End of life issues

Show and Tell: Photography and Storytelling to Better Understand the End-of-Life Experience of Families in the Intensive Care Unit

End-of-life in the Intensive Care Unit (ICU) is common, costly, and can contribute to negative health outcomes for bereaved family members. Insufficient understanding of the family experience results in poor quality, highly variable care riddled with deficiencies including effective identification and application of evidence-based clinical interventions. Successfully managing the multitude of transitions, for example changes in family role or personal identity requires creative practice guided by theory. This project supports the feasibility of using peri-mortem photographs captured by family members with story-telling and a standardized measurement of grief to explore the family experience of end-of-life in the ICU. Project findings reveal shared experiential themes and emphasize the value of photography and storytelling as meaning-making interventions for families. Further study to generalize findings and develop additional preventative and therapeutic interventions at and beyond end-of-life in the ICU is needed to better meet family needs and improve their health outcomes.

Interventions and decision-making at the end of life: the effect of establishing the terminal illness situation

Background

Many ‘routine’ interventions performed in hospital rooms have repercussions for the comfort of the patient, and the decision to perform them should depend on whether the patient is identified as in a terminal phase. The aim of this study is to analyse the health interventions performed and decisions made in the last days of life in patients with advanced oncological and non-oncological illness to ascertain whether identifying the patient’s terminal illness situation has any effect on these decisions.

Methods

Retrospective study of the clinical histories of deceased patients in four hospitals in Granada (Spain) in 2010. Clinical histories corresponding to the last three months of the patient’s life were reviewed.

Results

A total of 202 clinical histories were reviewed, 60 % of which were those of non-oncology patients. Opioid prescriptions (58.4 %), palliative sedation (35.1 %) and Do Not Resuscitate (DNR) orders (34.7 %) were the decisions most often reflected in the histories, and differences in these decisions were found between patients registered as terminal and those who were not registered as terminal. The most frequent interventions in the final 14 days and 48 h were parenteral hydration (96–83 %), peripheral venous catheter (90.1–82 %) and oxygen therapy (81.2–70.5 %). There were statistically significant differences between the patients who were registered as terminal and those not registered as terminal in the number of interventions applied in the final 14 days and 48 h (p = 0.01–p = 0.00) and in many of the described treatments.

Conclusion

The recognition of a patient’s terminal status in the clinical history conditions the decisions that are made and is generally associated with a lower number of interventions.

Eluding meaninglessness: a note to self in regard to Camus, critical care, and the absurd

Here I present a medical narrative, as a catharsis, regarding Albert Camus’s The Myth of Sisyphus in an attempt to elude meaninglessness in my difficult everyday practice of critical care medicine. It is well documented that physicians who practice critical care medicine are subject to burnout. The sense of despair that occasionally overwhelms me prompted my rereading of Camus’s classic text and caused me to recount his arguments that life is meaningless unless one is willing to take a leap of faith to the divine or, alternately, to commit suicide. This set up the examination of his third alternative, acceptance of a life without prima facie evidence of purpose and meaning, a view that may truly have some bearing on my professional life in the intensive care unit.

An overview of end-of-life issues in the intensive care unit

The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.

As death approaches: a retrospective survey of the care of adults dying in Alice Springs Hospital

OBJECTIVE

Australians are more likely to die in a hospital than anywhere else, and most of these deaths are 'expected'. The aims of this survey were to identify if specific end-of-life issues were documented in clinical records of a regional hospital serving remote Australia.

DESIGN

A retrospective consecutive case-note audit covering 18 months from 1 January 2006.

SETTING

Alice Springs Hospital.

PARTICIPANTS

Adult deaths in Alice Springs Hospital. During this period there were 128 deaths.

OUTCOME MEASURES

Demographic, process (diagnosis of dying documented, 'not for resuscitation' documentation, intensive care unit (ICU) admission, social worker referral and specialised palliative care service referral) and outcome data ('comfort at end of life') were surveyed.

RESULTS

Of the 128 admissions, 55 cases were excluded: 10 were children under 18, 33 died in < 48 hours, nine were coroner's cases and three files could no't be found. Of the 73 deaths surveyed (33 men), 47 (64%) were Aboriginal. A diagnosis of dying was made in 84%, 88% had an 'not for resuscitation' order, 48% were admitted to ICU during their last admission, 66% were referred to social workers, 68% were referred to palliative care and 85% of people were documented to be 'comfortable' during the dying process with no differential outcomes for Aboriginal and non-Aboriginal decedents except age (P < 0.0001).

CONCLUSION

  This survey highlights the continuing need to diagnose dying, understand optimal use of intensive care and improve comfort care at the end of life.

Opioid use at the end of life and survival in a Hospital at Home unit

BACKGROUND AND SIGNIFICANCE

Although opioids are commonly used to treat pain, dyspnea, and other symptoms at the end of life, little information is available on the safety and efficacy of the use of these medications in terminally ill patients in the home care setting.

OBJECTIVES

To explore whether high doses of opioids, or increasing doses, influence survival in patients with terminal cancer in a Hospital at Home unit.

METHODOLOGY

A retrospective cohort study. Clinical records of 223 oncologic patients admitted to the Hospital at Home unit of Hospital Galdakao-Usansolo from 2003 to 2007 and who died at home were reviewed. Demographic variables (age and gender) as well as clinical variables at the time of admission (Eastern Cooperative Oncology Group Performance Status scale, previous intake of opioids, type of cancer, use of coadjuvant drugs) and daily doses of morphine during the admission were recorded. Main outcomes were the number of days from the maximum dose of opioids administered to death and total length of survival during the admission.

RESULTS

Median survival from day of maximum dose to death was longer for patients who received higher doses of opioids (6 days) than those who received lower doses (2 days; p = 0.010). These differences disappeared after adjusting by demographic and clinical variables (HR, 0.86; 95% CI, 0.62-1.18 [p = 0.338]). Patients who received more than twofold increases in their initial doses had longer median survival (22 days) than those who did not (9 days; hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.34-0.60 [p < 0.0001]); these differences persisted after adjustment.

CONCLUSIONS

Our results suggest that the use of opioids is safe in for use in Hospital at Home patients with cancer and is not associated with reduced survival.

Care for Imminently Dying Cancer Patients: Family Members' Experiences and Recommendations

Purpose

The aim of this study was to clarify the level of emotional distress experienced by bereaved family members and the perceived necessity for improvement in the care for imminently dying patients and to explore possible causes of distress and alleviating measures.

Methods

A cross-sectional nationwide survey was performed in 2007 of bereaved families of cancer patients at 95 palliative care units across Japan.

Results

Questionnaires were sent to 670 families, and 76% responded. Families reported their experiences as very distressing in 45% of cases. Regarding care, 1.2% of respondents believed that a lot of improvement was needed, compared with 58% who believed no improvement was needed. Determinants of high-level distress were a younger patient age, being a spouse, and overhearing conversations between the medical staff outside the room at the time of the patient's death; those reporting high-level necessity of improvement were less likely to have encountered attempts to ensure the patient's comfort, received less family coaching on how to care for the patient, and felt that insufficient time was allowed for the family to grieve after the patient's death.

Conclusion

A considerable number of families experienced severe emotional distress when their family member died. Thus, we propose that a desirable care concept for imminently dying cancer patients should include relief of patient suffering, family advisement on how to care for the patient, allowance of enough time for the family to grieve, and ensuring that family members cannot overhear medical staff conversations at the time of the patient's death.