Barriers, enablers and challenges to initiating end-of-life care in an Australian intensive care unit context

Practice recommendations for culturally sensitive communication at the end of life in intensive care: A modified eDelphi study

BACKGROUND

Clinicians need specific knowledge and skills to effectively communicate with patients and their family when a patient is dying in the ICU. End-of-life communication is compounded by language differences and diverse cultural and religious beliefs.

AIM

The aim was to develop and evaluate practice recommendations for culturally sensitive communication at the end of life.

METHOD

Modified two-round eDelphi study. An Australian national sample of 58 expert ICU clinicians of nursing and medical backgrounds participated in an online survey to rate the relevance of 13 practice recommendations. Ten clinicians participated in a subsequent expert panel interview to provide face validity and comprehensive details about the practical context of the recommendations. Survey data were analysed using descriptive statistics, interview data using deductive content analysis.

RESULTS

All 13 practice recommendations achieved item content validity index (I-CVI) above 0.8, and scale content validity index (S-CVI) of 0.95, indicating sufficient consensus. Recommendations prioritising use of professional interpreters and nurse involvement in family meetings achieved near perfect agreement amongst participants. Recommendations to facilitate family in undertaking cultural, spiritual and religious rituals and customs, advocate for family participation in treatment limitation discussions, and clinician access to professional development opportunities about culturally sensitive communication also achieved high level consensus.

CONCLUSION

These practice recommendations provide guidance for ICU clinicians in their communication with patients and families from culturally diverse backgrounds.

IMPLICATIONS FOR CLINICAL PRACTICE

Clinicians want practice recommendations that are understandable and broadly applicable across diverse ICU contexts. The high consensus scores confirm these practice recommendations are relevant and feasible to clinicians who provide end-of-life care for patients and their family members. The recommendations also provide clear guidance for ICU leaders, managers and organisational policy makers.

The impact of COVID-19 on the provision of bereavement support in Australian intensive care units: A national survey

BACKGROUND

Bereavement support is a vital part of caring for families when a patient dies in the intensive care unit (ICU). Previous research has demonstrated that while many ICUs provide some informal aspects of bereavement care, formalised follow-up programmes are uncommon. The impacts of COVID-19 on ICU-based bereavement support are currently unknown.

OBJECTIVES

The objectives of this study were to explore the current provision of bereavement support in Australian ICUs and identify the impacts of the COVID-19 pandemic on these services.

METHODS

A cross-sectional exploratory web-based survey was used. The survey was distributed to one senior nurse in each public and private adult, paediatric, and neonatal ICU in Australia between April and July 2022. Descriptive statistics and reflexive thematic analysis were used to analyse the data. Ethical approval was received from La Trobe University.

RESULTS

One hundred and four ICUs from 82 hospitals responded to the survey, with 36 units reporting a formal bereavement follow-up service. When compared to prepandemic levels, almost all of the common bereavement care practices explored in the survey were significantly reduced during the COVID-19 pandemic. Open-ended responses also demonstrated significant impacts of COVID-19 on bereavement care provision, particularly related to Restricted family togetherness, Logistical Challenges, and Impacts on Staff. Staff members reported adjusting care provision in response to these challenges by exploring Alternative family communications, Facilitation of family togetherness, and Increasing familysupports.

CONCLUSIONS

Many of the common elements of ICU-based bereavement care were significantly reduced during the COVID-19 pandemic. In addition, the number of formal bereavement follow-up services in Australian ICUs remains largely unchanged since 2015. Ongoing research is needed to explore the long-term effects of these changes on staff and family wellbeing and on ongoing provision of ICU-based bereavement support.

Healthcare Staff Perceptions Regarding Barriers and Enablers to End-of-Life Care Provision in Non-Palliative Care Settings in Ghana: A Multicentre Qualitative Study

The projected rise in health-related suffering warrants the integration of palliative care across all health systems. For traditionally non-palliative care settings, barriers and enablers to palliative care integration remain poorly understood. This study sought to explore these barriers and enablers in the Emergency and Burn Units across two healthcare facilities in the middle belt of Ghana using qualitative description. Thirty-nine healthcare staff comprising 20 burn care staff and 19 ED staff were purposively recruited and interviewed. Interviews were transcribed following which thematic analysis was performed inductively. Two themes and six subthemes emerged from the data. The Ghanaian socio-cultural context often crippled the discussion of death and dying. Overall, there is a perceived tension between emergency/burns and end-of-life care. Opportunities however exist to improve the situation which will require more work regarding curricula improvement, providing avenues for professional development, culturally sensitive communication, and identifying strategies of engaging relatives.

Communication strategies for expressing empathy during family-clinician conversations in the intensive care unit: A mixed methods study

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.

What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries? A systematic review

BACKGROUND

As many patients are spending their last days in critical care units, it is essential that they receive appropriate end-of -life care. However, cultural differences, ethical dilemmas and preference practices can arise in the intensive care settings during the end of life. Limiting therapy for dying patients in intensive care is a new concept with no legal definition and therefore there may be confusion in interpreting the terms 'no resuscitation' and 'comfort care' among physicians in Middle East. Therefore, the research question is 'What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries?'

METHODS

The authors conducted a comprehensive systematic literature review using five electronic databases. We identified primary studies from Medline, Embase, CINAHL, Psycinfo and Scopus. The team assessed the full-text papers included in the review for quality using the Joanna Briggs Institute checklist (JBI). We completed the literature search on the first of April 2022 and was not limited to a specific period.

RESULTS

We identified and included nine relevant studies in the review. We identified five main themes as end-of-life care challenges and/or facilitators: organisational structure and management, (mis)understanding of end-of-life care, spirituality and religious practices for the dying, communication about end-of-life care, and the impact of the ICU environment.

CONCLUSIONS

This review has reported challenges and facilitators to providing end-of-life care in ICU and made initial recommendations for improving practice. These are certainly not unique to the Middle East but can be found throughout the international literature. However, the cultural context of Middle East and North Africa countries gives these areas of practice special challenges and opportunities. Further observational research is recommended to confirm or modify the results of this review, and with a view to developing and evaluating comprehensive interventions to promote end-of-life care in ICUs in the Middle East.

Community engagement approaches for malaria prevention, control and elimination: a scoping review

INTRODUCTION

Globally malaria programmes have adopted approaches to community engagement (ACE) to design and deliver malaria interventions. This scoping review aimed to understand, map, and synthesise intervention activities guided by ACE and implemented by countries worldwide for the prevention, control and elimination of malaria.

METHODS

Three databases (Web of Science, Proquest, and Medline) were searched for peer-reviewed, primary studies, published in English between 1 January 2000 and 31 December 2022. Advanced Google was used to search for grey literature. The five levels of the International Association for Public Participation were used to categorise ACE - (1) Inform, (2) Consult, (3) involve, (4) Collaborate, and (5) Co-lead. Intervention activities were categorised as health education (HE), and/or health services (HS), and/or environmental management (EM). Outcomes were collected as knowledge, attitude, behaviour, help-seeking, health and HS and environment. Enablers and barriers were identified. Malaria intervention phases were categorised as (1) prevention (P), or (2) control (C), or (3) prevention and control (PC) or prevention, control and elimination (PCE).

RESULTS

Seventy-five studies were included in the review. Based on ACE levels, most studies were at the inform (n=37) and involve (n=26) level. HE (n=66) and HS (n=43) were the common intervention activities. HE informed communities about malaria, its prevention and vector control. EM activities were effective when complemented by HE. Community-based HS using locally recruited health workers was well-accepted by the community. Involvement of local leaders and collaboration with local stakeholders can be enablers for malaria intervention activities.

CONCLUSION

Involving local leaders and community groups in all stages of malaria prevention programmes is vital for successful interventions. Key elements of successful ACE, that is, consult, collaborate, and co-lead were under-represented in the literature and require attention. National programes must consult and collaborate with community stakeholders to develop ownership of the interventions and eventually co-lead them.

Nurses' perceptions of the obstacles and supportive behaviors of end-of-life care in intensive care units

PURPOSE

This study examined the Jordanian registered nurses' perceptions of the obstacles and supportive behaviors of End-of-Life Care in Intensive Care Units and examined the differences in the concepts based on the samples' demographics.

METHODS

A cross-sectional and comparative study was conducted using a convenience sample of 230 Intensive Care Unit registered nurses in Jordan. Data were analyzed descriptively, and differences were measured using the independent sample t-test, the one-way Analysis of Variance, and Scheffe's post hoc test.

RESULTS

The registered nurses' scored moderately on obstacles (74.98 ± 14.54) and supportive behaviors (69.22 ± 4.84). The commonly perceived obstacle and supportive behaviors to End-of-Life Care in Intensive Care Units s were reported. The perceived obstacles differ based on the registered nurses' certification as an Intensive Care Units nurse (3.04 ± 0.58 vs. 2.74 ± 0.49, p = 0.008), type of Intensive Care Unit (3.28 ± 0.34 vs. 2.86 ± 0.62, p < 0.001), type of facility (3.16 ± 0.59 vs. 2.77 ± 0.61, p < 0.001), number of beds in the unit (3.07 ± 0.48 vs. 2.69 ± 0.48, p = 0.020), and the number of hours worked per week (3.06 ± 0.56 vs. 2.81 ± 0.60, p = 0.005). In contrast, supportive behaviors only differ based on the registered nurses' age (3.22 ± 0.69 vs. 2.90 ± 0.64, p = 0.019).

CONCLUSIONS

The common End-of-Life Care perceived obstacle in Intensive Care Units was the lack of nursing education and training regarding the studies concept, which warrants immediate intervention such as on-job training. The common End-of-Life Care perceived supportive behavior in Intensive Care Units was when family members accepted that the patient was dying when nurses offered support to family members; motivational interventions are needed to sustain such behavior. Differences in the perceived obstacles and supportive behaviors should be leveraged for the benefit of patients, nurses, and hospitals.

Barriers for Adult Patients to Access Palliative Care in Hospitals: A Mixed Methods Systematic Review

BACKGROUND

Access to palliative care services is variable, and many inpatients do not receive palliative care. An overview of potential barriers could facilitate the development of strategies to overcome factors that impede access for patients with palliative care needs.

AIM

To review the current evidence on barriers that impair, delay, or prohibit access to palliative care for adult hospital inpatients.

DESIGN

A mixed methods systematic review was conducted using an integrated convergent approach and thematic synthesis (PROSPERO ID: CRD42021279477).

DATA SOURCES

The Cochrane Library, MEDLINE, CINAHL, and PsycINFO were searched from 10/2003 to 12/2020. Studies with evidence of barriers for inpatients to access existing palliative care services were eligible and reviewed.

RESULTS

After an initial screening of 3,359 records and 555 full-texts, 79 studies were included. Thematic synthesis yielded 149 access-related phenomena in 6 main categories: 1) Sociodemographic characteristics, 2) Health-related characteristics, 3) Individual beliefs and attitudes, 4) Interindividual cooperation and support, 5) Availability and allocation of resources, and 6) Emotional and prognostic challenges. While evidence was inconclusive for most socio-demographic factors, the following barriers emerged: having a noncancer condition or a low symptom burden, the focus on cure in hospitals, nonacceptance of terminal prognosis, negative perceptions of palliative care, misleading communication and conflicting care preferences, lack of resources, poor coordination, insufficient expertise, and clinicians' emotional discomfort and difficult prognostication.

CONCLUSION

Hospital inpatients face multiple barriers to accessing palliative care. Strategies to address these barriers need to take into account their multidimensionality and long-standing persistence.

Effectiveness of the SHARE Model in Improving the Knowledge of, Attitudes Toward, Intention to Provide, and Initiation of Hospice Care Among Caregivers of Terminally ill Patients With the Eight Major Non-Cancer Diseases

OBJECTIVES

To investigate the effects of a care intervention on the knowledge of, attitudes toward, intention to provide, and initiation of hospice care among caregivers of terminally ill patients with the eight major non-cancer diseases.

METHODS

A two-group pre-post-test randomized intervention design was adopted. The intervention group received the SHARE model intervention. The SHARE intervention was implemented once a week for 6 weeks, with each session lasting 20-60 min.

RESULTS

The intervention and control groups differed significantly in mean post-test scores for knowledge of hospice care (t = -4.973, p = .00) and intentions to provide hospice care (t = -2.424, p = .02). In the intervention group, pre- and post-test scores differed significantly for knowledge of hospice care (t = -6.201, p = .000), attitudes toward hospice care (t = -2.848, p = .008), and intentions to provide hospice care (t = -2.781, p = .009).

CONCLUSIONS

The SHARE intervention improved knowledge of hospice care, intentions to provide, and initiation of hospice care among the caregivers of terminally ill patients with non-cancer diseases.

Protective factors of ethical conflict during a pandemic-Quali-Ethics-COVID-19 research part 2: An international qualitative study

AIMS AND OBJECTIVES

To determine which factors can be considered protective of ethical conflicts in intensive care unit healthcare professionals during a pandemic.

BACKGROUND

The COVID-19 pandemic gave rise to new ethical concerns in relation to the management of public health and the limitations on personal freedom. Continued exposure to ethical conflict can have a range of psychological consequences.

DESIGN

A qualitative design based on phenomenological approach.

METHODS

A total of 38 nurses and physicians who were regular staff members of Barcelona and Milan's public tertiary university hospitals and working in intensive care units during the first wave of the COVID-19 pandemic. Semi-structured online in-depth interviews were conducted. A thematic analysis was performed by two independent researchers following the seven steps of Colaizzi's methods. We adhere COREQ guidelines.

RESULTS

One theme 'Protective factors of ethical conflict in sanitary crisis' and four subthemes emerged from the data: (1) knowledge of the infectious disease, (2) good communication environment, (3) psychological support and (4) keeping the same work team together.

CONCLUSIONS

Four elements can be considered protective factors of ethical conflict for healthcare professionals during a sanitary crisis. While some of these factors have already been described, the joint identification of this set of four factors as a single element is, in itself, novel. This should help in ensuring the right mechanisms are in place to face future pandemics and should serve to improve institutional organisation and guarantee safe and high-quality patient care in times of healthcare crisis.

RELEVANCE TO CLINICAL PRACTICE

Future strategies for the prevention of ethical conflict during sanitary crises, pandemics or other catastrophes need to consider a set of four factors as a single element. These factors are the knowledge of the infectious disease, a good communication environment, psychological support and keeping the same work team together into joint consideration.

Psychometric Properties of the Brazilian Version of the Quality of Dying and Death for Adult Family Members of ICU Patients

Death is a complex, subjective phenomenon that requires an understanding of experiences to be qualified to provide care during the end-of-life process. This study aimed to analyze the psychometric properties of the Portuguese version (Brazil) of the Quality of Dying and Death (QODD) scale on family members of patients who died in adult intensive care units. A methodological study was conducted with 326 family members of patients that died in three ICUs of public hospitals in the state of São Paulo, Brazil. For this study, the QODD 3.2a (25 items and six domains) was administered during the period from December 2020 to March 2022. The analysis was performed using the classic theory of the tests and the goodness of fit of the model was tested using confirmatory factor analysis. We have used Spearman's correlation coefficients between the scores of the overall scale and domains. Cronbach's alpha coefficient and the intraclass correlation coefficient (ICC) were used for the evaluation of internal consistency and temporal stability, respectively. The Horn's parallel analysis indicated two factors that were not confirmed in the exploratory factor analysis. A single factor retained 18 of the initial 25 items and the analysis of the goodness of fit to the unidimensional model resulted in the following: CFI = 0.7545, TLI = 0.690, chi-squared = 767.33, df = 135, RMSEA = 0.121 with 90%CI, and p = 5.04409. The inter-item correlations indicated a predominance of weak correlations among the items of the instrument. The items with the largest number of moderate correlations were questions 13b, 9b, and 10b and a strong correlation was found between questions 15b and 16b. Cronbach's alpha coefficient was 0.8 and the ICC was 0.9. The Quality of Dying and Death-Version 3.2a (intensive therapy) in Brazilian Portuguese has a unidimensional structure and acceptable reliability. However, it did not obtain a good fit to the proposed factorial model.

Barriers and facilitators in the provision of palliative care in adult intensive care units: a scoping review

The provision of palliative care in the intensive care unit (ICU) is increasing. While some scholars have suggested the goals of palliative care to not be aligned with the ICU, some evidence show benefits of the integration. This review aimed to explore and synthesize research that identified barriers and facilitators in the provision of palliative care in the ICU. This review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review guidelines based on population, concept, and context. We searched for eligible studies in five electronic databases (Scopus, PubMed, ProQuest, Science Direct, and Sage) and included studies on the provision of palliative care (concept) in the ICU (context) that were published in English between 2005-2021. We describe the provision of palliative care in terms of barriers and facilitators. We also describe the study design and context. A total of 14 papers was included. Several barriers and facilitators in providing palliative care in the ICU were identified and include lack of capabilities, family boundaries, practical issues, cultural differences. Facilitators of the provision of palliative care in an ICU include greater experience and supportive behaviors, i.e., collaborations between health care professionals. This scoping review demonstrates the breadth of barriers and facilitators of palliative care in the ICU. Hospital management can consider findings of the current review to better integrate palliative care in the ICU.

Improving the quality of family meeting documentation in the ICU at the end of life

Objective

Improve documentation quality of end-of-life family meetings in a tertiary intensive care unit (ICU).

Design

Before-and-after interventional quality improvement project between October 2018 and February 2020 utilising an electronic pro-forma record.

Setting

Australian, University affiliated, mixed medical-surgical 22 bed adult ICU.

Participants

Patients who were admitted to the ICU for active management and subsequently died during that ICU admission. We enrolled 50 patients who died before and 50 patients after the introduction of the electronic family meeting pro-forma record.

Intervention

Through collaboration with ICU medical and nursing staff, End-of-life Special Interest Group and Clinical Documentation Committee we developed the ICU Family Meeting Discussion Note as an electronic pro-forma record with multiple key fields of entry.

Main outcome measures

Patient records were examined for the presence of documented details around patient's admission, family meetings and specific elements surrounding the patient's death.

Results

The introduction of a pro-forma record markedly improved the quality of documentation of end-of-life care related family meetings. Documentation increased in recording hospital admission date/time (6% vs 84%), meeting location (14% vs 70%), the reason patients were absent from the meeting (34% vs 72%), the Medical Treatment Decision Maker (MTDM) (10% vs 44%), the patient's resuscitation status (22% vs 54%), and treatment options discussed (78% vs 94%) (p ⩽ 0.005 for all).

Conclusion

Introducing an electronic pro-forma record to facilitate family meeting documentation increased the frequency of important recorded information. Further studies are required to assess whether documentation quality improvements are sustainable and whether they affect patient- or relative-centred outcomes.

Nurses' perceptions of barriers and supportive behaviors in end-of-life care in the intensive care unit: a cross-sectional study

BACKGROUND AND AIM

Patient deaths are common in the intensive care unit, and a nurse's perception of barriers to and supportive behaviors in end-of-life care varies widely depending upon their cultural background. The aim of this study was to describe the perceptions of intensive care nurses regarding barriers to and supportive behaviors in providing end-of-life care in a Chinese cultural context.

METHODS

A cross-sectional survey was conducted among intensive care nurses in 20 intensive care units in 11 general hospitals in central and eastern China. Instruments used in this study were general survey and Beckstrand's questionnaire. Data were collected via online survey platform. Descriptive analysis was used to describe general characteristics of participants and mean and standard deviations of the barriers and supportive behaviors. The mean and standard deviation were used to describe the intensity and frequency of each barrier or supportive behavior following Beckstrand's method to calculate the score of barriers and supportive behaviors. Content analysis was used to analyze the responses to open-ended questions.

RESULTS

The response rate was 53% (n = 368/700). Five of the top six barriers related to families and the other was the nurse's lack of time. Supportive behaviors included three related to families and three related to healthcare providers. Nurses in the intensive care unit felt that families should be present at the bedside of a dying patient, there is a need to provide a quiet, independent environment and psychological support should be provided to the patient and family. Nurses believe that if possible, families can be given flexibility to visit dying patients, such as increasing the number of visits, rather than limiting visiting hours altogether. Families need to be given enough time to perform the final rites on the dying patient. Moreover, it is remarkable that nurses' supportive behaviors almost all concern care after death.

CONCLUSIONS

According to ICU-nurses family-related factors, such as accompany of the dying patients and acceptence of patient's imminent death, were found the major factors affecting the quality of end-of-life care. These findings identify the most prominent current barriers and supportive behaviors, which may provide a basis for addressing these issues in the future to improve the quality of end-of-life care.

Understanding public attitudes to death talk and advance care planning in Northern Ireland using health behaviour change theory: a qualitative study

OBJECTIVES

Advance care planning is a key preparatory step in ensuring high-quality palliative and end of life care, and should be considered as a process, beginning with community-level conversations among lay persons. There is, however, indication that death talk among community-dwelling adults is not occurring, and there is a dearth of research examining why this is the case. This study aims to provide the first examination of barriers and facilitators to talking about death and dying among the general population in a UK region (Northern Ireland), and to provide a novel application of health behaviour change theory towards developing a theoretical understanding of the sources of this behaviour.

METHODS

The study involved qualitative analysis of responses (n = 381 participants) to two open-ended questions within a cross-sectional online survey, with recruitment via social media of adults currently living in Northern Ireland. Reflexive thematic analysis was conducted on open text responses per question, with the barriers and facilitators mapped on to health behaviour change models (the Behaviour Change Wheel COM-B and the Theoretical Domains Framework).

RESULTS

The findings evidence a myriad of barriers and facilitators to engaging in death talk, with themes aligning to areas such as lack of acceptance of death in social contexts and fear of upsetting self or others, and a need to improve interpersonal communication skills for facilitating conversations and improve knowledge of the existing services around death and dying. A theoretical understanding of the drivers of death talk is presented with findings mapped across most components of the COM-B Behaviour Change Model and the Theoretical Domains Framework.

CONCLUSIONS

This study contributes to a small but emergent research area examining barriers and facilitators to talking about death and dying. Findings from this study can be used to inform new public health programmes towards empowering adults to have these conversations with others in their community towards upstreaming advance care planning.

Translation and Cultural Adaptation into Portuguese of the Quality of Dying and Death Scale for Family Members of Patients in Intensive Care Units

The translation and cultural adaptation of the Quality of Dying and Death in Brazil may provide a reliable and reproducible scale for collecting and analyzing data on the process of dying and death, given the absence of Brazilian studies that have produced or used scales in this topic. The purpose of this study was to perform the translation and cultural adaptation of the Quality of Dying and Death (QODD 3.2a) scale for intensive care patients' relatives into Portuguese (Brazil). This methodological study was carried out in a public university of the São Paulo State University (UNESP) medical school, São Paulo, Brazil, in three stages: translation and back-translation by two native-speaking independent professionals, analysis by a committee of specialists, and a pre-test phase. The final version was created by seven experts after making semantic, idiomatic, and cultural changes to 16 items. The results indicated a satisfactory content validation index (CVI ≥ 0.80). This version was applied on 32 relatives of patients who were hospitalized in a public hospital in the interior of São Paulo. No item was excluded from the instrument. The content and face validity were achieved to a satisfactory standard, in addition to reaching the minimum parameters recommended in the literature. The Portuguese version of QODD 3.2a for relatives of deceased patients in intensive care is appropriate and culturally adapted for use in Brazil.

Rehabilitation Workforce Challenges to Implement Person-Centered Care

There is an increasing emphasis on developing person-centered care in rehabilitation settings. However, this care practice has not been fully implemented due to several factors. This study explores rehabilitation workforce perspectives on the barriers and facilitators to implementing person-centered care (PCC). This was a quantitative descriptive study, which was developed based on interviews with 12 healthcare professionals from a private institution in the region of Lisbon and Tagus Valley in Portugal. The recruitment was made in October 2020. Braun, Clarke, Hayfield, and Terry’s content analysis was applied to the transcripts, and these were transcribed verbatim. The consolidated criteria for reporting qualitative research (COREQ) checklist were applied to this study. Participants described barriers such as an unsupportive organization and leadership, staff constraints, heavy workload, and resistance to change. Unique to this study, a patient’s clinical characteristics were identified as barriers to person-centered care. As facilitators, they described leadership, staff satisfaction, a positive physical environment, training and education, and shared decision-making. It is essential to understand the perceptions of the rehabilitation workforce, as they play an integral role in providing PCC. This study serves as a guide to facilitate person-centered care, as it provides an understanding of key barriers and facilitators for its implementation in rehabilitation settings.

Extending the Ring Theory of Personhood to the Care of Dying Patients in Intensive Care Units

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.

An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile

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.

Facing the Inevitable: Preparing Nurses to Deliver End-of-Life Care

Health care providers have an ethical obligation to reduce suffering during a patient's end of life (EOL), but few receive formal education on EOL care principles. The objective of this project was to determine the feasibility and potential benefits of an education initiative in which the principles of EOL care were taught to senior-level nursing students and practicing nurses. To assess feasibility, data regarding recruitment rates, retention rates, and implementation issues were collected. Workshop effectiveness was evaluated through use of the End-of-Life Nursing Education Consortium-Knowledge Assessment Test survey, which evaluates knowledge levels regarding EOL care principles. A mixed-effects linear model was used to test for changes from the preworkshop to postworkshop scores. Demographic information and satisfaction data were also collected. Nineteen students and 24 nurses participated (total N = 43). There was a statistically significant time difference (P = .0001), with the postworkshop scores being higher (43.5 ± 0.93) versus the preworkshop scores (41.2 ± 0.93). However, no statistically significant workshop date difference (P = .3146) emerged. Satisfaction data were positive. Retention for the second workshop was negatively affected by COVID-19. The unique needs of patients nearing their EOL are significant. This project describes the implementation and outcomes of an education initiative, focused on EOL care principles, that was both feasible and beneficial.

A national Position Statement on adult end-of-life care in critical care

Patient death in critical care is not uncommon. Rather, the provision of end-of-life care is a core feature of critical care nursing, yet not all nurses feel adequately prepared for their role in the provision of end-of-life care. For this reason, the Australian College of Critical Care Nurses (ACCCN) supported the development of a Position Statement to provide nurses with clear practice recommendations to guide the provision of end-of-life care, which reflect the most relevant evidence and information associated with end-of-life care for adult patients in Australian critical care settings. A systematic literature search was conducted between June and July, 2020 in CINAHL Complete, Medline, and EMBASE databases to locate research evidence related to key elements of end-of-life care in critical care. Preference was given to the most recent Australian or Australasian research evidence, where available. Once the practice recommendations were drafted in accordance with the research evidence, a clinical expert review panel was established. The panel comprised clinically active ACCCN members with at least 12 months of clinical experience. The clinical expert review panel participated in an eDelphi process to provide face validity for practice recommendations and a subsequent online meeting to suggest additional refinements and ensure the final practice recommendations were meaningful and practical for critical care nursing practice in Australia. ACCCN Board members also provided independent review of the Position Statement. This Position Statement is intended to provide practical guidance to critical care nurses in the provision of adult end-of-life care in Australian critical care settings.

A Phenomenological Analysis of Experiences and Practices of Nurses Providing Palliative and End of Life Care

The aim of this study was to describe the experiences and practices of nurses providing palliative and end of life care. The study was conducted in the palliative care unit of a territory hospital in Turkey. The sample consisted of 11 nurses who had been working as palliative care nurses for at least one year. The face to face interview method was used to collect data, with a semi-structured in-depth individual interview. 5 main themes and 24 sub-themes were emerged in relation to the experiences and practices of the nurses. The majority of participant nurses pointed that inadequacy in the number of nurses, secondary nursing care activities, refusal of treatment, cultural and ethical problems were barriers in the provision of nursing care. They frequently experienced ethical issues when caring for end of life patients, and for this reason they felt the need for ethics counselling which they could consult.

Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit

OBJECTIVES

To evaluate values and experience with facilitating end-of-life care among intensive care professionals (registered nurses, medical practitioners and social workers) to determine perceived education and support needs.

RESEARCH DESIGN

Using a cross-sectional study design, 96 professionals completed a survey on knowledge, preparedness, patient and family preferences, organisational culture, resources, palliative values, emotional support, and care planning in providing end-of-life care.

SETTING

General adult intensive care unit at a tertiary referral hospital.

RESULTS

Compared to registered nurses, medical practitioners reported lower emotional and instrumental support after a death, including colleagues asking if OK (p = 0.02), lower availability of counselling services (p = 0.01), perceived insufficient time to spend with families (p = 0.01), less in-service education for end-of-life topics (p = 0.002) and symptom management (p = 0.02). Registered nurses reported lower scores related to knowing what to say to the family in end-of-life care scenarios (p = 0.01).

CONCLUSION

Findings inform strategies for practice development to prepare and support healthcare professionals to provide end-of-life care in the intensive care setting. Professionals reporting similar palliative care values and inclusion of patient and family preferences in care planning is an important foundation for planning interprofessional education and support with opportunities for professionals to share experiences and strengths.

Quality of end-of-life communication in 2 high-risk ICU cohorts: a retrospective cohort study

BACKGROUND

Factors influencing the quality of end-of-life communication are relevant to improving end-of-life care. We assessed the quality of end-of-life communication and influencing factors in 2 intensive care unit (ICU) cohorts at high risk of death: patients living in nursing homes and those on extracorporeal membrane oxygenation (ECMO).

METHODS

This retrospective cohort study included admissions to 4 ICUs in Winnipeg, Manitoba, from 2000 to 2017. We identified cohorts and influencing factors from the Winnipeg ICU database and by manual chart review. We assessed quality of end-of-life communication using 18 validated, binary quality indicators to calculate a weighted, scaled, composite score (range 0-100). We used median regression to identify factors associated with the composite score.

RESULTS

The ECMO cohort (n = 109) was younger than the nursing home cohort (n = 230), with longer hospital stays and higher disease severity. Mean composite scores of end-of-life communication were extremely low in both cohorts (mean 48.5 [standard error of the mean (SEM) 1.7] for the nursing home cohort, 49.1 [SEM 2.5] for the ECMO cohort). Patient characteristics associated with higher median composite scores were older age (5.0 per decade, 95% confidence interval [CI] 2.1-7.8) and lower (worse) Glasgow Coma Scale (GCS) scores (1.8 per GCS point, 95% CI 0.5-3.2). The median composite score rose significantly over time (1.7 per year, 95% CI 0.5-2.8).

INTERPRETATION

The quality of end-of-life communication in ICUs is poor, and factors associated with better prognosis are also associated with worse communication. Direct and early communication should occur with all patients in the ICU and their surrogates, not just those who are believed most likely to die.

Evaluating the Outcomes of an Organizational Initiative to Expand End-of-Life Resources in Intensive Care Units With Palliative Support Tools and Floating Hospice

BACKGROUND

There is evidence that palliative care and floating (inpatient) hospice can improve end-of-life experiences for patients and their families in the intensive care unit (ICU). However, both palliative care and hospice remain underutilized in the ICU setting.

OBJECTIVES

This study examined palliative consultations and floating hospice referrals for ICU patients during a phased launch of floating hospice, 2 palliative order sets, and general education to support implementation of palliative care guidelines.

METHODS

This descriptive, retrospective study was conducted at a level I trauma and academic medical center. Electronic medical records of 400 ICU patients who died in the hospital were randomly selected. These electronic medical records were reviewed to determine if patients received a palliative consult and/or a floating hospice referral, as well as whether the new palliative support tools were used during the course of care. The numbers of floating hospice referrals and palliative consults were measured over time.

RESULTS

Although not significant, palliative consults increased over time (P = .055). After the initial introduction of floating hospice, 27% of the patients received referrals; however, referrals did not significantly increase over time (P = .807). Of the 68 patients who received a floating hospice referral (24%), only 38 were discharged to floating hospice. There was a trend toward earlier palliative care consults, although this was not statistically significant (P = .285).

CONCLUSION

This study provided the organization with vital information about their initiative to expand end-of-life resources. Utilization and timing of palliative consults and floating hospice referrals were lower and later than expected, highlighting the importance of developing purposeful strategies beyond education to address ICU cultural and structural barriers.

Australian College of Critical Care Nurses and Australasian College for Infection Prevention and Control position statement on facilitating next-of-kin presence for patients dying from coronavirus disease 2019 (COVID-19) in the intensive care unit

The coronavirus disease 2019 (COVID-19) pandemic is challenging healthcare systems worldwide, none more so than critical and intensive care settings. Significant attention has been paid to the capacity of Australian intensive care unit (ICUs) to respond to a COVID-19 surge, particularly in relation to beds, ventilators, staffing, personal protective equipment, and unparalleled increase in deaths in ICUs associated with COVID-19 seen internationally. While death is not uncommon in critical care, the international experience demonstrates that restrictions to family presence at the end of life result in significant distress for families and clinicians. As a result, the Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control supported the development of a position statement to provide critical care nurses with specific guidance and recommendations for practice for this emerging priority area. Where possible, position statements are founded on high-quality evidence. However, the short time period since the first recognition of a cluster of pneumonia-like cases in China in January, 2020, meant that an integrative approach was required to expedite timely development of this position statement in preparation for a COVID-19 surge in Australia. This position statement is intended to provide practical guidance to critical care nurses in facilitating next-of-kin presence for patients dying from COVID-19 in the ICU.

Critical Care Nurses’ Experiences of End-of-Life Care: A Qualitative Study

Background: Patients admitted to the intensive care unit (ICU) may face terminal illness situations, which may lead to death. In this case, the role of critical care nurses shifts from life-sustaining to end-of-life care (EOLC). Nurses’ involvement in EOLC varies between countries, even in one country due to differences in religion, culture, organization, laws, cases and patient quality. In Indonesia, research on EOLC in ICU has not been carried out.Purpose: This study aimed to explore the experiences of critical care nurses in providing EOLC.Methods: A qualitative study with a phenomenological approach was conducted. Ten critical care nurses having the experiences of caring for dying patients were recruited through a purposive sampling technique for in-depth interviews. Manual content analysis was used to identify themes.Results: The results of the study found five themes, including the challenge of communication with the family, support for the family, support for the patient, discussion and decision making, and nurses’ emotions. Conclusion: Most of EOLC provided by critical care nurses was focused on the family. They had some challenges in communication and decision making. Nurses need to get training and education about how to care for patients towards the end of life.

The impact of caring for dying patients in intensive care units on a physician's personhood: a systematic scoping review

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.

Psychometric properties of the Chinese version of the End-of-Life Decision-Making and Staff Stress Questionnaire

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.

Challenges and facilitators in providing effective end of life care in intensive care units

Caring for patients who are at the end of their lives is an essential aspect of practice in intensive care units (ICUs). While intensive care is one of the fastest-growing healthcare specialties as a result of technological and scientific advances, a significant proportion of patients admitted to an ICU in the UK will not survive their ICU stay. Therefore, it is important to examine ways to enhance practice in this area and the factors that might affect the care provided to patients and their families.

AIM

To identify the challenges and facilitators that members of the ICU multidisciplinary team encounter in the delivery of end of life care to dying patients in ICUs.

METHOD

A scoping literature review was undertaken. Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with full text, MEDLINE Complete and the EBSCOhost E-Journals Database were searched electronically to identify literature from April 2007 to April 2017, alongside hand-searching. Critical appraisal tools were used and thematic analysis was undertaken to analyse the data and identify themes.

FINDINGS

Ten articles were included in the literature review, which identified various challenges and facilitators in providing effective end of life care in ICUs. The main themes identified were: communication, family involvement, personal factors and the ICU environment.

CONCLUSION

All of the studies included in the literature review identified several important challenges related to communication, such as time constraints, disagreements among healthcare professionals, and a lack of knowledge among healthcare professionals about how to conduct challenging conversations with patients and families. Future developments in practice should consider the role of effective multidisciplinary team-working in end of life care.

End-of-Life Care in Acute Hospitals: Practice Change Reported by Health Professionals Following Online Education

Providing quality care for those dying in hospital is challenging for health professionals who receive little training in this. “End of Life Essentials” (EOLE) was developed to address gaps in health professionals’ knowledge, skills and confidence in end-of-life care via the provision of online learning modules and practice resources. This study aimed to determine whether respondents could describe clinical practice change as a result of module completion. Deidentified data were collected between October and November 2018 from learners registered for the online learning modules. Both quantitative and qualitative data were extracted and analysed. The survey design and conduct were reviewed, and ethical approval was obtained. Although the response rate was very low, results from n = 122 learners show improvements in knowledge, skills, awareness and confidence as a result of the undertaking of the learning modules. Two thirds self-reported practice changes (71%, n = 59) following the education, with “communication” cited most commonly (n = 19). The findings suggest that the EOLE education modules can help to improve end-of-life care by increasing health professionals’ awareness of good practice as well as their knowledge, skills and confidence. Online learning has also been reinforced as an appropriate forum for end-of-life education. Following education, implementing what has been learned occurs more easily at a personal level rather than at a team and organisational level. Barriers to and enablers of clinical practice change in hospital are described, including the fact that the organisation may not be responsive to changes or have the relevant resources to support change.

Difficulties Perceived by ICU Nurses Providing End-of-Life Care: A Qualitative Study

Background

With advances in medicine and technology, intensive care units (ICUs) have the capacity to treat patients who would have previously not been expected to survive and would therefore not have been managed in ICUs. When an individual is not expected to survive, doctors and nurses face the modern ethical dilemma of death associated with withdrawal of life-supporting strategies. The aim of this study was to identify difficulties perceived by ICU nurses providing end-of-life care (EOLC) in Poland.

Methods

The qualitative study was designed to investigate the difficulties, and the related barriers, to EOLC provided in ICUs in Poland. We conducted individual telephone interviews with ICU nurses from across Poland.

Results

The main issues raised during the interviews included (1) barriers attributable to the hospital, (2) barriers related to the patient's family, and (3) barriers related to the ICU personnel providing direct EOLC. The interviewed nurses considered the lack of support from managers to be the main barrier. We found that ICU nurses in Poland dealt with end-of-life aspects that were emotionally and psychologically taxing. In addition, they lacked specialized training in this area, especially with regard to family care and care provision.

Conclusions

A pressing need exists to improve facilities and make equipment ensuring a desirable standard of care more available. Specialized palliative care training programs should be incorporated into compulsory nursing curricula for ICU nurses.

Improving Family Intensive Care Unit Experiences at the End of Life: Barriers and Facilitators

Experiencing the end of life of a family member in the intensive care unit is clearly difficult. An important role of critical care nurses is to help family members through this challenging period. This article highlights a few clinically significant barriers and facilitators related to improving family experiences at the patient's end of life that have received less attention in the literature thus far. Facilitators include specific aspects of communication, the nurse's role as the coordinator of care, bereavement care, promoting a "good death," and caring for health care providers. Barriers include medical uncertainty and differences in values and culture.

Perceptions of Palliative Care Nurses Related to Death and Palliative Care Practices

This study has been conducted with the purpose of identifying the perceptions of palliative nurses about death and determining palliative care practices. We conducted qualitative interviews with 23 palliative care nurses in Turkey. Content analysis was used in the evaluation of the data. Three themes have been identified about perception of death. Furthermore, three themes have been identified about palliative care practices. It was concluded that the palliative nurses perceive death as a natural and inevitable process and that as long as their working period increases, they become desensitized. It was identified that the participants generally perform the following procedures in palliative care practices.

End-of-life care content in postgraduate critical care nursing programs: Structured telephone interviews to evaluate content-informing practice

BACKGROUND

The provision of end-of-life care remains a significant component of work for clinicians in critical care settings. Critical care nurses report that this area of practice receives limited attention in education and training.

OBJECTIVES

The objective of this study was to identify and describe the end-of-life care content in postgraduate critical care nursing programs in Australia.

METHODS

Using a descriptive exploratory research design, an Internet search was undertaken in August 2015, identifying 17 education providers offering postgraduate critical care nursing programs. Thirteen individuals agreed to participate in a structured telephone interview regarding end-of-life content in their postgraduate program. Descriptive statistics were calculated to summarise the data obtained.

RESULTS

Twelve participants reported that end-of-life care content was explicitly addressed in their postgraduate critical care nursing programs, yet variation in actual content areas covered was evident. The majority of programs addressed content related to organ donation (92%) and legal and ethical issues (77%). However, content least commonly identified as covered pertained to the work of the nurse in providing direct clinical care to the patient at the end of life and his or her family, including the physical changes experienced by the dying patient (31%), respiratory management encompassing withdrawal of ventilation and symptom management (23%), emotional support of family (23%), care of the body after death (23%), and the process of withdrawing life-sustaining treatment (15%). Participants (92%) agreed that end-of-life content was important in postgraduate critical care nursing programs, with 77% of participants agreeing that more time should be allocated to end-of-life content.

CONCLUSIONS

This study provides preliminary evidence of the variation in end-of-life content in postgraduate critical care nursing programs in Australia. Addressing gaps in end-of-life care content in formal education, including clinical care of the dying patient, is urgently needed to address the complexity of this phase of care that is so frequently provided in critical care units.

Family presence during resuscitation in emergency departments: professionals' attitudes in Brazil

AIM

The study explored the views and attitudes of nurses and physicians on family presence during resuscitation in emergency departments in Brazil.

BACKGROUND

International emergency associations endorse family presence during resuscitation; however, the extent to which it is practiced remains unclear, particularly in the Brazilian context. Research of emergency staff views and attitudes towards this practice is desirable so that actions can be identified to support families at the bedside.

METHODS

A qualitative research was conducted. Thirty-two health professionals (11 physicians and 21 nurses) working in two emergency departments in southern Brazil were purposefully recruited in January 2015. In-depth interviews were conducted, and data were analysed using content analysis.

FINDINGS

Nurses and physicians found family presence during resuscitation controversial and the general attitude towards this practice was negative. They reported that 'changes are needed' to adapt hospital infrastructures for family presence, and to train staff to respond to the information and emotional needs of families.

DISCUSSION

Translating a family nursing framework into clinical practice involves the need for reassessing educational and management policies in clinical contexts.

CONCLUSION

This research brings new understanding about the attitudes of some Brazilian nurses and physicians on the implementation of family presence during resuscitation and identifies the need to develop policies and strategies to improve family presence in emergency departments.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Hospital-based policies are required to improve family-centred care in emergency departments while providing a criterion of legality and safety to professionals to invite families to be present during invasive procedures. Also, family-focused education in health science degrees, continuing education and in the community is required.

Emotional Impact of End-of-Life Decisions on Professional Relationships in the ICU: An Obstacle to Collegiality?

OBJECTIVES

End-of-life decisions are not only common in the ICU but also frequently elicit strong feelings among health professionals. Even though we seek to develop more collegial interprofessional approaches to care and health decision-making, there are many barriers to successfully managing complex decisions. The aim of this study is to better understand how emotions influence the end-of-life decision-making process among professionals working in ICU.

DESIGN

Qualitative study with clinical interviews. All interviews were transcribed verbatim and analyzed thematically using interpretative phenomenological analysis.

SETTING

Two independent ICUs at the "Centre Hospitalier de l'Université de Montréal."

SUBJECTS

Ten physicians and 10 nurses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the end-of-life decision-making process, families and patients restructure the decision-making frame by introducing a strong emotional dimension. This results in the emergence of new challenges quite different from the immediacy often associated with intensive care. In response to changes in decision frames, physicians rely on their relationship with the patient's family to assist with advanced care decisions. Nurses, however, draw on their relationship and proximity to the patient to denounce therapeutic obstinacy.

CONCLUSIONS

Our study suggests that during the end-of-life decision-making process, nurses' feelings toward their patients and physicians' feelings toward their patients' families influence the decisions they make. Although these emotional dimensions allow nurses and physicians to act in a manner that is consistent with their professional ethics, the professionals themselves seem to have a poor understanding of these dimensions and often overlook them, thus hindering collegial decisions.

"I Just Felt Like I Was Stuck in the Middle": Physician Assistants' Experiences Communicating With Terminally Ill Patients and Their Families in the Acute Care Setting

CONTEXT

Terminally ill hospitalized patients and their families consistently rank effective communication and shared decision-making among their top priorities. Advance practice providers such as physician assistants (PAs) are increasingly providing care in the hospital setting and are often called to communicate with patients and families. A first step to improving PA communication is to better understand PAs' current experiences in their daily practices.

OBJECTIVES

This study aimed to explore roles PAs serve in communicating with terminally ill patients/families; PAs' attitudes and opinions about communication roles; and perceived barriers and facilitators of communication with patients/families in the hospital setting.

METHODS

Five focus groups were conducted with PAs practicing on adult medical services at three acute care hospitals of an academic medical center in Bronx, New York. An open-ended question guide was used. An inductive thematic analysis strategy was used to examine the data from transcribed audiotapes of focus group sessions to identify emergent concepts and themes.

RESULTS

The overarching theme that emerged was being stuck in the middle. PAs experienced ambiguity around their roles and responsibilities in communications between the medical team as well as patients and families; gaps in knowledge and skills; and organizational or structural deficits in the patient care systems that placed them in uncomfortable situations.

CONCLUSION

Interventions aimed at improving PA communication with terminally ill patients and their families should target institutional structures, systems, and culture around roles and responsibilities in addition to skill and knowledge gaps to be most effective.