Care Unit (ICU) – Exploring the experiences of ICU nurses and doctors – A critical literature review. Aust Crit Care 2016; 29:97-103. [DOI: 10.1016/j.aucc.2015.07.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022] Open
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Bjørshol CA, Sollid S, Flaatten H, Hetland I, Mathiesen WT, Søreide E. Great variation between ICU physicians in the approach to making end-of-life decisions. Acta Anaesthesiol Scand 2016; 60:476-84. [PMID: 26941116 DOI: 10.1111/aas.12640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/07/2015] [Accepted: 09/11/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- C. A. Bjørshol
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - S. Sollid
- Department of Research and Development; Norwegian Air Ambulance Foundation; Drøbak Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
| | - H. Flaatten
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Anaesthesiology and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - I. Hetland
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
| | - W. T. Mathiesen
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
| | - E. Søreide
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
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Konstantara E, Vandrevala T, Cox A, Creagh-Brown BC, Ogden J. Balancing professional tension and deciding upon the status of death: Making end-of-life decisions in intensive care units. Health Psychol Open 2016; 3:2055102915622928. [PMID: 28070383 PMCID: PMC5193261 DOI: 10.1177/2055102915622928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This study investigated how intensivists make decisions regarding withholding and withdrawing treatment for patients at the end of their lives. This involved completing in-depth interviews from two sites of the South of England, United Kingdom by twelve intensivists. The data collected by these intensivists were analysed using thematic analysis. This resulted in the identification of three themes: intensivists' role, treatment effectiveness, and patients' best interest. Transcending these were two overarching themes relating to the balance between quantity and quality of life, and the intensivists' sense of responsibility versus burden. The results are considered in terms of making sense of death and the role of beliefs in the decision-making process.
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Park JH, Koh SO, Cho JS, Na S. Evaluation of Informed Consent for Withholding and Withdrawal of Life Support in Korean Intensive Care Units. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Hartog CS, Schwarzkopf D, Riedemann NC, Pfeifer R, Guenther A, Egerland K, Sprung CL, Hoyer H, Gensichen J, Reinhart K. End-of-life care in the intensive care unit: a patient-based questionnaire of intensive care unit staff perception and relatives' psychological response. Palliat Med 2015; 29:336-45. [PMID: 25634628 DOI: 10.1177/0269216314560007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Christiane S Hartog
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Daniel Schwarzkopf
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Niels C Riedemann
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Ruediger Pfeifer
- Department of Internal Medicine I, Jena University Hospital, Jena, Germany
| | | | - Kati Egerland
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Heike Hoyer
- Institute of Medical Statistics, Information Sciences and Documentation, Jena University Hospital, Jena, Germany
| | - Jochen Gensichen
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany Department of General Medicine, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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Abstract
PURPOSE OF REVIEW Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. RECENT FINDINGS DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. SUMMARY There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes.
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Abstract
The interdisciplinary approach is a cornerstone of a well-functioning pediatric palliative care team. These teams are most often available as an inpatient consultation service, are composed of professionals representing multiple disciplines, and are used during the illness course of a child with life-threatening and chronic complex conditions, especially during challenging health care decision-making near end of life. This article reviews the current structure of the palliative care team, explores opportunities for inclusion of other vital team members, and proactively identifies the challenges that may occur when involving more providers in a child's and family's care.
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Affiliation(s)
- Monica Ogelby
- Pediatric Palliative Care Program, Department of Vermont Health Access, State of Vermont, 312 Hurricane Lane, Suite 201, Williston, VT 05495, USA
| | - Richard D Goldstein
- Pediatric Advanced Care Team, Boston Children's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA.
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The mourning after: the potential for critical care nurses to improve family outcome and experience in end of life care. Aust Crit Care 2014; 27:155-6. [PMID: 24933035 DOI: 10.1016/j.aucc.2014.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/06/2014] [Indexed: 11/20/2022] Open
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Granero-Molina J, Díaz Cortés MM, Márquez Membrive J, Castro-Sánchez AM, López Entrambasaguas OM, Fernández-Sola C. Religious faith in coping with terminal cancer: what is the nursing experience? Eur J Cancer Care (Engl) 2013; 23:300-9. [PMID: 24661394 DOI: 10.1111/ecc.12150] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2013] [Indexed: 01/12/2023]
Abstract
This qualitative study describes nurses' reports on the role played by religious faith in the care of patients with terminal cancer. Using Gadamer's philosophical hermeneutics and C. Roy's adaptation model as a base, in-depth interviews were carried out with 23 nurses who had cared for patients with terminal cancer for at least 6 months. Three main themes emerged when a Gadamerian-based hermeneutic research method was applied: faith facilitates the coping process in cases of terminal cancer, faith hinders the coping process in cases of terminal cancer and terminal illness impacts faith. The lack of univocal results indicates that the role of faith in coping with death is essentially practical, individualised and changeable. The nurse-patient relationship can help to determine the spiritual needs of cancer patients at the end of life. This source of knowledge held by the nurse, together with the rest of the multidisciplinary team, can help to improve end-of-life care.
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Affiliation(s)
- J Granero-Molina
- Department of Nursing, Physiotherapy and Medicine, University of Almería, Almería, Spain
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Peter E, Mohammed S, Simmonds A. Narratives of aggressive care: Knowledge, time, and responsibility. Nurs Ethics 2013; 21:461-72. [PMID: 24106260 DOI: 10.1177/0969733013502804] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While witnessing and providing aggressive care have been identified as predominant sources of moral distress, little is known about what nurses "know" to be the "right thing to do" in these situations. RESEARCH OBJECTIVES The purpose of this study was to explore what nurses' moral knowledge is in situations of perceived overly aggressive medical care. RESEARCH DESIGN A critical narrative approach was used. PARTICIPANTS A total of 15 graduate nursing students from various practice areas participated. FINDINGS Four narrative types were identified, including "Wait and see: medical uncertainty," "Deflected responsibilities to respond to dying, death, or futility," "Divergent understandings, responsibilities, and temporalities," and "Privileged medical understandings and responsibilities." DISCUSSION The knowledge of differentially situated persons is acknowledged in dissimilar ways, the time required to determine that enough has been done is perceived differently, and how moral responsibilities are understood also varies. CONCLUSIONS A better understanding of how social roles influence how time, knowledge, and responsibility are related to the provision of aggressive care is needed.
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