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Gagnon M, Kunyk D. Beyond technology, drips, and machines: Moral distress in PICU nurses caring for end-of-life patients. Nurs Inq 2021; 29:e12437. [PMID: 34157180 DOI: 10.1111/nin.12437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Moral distress is an experience of profound moral compromise with deeply impactful and potentially long-term consequences to the individual. Critical care areas are fraught with ethical issues, and end-of-life care has been associated with numerous incidences of moral distress among nurses. One such area where the dichotomy of life and death seems to be at its sharpest is in the pediatric intensive care unit. The purpose of this study was to understand the moral distress experiences of pediatric intensive care nurses when caring for pediatric patients at the end of life. A secondary analysis was undertaken of seven transcripts from registered nurses across six Canadian pediatric intensive care units and produced three themes: under prioritization of child patient dignity, burden of insider knowledge, and environmental constraints on nursing roles and responsibilities. When caring for patients at the end of life, nurses experienced moral distress when a dignified death was not realized. Furthermore, despite interprofessional collaboration efforts in Canada, the concept of silo mentality persists and contributes to moral distress. Organizational involvement is needed to address moral distress in pediatric intensive care nurses both to achieve a dignified death for child patients and in addressing silo mentality.
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Affiliation(s)
- Michelle Gagnon
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Diane Kunyk
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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2
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Efstathiou N, Vanderspank-Wright B, Vandyk A, Al-Janabi M, Daham Z, Sarti A, Delaney JW, Downar J. Terminal withdrawal of mechanical ventilation in adult intensive care units: A systematic review and narrative synthesis of perceptions, experiences and practices. Palliat Med 2020; 34:1140-1164. [PMID: 32597309 DOI: 10.1177/0269216320935002] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND During the terminal withdrawal of life-sustaining measures for intensive care patients, the removal of respiratory support remains an ambiguous practice. Globally, perceptions and experiences of best practice vary due to the limited evidence in this area. AIM To identify, appraise and synthesise the latest evidence around terminal withdrawal of mechanical ventilation in adult intensive care units specific to perceptions, experiences and practices. DESIGN Mixed methods systematic review and narrative synthesis. A review protocol was registered on PROSPERO (CRD42018086495). DATA SOURCES Four electronic databases were systematically searched (Medline, Embase, CENTRAL and CINAHL). Obtained articles published between January 2008 and January 2020 were screened for eligibility. All included papers were appraised using relevant appraisal tools. RESULTS Twenty-five papers were included in the review. Findings from the included papers were synthesised into four themes: 'clinicians' perceptions and practices'; 'time to death and predictors'; 'analgesia and sedation practices'; 'physiological and psychological impact'. CONCLUSIONS Perceptions, experiences and practices of terminal withdrawal of mechanical ventilation vary significantly across the globe. Current knowledge highlights that the time to death after withdrawal of mechanical ventilation is very short. Predictors for shorter duration could be considered by clinicians and guide the choice of pharmacological interventions to address distressing symptoms that patients may experience. Clinicians ought to prepare patients, families and relatives for the withdrawal process and the expected progression and provide them with immediate and long-term support following withdrawal. Further research is needed to improve current evidence and better inform practice guidelines.
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Affiliation(s)
- Nikolaos Efstathiou
- College of Medical and Dental Sciences, Institute of Clinical Sciences, School of Nursing, University of Birmingham, Birmingham, UK
| | | | - Amanda Vandyk
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Mustafa Al-Janabi
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Zeinab Daham
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Aimee Sarti
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - James Downar
- Divisions of Critical Care and Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Coventry A, Ford R, Rosenberg J, McInnes E. A qualitative meta-synthesis investigating the experiences of the patient's family when treatment is withdrawn in the intensive care unit. J Adv Nurs 2020; 76:2222-2234. [PMID: 32406076 DOI: 10.1111/jan.14416] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/24/2020] [Accepted: 04/21/2020] [Indexed: 11/26/2022]
Abstract
AIM To synthesize qualitative studies of patients' families' experiences and perceptions of end-of-life care in the intensive care unit when life-sustaining treatments are withdrawn. DESIGN Qualitative meta-synthesis. DATA SOURCES Comprehensive search of 18 electronic databases for qualitative studies published between January 2005 - February 2019. REVIEW METHOD Meta-aggregation. RESULTS Thirteen studies met the inclusion criteria. A conceptual 'Model of Preparedness' was developed reflecting the elements of end-of-life care most valued by families: 'End-of-life communication'; 'Valued attributes of patient care'; 'Preparing the family'; 'Supporting the family'; and 'Bereavement care'. CONCLUSION A family-centred approach to end-of-life care that acknowledges the values and preferences of families in the intensive care unit is important. Families have unmet needs related to communication, support, and bereavement care. Effective communication and support are central to preparedness and if these care components are in place, families can be better equipped to manage the death, their sadness, loss, and grief. The findings suggest that health professionals may benefit from specialist end-of-life care education to support families and guide the establishment of preparedness. IMPACT Understanding the role and characteristics of preparedness during end-of-life care will inform future practice in the intensive care unit and may improve family member satisfaction with care and recovery from loss. Nurses are optimally positioned to address the perceived shortfalls in end-of-life care. These findings have implications for health education, policies, and standards for end-of-life care in the intensive care unit.
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Affiliation(s)
- Alysia Coventry
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Australia
| | - Rosemary Ford
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Australia
| | - John Rosenberg
- School of Nursing, Midwifery and Paramedicine, University of Sunshine Coast, Maroochydore DC, Australia
| | - Elizabeth McInnes
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Australia.,Professor of Nursing, St Vincent's Hospital Melbourne, Deputy Director, Nursing Research Institute St Vincent's Health Australia Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Fitzroy, Australia
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Breen LJ, Szylit R, Gilbert KR, Macpherson C, Murphy I, Nadeau JW, Reis E Silva D, Wiegand DL. Invitation to grief in the family context. DEATH STUDIES 2018; 43:173-182. [PMID: 29733763 DOI: 10.1080/07481187.2018.1442375] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Grief is a family affair, yet it is commonly viewed as an individual phenomenon. As an international, interdisciplinary team, we explore grief within a family context across theoretical, research, practice, and educational domains. Families are complex and working with this complexity is challenging but necessary for a holistic view of grief. We therefore encourage an increased focus on theorizing, researching, practicing, and educating using innovative approaches to address the complexities of grief within the context of families. Learnings from within each domain will affirm and enhance the development of family-level thinking and approaches.
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Affiliation(s)
- Lauren J Breen
- a School of Psychology , Curtin University , Perth, Western Australia, Australia
| | - Regina Szylit
- b School of Nursing, University of São Paulo , São Paulo , Brazil
| | | | - Catriona Macpherson
- d Fife Specialist Palliative Care, Victoria Hospice, Kirkcaldy , Fife , Scotland
| | - Irene Murphy
- e Marymount University Hospital and Hospice , Cork , Ireland
| | | | - Daniela Reis E Silva
- g Laboratory for Research and Intervention on Grief and Bereavement, Pontifical Catholic University of São Paulo, São Paulo , Brazil
| | - Debra L Wiegand
- h School of Nursing , University of Maryland , Baltimore, Maryland, USA
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A scoping research literature review to assess the state of existing evidence on the “bad” death. Palliat Support Care 2017; 16:90-106. [DOI: 10.1017/s1478951517000530] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTObjective:A scoping research literature review on “bad death” was undertaken to assess the overall state of the science on this topic and to determine what evidence exists on how often bad deaths occur, what contributes to or causes a bad death, and what the outcomes and consequences of bad deaths are.Method:A search for English-language research articles was conducted in late 2016, with 25 articles identified and all retained for examination, as is expected with scoping reviews.Results:Only 3 of the 25 articles provided incidence information, specifying that 7.8 to 23% of deaths were bad and that bad deaths were more likely to occur in hospitals than in community-care settings. Many different factors were associated with bad deaths, with unrelieved pain being the most commonly identified. Half of the studies provided information on the possible consequences or outcomes of bad deaths, such as palliative care not being initiated, interpersonal and team conflict, and long-lasting negative community effects.Significance of results:This review identified a relatively small number of research articles that focused in whole or in part on bad deaths. Although the reasons why people consider a death to be bad may be highly individualized and yet also socioculturally based, unrelieved pain is a commonly held reason for bad deaths. Although bad and good deaths may have some opposing causative factors, this literature review revealed some salient bad death attributes, ones that could be avoided to prevent bad deaths from occurring. A routine assessment to allow planning so as to avoid bad deaths and enhance the probability of good deaths is suggested.
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Family Experiences During the Dying Process After Withdrawal of Life-Sustaining Therapy. Dimens Crit Care Nurs 2016; 35:160-6. [DOI: 10.1097/dcc.0000000000000174] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Wiegand DL, Grant MS, Cheon J, Gergis MA. Family-Centered End-of-Life Care in the ICU. J Gerontol Nurs 2013; 39:60-8. [DOI: 10.3928/00989134-20130530-04] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/10/2013] [Indexed: 11/20/2022]
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Wiegand DL. Family management after the sudden death of a family member. JOURNAL OF FAMILY NURSING 2012; 18:146-63. [PMID: 22223496 DOI: 10.1177/1074840711428451] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Although more is known about how individuals within families make decisions and manage more discrete issues when a family member is dying, less is known about how families as a unit manage after the sudden death of a family member. The article discusses an investigation that was conducted to better understand how families respond to the life-threatening illness or injury and eventual death of a family member. The purpose of the study was to define Family Management Styles (FMSs) and determine distinctive characteristics of each FMS used by families after the death of a family member who had life-sustaining therapy withdrawn as a result of an unexpected, life-threatening illness or injury. Interviews are conducted with 8 families (22 family members) 1 to 2 years after the death of their family members. A modified typology of FMSs based on a directed analysis that was then inductively modified includes: progressing, accommodating, maintaining, struggling, and floundering. Understanding FMSs and how FMSs may change over time, reflecting the changing focus of family work, will further aid in the development of family-focused interventions as well as develop FMSs within the context of end of life.
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Affiliation(s)
- Debra L Wiegand
- University of Maryland School of Nursing, Baltimore, MD 21201, USA.
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