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Hewitt J, Alsaba N, May K, Kang E, Cartwright C, Willmott L, White B, Marshall AP. End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland. Emerg Med Australas 2024; 36:429-435. [PMID: 38361400 DOI: 10.1111/1742-6723.14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/20/2023] [Accepted: 01/13/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia. METHODS An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. RESULTS The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. CONCLUSIONS The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.
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Affiliation(s)
- Jayne Hewitt
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Law Futures Centre, Griffith University, Southport, Queensland, Australia
| | - Nemat Alsaba
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Science and Medicine, Bond University, Robina, Queensland, Australia
| | - Katya May
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Evelyn Kang
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
| | - Colleen Cartwright
- Office of the Deputy Vice Chancellor (Research), Southern Cross University, Lismore, New South Wales, Australia
| | - Lindy Willmott
- Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben White
- Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
- ARC Future Fellow, Brisbane, Queensland, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Nursing Education and Research Unit, Gold Coast University Hospital, Southport, Queensland, Australia
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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:S1036-7314(24)00049-3. [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] [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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Salins N, Rao A, Dhyani VS, Prasad A, Mathew M, Damani A, Rao K, Nair S, Shanbhag V, Rao S, Iyer S, Gursahani R, Mani RK, Simha S. Palliative and end-of-life care practices for critically ill patients and their families in a peri-intensive care setting: A protocol for an umbrella review. Palliat Support Care 2024:1-8. [PMID: 38420705 DOI: 10.1017/s1478951524000130] [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: 03/02/2024]
Abstract
OBJECTIVES This umbrella review will summarize palliative and end-of-life care practices in peri-intensive care settings by reviewing systematic reviews in intensive care unit (ICU) settings. Evidence suggests that integrating palliative care into ICU management, initiating conversations about care goals, and providing psychological and emotional support can significantly enhance patient and family outcomes. METHODS The Joanna Briggs Institute (JBI) methodology for umbrella reviews will be followed. The search will be carried out from inception until 30 September 2023 in the following databases: Cochrane Library, SCOPUS, Web of Science, CINAHL Complete, Medline, EMBASE, and PsycINFO. Two reviewers will independently conduct screening, data extraction, and quality assessment, and to resolve conflicts, adding a third reviewer will facilitate the consensus-building process. The quality assessment will be carried out using the JBI Critical Appraisal Checklist. The review findings will be reported per the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews statement. RESULTS This umbrella review seeks to inform future research and practice in critical care medicine, helping to ensure that end-of-life care interventions are optimized to meet the needs of critically ill patients and their families.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Arathi Rao
- Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vijay Shree Dhyani
- Evidence Synthesis Specialist, Kasturba Medical College, Manipal, Karnataka, India
| | - Ashmitha Prasad
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
| | - Mebin Mathew
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
| | - Anuja Damani
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Krithika Rao
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shreya Nair
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vishal Shanbhag
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth University Medical College, Pune, India
| | - Roop Gursahani
- Department of Neurology, P D Hinduja Hospital, Mahim, Mumbai, India
| | - R K Mani
- Department of Critical care, Yashoda Super Speciality Hospitals, Ghaziabad, India
| | - Srinagesh Simha
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
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Hewitt J, Alsaba N, May K, Cartwright C, Willmott L, White BP, Marshall AP. The role of law in end-of-life decision-making in emergency departments and intensive care units: a retrospective review of current practice in a Queensland health service. AUST HEALTH REV 2024; 48:95-102. [PMID: 38081044 DOI: 10.1071/ah23160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/17/2023] [Indexed: 02/02/2024]
Abstract
Objective There is limited evidence about how legal frameworks that underpin end-of-life decisions are applied in practice. This study aimed to identify how end-of-life decisions are made and documented in emergency departments and intensive care units. The secondary aim was to explore the extent to which the legal processes featured in these decisions. Methods A retrospective chart audit of 85 adult patients who died in the emergency departments and intensive care units of a Queensland health service was undertaken. Quantitative data were analysed and reported using descriptive statistics. Qualitative textual data were analysed using inductive content analysis. Results Nearly all admissions were unplanned (97.6%), and most patients (74.1%) were admitted from home. Only one patient had an advance health directive, although all had an eligible substitute decision-maker. The qualitative analysis revealed two main concepts - 'healthcare professionals choreograph the end of life' and 'patients and families are carried on an unplanned journey'. Conclusions There was limited documentation related to the application of the legal framework in these decisions. Healthcare professionals relied on their clinical judgment about what was in the best interest of the patient. It was common for there to be a substantial effort to achieve consensus in decision-making which coincidently complied with the law.
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Affiliation(s)
- Jayne Hewitt
- School of Nursing and Midwifery, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Griffith University, Law Futures Centre, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia
| | - Nemat Alsaba
- Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia; and Faculty of Health Science and Medicine, Bond University, 14 University Drive, Robina, Qld 4226, Australia
| | - Katya May
- School of Nursing and Midwifery, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia
| | - Colleen Cartwright
- Faculty of Health, Southern Cross University, Southern Cross Drive, Bilinga, Qld 4225, Australia
| | - Lindy Willmott
- Faculty of Business and Law, Queensland University of Technology, Gardens Point campus, 2 George Street, Brisbane, Qld 4000, Australia
| | - Ben P White
- Faculty of Business and Law, Queensland University of Technology, Gardens Point campus, 2 George Street, Brisbane, Qld 4000, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia; and Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia
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Georgakis S, Dragioti E, Gouva M, Papathanakos G, Koulouras V. The Complex Dynamics of Decision-Making at the End of Life in the Intensive Care Unit: A Systematic Review of Stakeholders' Views and Influential Factors. Cureus 2024; 16:e52912. [PMID: 38406151 PMCID: PMC10893775 DOI: 10.7759/cureus.52912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
A lack of consensus resulting in severe conflicts is often observed between the stakeholders regarding their respective roles in end-of-life (EOL) decision-making in the ICU. Since the burden of these decisions lies upon the individuals, their opinions must be known by medical, judicial, legislative, and governmental authorities. Part of the solution to the issues that arise would be to examine and understand the views of the people in different societies. Hence, in this systematic review, we assessed the attitudes of the physicians, nurses, families, and the general public toward who should be involved in decision-making and influencing factors. Toward this, we searched three electronic databases, i.e., PubMed, CINAHL (Cumulative Index to Nursing & Allied Health), and Embase. A matrix was developed, discussed, accepted, and used for data extraction by two independent investigators. Study quality was evaluated using the Newcastle-Ottawa Scale. Data were extracted by one researcher and double-checked by a second one, and any discrepancies were discussed with a third researcher. The data were analyzed descriptively and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-three studies met our inclusion criteria. Most involved healthcare professionals and reported geographic variations in different timeframes. While paternalistic features have been observed, physicians overall showed an inclination toward collaborative decision-making. Correspondingly, the nursing staff, families, and the public are aligned toward patient and relatives' participation, with nurses expressing their own involvement as well. Six categories of influencing factors were identified, with high-impact factors, including demographics, fear of litigation, and regulation-related ones. Findings delineate three key points. Firstly, overall stakeholders' perspectives toward EOL decision-making in the ICU seem to be leaning toward a more collaborative decision-making direction. Secondly, to reduce conflicts and reach a consensus, multifaceted efforts are needed by both healthcare professionals and governmental/regulatory authorities. Finally, due to the multifactorial complexity of the subject, directly related to demographic and regulatory factors, these efforts should be more extensively sought at a regional level.
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Affiliation(s)
- Spiros Georgakis
- Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, GRC
| | - Elena Dragioti
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
| | - Mary Gouva
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
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