End-of-life care in intensive care unit: Family experiences

Family-Focused Nursing Research in WHO Afro-Region Member States: A Scoping Review

Although family nursing research has become an important focus for over the past 20 years, the evolution and extent of family nursing research in the World Health Organization (WHO) Afro-regions is less explored. The purpose of this scoping review was to map the evidence of family-focused nursing research using the Joanna Briggs Institute Scoping Review methodology. A systematic electronic search of articles was carried out for the period January 1, 2000 to December 31, 2020. The review process culminated in 85 articles, evidencing an increase in publications particularly in 2019 (n = 12). Eighteen countries were involved, with the Southern African region contributing 52% of the studies. Family members were predominantly described as parents, siblings, and children, with the most focused area of study being family experiences (n = 52). The majority of studies (n = 59) used qualitative methodologies. Despite the recent increase in family-focused nursing research in the WHO Afro-regions, further qualitative research, including more complex methodologies and interventions are still required to build contextualized evidence-based family-focused nursing.

Needs of Family Members of Intensive Care Patients

This article reports the results of a research project designed to identify the needs of family members and others who are coping with hospitalization of loved one in the intensive care unit, thus alleviating stress. The health care provider's viewpoints were also considered. Study participants were 9 family members of intensive care unit patients and 24 health care providers working in intensive care units. Data were collected and analyzed from 24 individual interviews (average of 35 minutes per interview) and 1 focus group interview (1 hour). The findings revealed 2 basic needs: (1) reducing concerns and (2) being supported. The first need could be addressed by open visitation, access to information, assurance of quality of care, and empowerment via education and involvement. The second need could be met by emotional support, access to facilities, and postdischarge support. Health care providers and decision makers can use these results to respond to these needs and increase people's satisfaction of intensive care unit services.

Agencies Displayed by Patients, Medical Teams, and Caregivers at the End of Life from the Perspectives of Family Members - A Qualitative Study

Background: End-of-life (EoL) Care is challenging for terminally-ill patients and their caregivers. This research is aimed to examine the relational agencies of the patients, the caregivers, and the medical teams in the context of EoL care, with a particular emphasis on the caregivers. Methods: This study is based on the qualitative analysis of interviews with 12 individuals who were closely supported a loved one to their death from a terminal illness. Results: Information collected revealed several agency-related themes. Family caregivers are significant entities in managing the 'case' of a seriously ill individual. At the final or more advanced stages of the EoL process, caregivers gradually shift from a supportive role to being active agents, but not always backed by the necessary experience, knowledge, or the requisite emotional resilience. Conclusions: Based on recognizing their agentic proactivity, a clear and elaborate articulation of the family caregivers' roles is needed.

Spiritual Care in the Intensive Care Unit: Experiences of Dutch Intensive Care Unit Patients and Relatives

BACKGROUND/OBJECTIVE

To gain insight into both patients' and relatives' experiences with spiritual care (SC) in the intensive care unit (ICU).

METHODS

Method used was qualitative interviewing. This was a thematic, topic-centered, biographical, and narrative approach, using semistructured interviews with thematic analysis. A purposive sampling method was used to select a sample of ICU patients and ICU patients' relatives. An interview guide facilitated individual, semistructured interviews. The interview data were recorded by means of note-taking and audio-recording. Verbatim transcripts were compiled for analysis and interpretation.

RESULTS

All 12 participants-7 ICU patients and 5 family members of 5 other ICU patients-experienced ICU admission as an existential crisis. Participants would appreciate the signaling of their spiritual needs by ICU health care professionals (HCPs) at an early stage of ICU admission and subsequent SC provision by a spiritual caregiver. They regarded the spiritual caregiver as the preferred professional to address spiritual needs, navigate during their search for meaning and understanding, and provide SC training in signaling spiritual needs to ICU HCPs.

DISCUSSION

Early detection of existential crisis signals with ICU patients and relatives contributes to the mapping of spiritual and religious needs. Spiritual care training of ICU HCPs in signaling spiritual needs by ICU patients and relatives is recommended. Effective SC contributes to creating room for processing emotions, spiritual well-being, and satisfaction with integrated SC as part of daily ICU care.

Health Literacy of Surrogates and Communication Issues in Palliative Care Conversations in Critical Care: An Integrative Review

Worldwide, 56.8 million persons are estimated to require palliative care. Critically ill patients benefit from palliative care by improving their quality of life through symptom management. Resistance to palliative care exists from surrogate decision-makers because of low health literacy and communication issues with providers. This research reviewed the literature to identify how health literacy and health care communication influenced palliative care conversations with decision-making surrogates and health outcomes of critically ill patients. The review included articles between 2011 and 2022 using the terms communication, health literacy, palliative care, critical care, intensive care, ICU, surrogate decision maker, family, and caregiver in PubMed, CINAHL, and Google Scholar. Fourteen articles were included. Quality was assessed through Joanna Briggs Institute appraisal tools. Health literacy of surrogates was not found to be significant for patient outcomes. However, there were significant differences between clinician and surrogate communication influenced by surrogates' previous health care experiences. Early communication about prognosis was important for surrogates. Structured communication approaches were preferred by surrogates. Limitations of the review included primarily White participants, small variability of research sites, and a few number of articles. Future research needs to study the effects of surrogate health literacy of critically ill patients on willingness to accept palliative care.

Healthcare Professionals' Perspective on Palliative Care in Intensive Care Settings: An Interpretive Descriptive Study

There is a growing need to integrate palliative care into intensive care units and to develop appropriate knowledge translation strategies. However, multiple challenges persist in attempts to achieve this objective. In this study, we aimed to explore intensive care professionals' perspectives on providing palliative and end-of-life care within an intensive care context. We used an interpretive description approach and interviewed 36 intensive care professionals at four hospitals in Saudi Arabia. Our findings reflect a discourse about end-of-life care driven by a do-not-resuscitate classification and challenges associated with family involvement in care goals. We provide key insights of importance for the development of strategies for the integration and knowledge translation of palliative care into intensive care contexts.

The impact of family visitor restrictions on healthcare workers in the ICU during the COVID-19 pandemic

PURPOSE

To obtain information on how family visitor restriction during the COVID-19 pandemic has impacted the workplace experience of physicians and nurses in the medical intensive care unit, and to assess differences by profession.

MATERIALS AND METHODS

We developed a survey containing closed- and open-ended questions, applying both quantitative and qualitative analyses to our results.

RESULTS

Of the 74 respondents, 29 (38%) were nurses and 45 (62%) were physicians. Nurses reported positive changes to daily workflow and the ability to provide medical care, while physicians reported negative changes in these areas. Both groups reported decreased comprehension and increased distress among families, and decreased ability to provide end-of-life care. For the qualitative analysis, eight themes were identified: the patient's room as space, creation of a new space through virtual communication, time, increased complexity of care, challenges around the use of technology, adjustments to team roles and responsibilities, desire for families to return, and internal tension.

CONCLUSION

Intensive care physicians and nurses reported both positive and negative effects of family visitor restriction during the COVID-19 pandemic, with significant differences based on profession. Both groups expressed concern for an overall negative impact of visitor restriction on healthcare workers, patients, and their families.

Bereavement Experiences of Families in the Cardiac Intensive Care Unit

BACKGROUND

Losing a loved one in the intensive care unit is associated with complicated grief and increased psychologic distress for families. Providing bereavement support may help families during this time. However, little is known about the bereavement experiences of families of patients in the cardiac intensive care unit.

OBJECTIVE

To describe the bereavement experiences of families of patients in the cardiac intensive care unit.

METHODS

In this secondary analysis, an exploratory, descriptive design was used to understand the families' bereavement experiences. Families from 1 cardiac intensive care unit in a tertiary medical center in the western United States participated. Audiotaped telephone interviews were conducted by using a semistructured interview guide 13 to 15 months after the patient's death. A qualitative, descriptive technique was used for data analysis. Two independent researchers coded the interview transcripts and identified themes.

RESULTS

Twelve family members were interviewed. The majority were female (n = 8, 67%), spouses (n = 10, 83%), and White (n = 10, 83%); the mean age (SD) was 58.4 (16.7) years. Five main themes emerged: (1) families' bereavement work included both practical tasks and emotional processing; (2) families' bereavement experiences were individual; (3) these families were resilient and found their own resources and coping mechanisms; (4) the suddenness of a patient's death influenced families' bereavement experiences; and (5) families' experiences in the intensive care unit affected their bereavement.

CONCLUSIONS

This study provided insight into the bereavement experiences of families of patients in the cardiac intensive care unit. These findings may be useful for professionals working with bereaved families and for cardiac intensive care units considering adding bereavement support.

The family in the intensive care unit in the face of a situational crisis

OBJECTIVE

to explore the experience of family members of a relative hospitalised in the Intensive Care Unit and recognise their emotions and needs and describe the phases or milestones they go through and the strategies they use to cope with the situations that arise.

METHOD

Qualitative study developed under the grounded theory method proposed by Anselm Strauss and Juliet Corbin. During the period from July 2017 to July 2019, semi-structured interviews were conducted with 26 relatives of hospitalised patients in fifteen third-level private clinics in the city of Manizales and Medellín, Colombia. In the latter, 200 h of participant observation were performed in ICUs of two private third-level clinics. The analysis procedure consisted of a microanalysis of the data and the process of open, axial, and selective coding of the information was continued.

RESULTS

We identified that the experience of relatives when they accompany their sick relative in the Intensive Care Unit is represented in two categories: family disorganisation which is characterised by generating a change and mismatch in family dynamics and, family reorganisation in which a restoration of order is sought to cope with the situation.

CONCLUSIONS

The family in the Intensive Care Unit develops a situational crisis characterised by intense, varied, and negative emotions and needs that wear down the relatives. Faced with this, family members undertake a reorganisation process to restore the order of family dynamics to cope with the situation and overcome difficulties.

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.

Practice Recommendations for End-of-Life Care in the Intensive Care Unit

TOPIC

A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices.

CLINICAL RELEVANCE

Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members.

PURPOSE OF PAPER

To provide recommendations for high-quality end-of-life care for patients and family members.

CONTENT COVERED

This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.

The family in the intensive care unit in the face of a situational crisis

OBJECTIVE

To explore the experience of family members of a relative hospitalized in the intensive care unit and recognize their emotions and needs and describe the phases or milestones they go through and the strategies they use to cope with the situations that arise.

METHOD

Qualitative study developed under the grounded theory method proposed by Anselm Strauss and Juliet Corbin. During the period from July 2017 to July 2019, semi-structured interviews were conducted with 26 relatives of hospitalized patients in fifteen third-level private clinics in the city of Manizales and Medellín, Colombia. In the latter, 200 hours of participant observation were performed in ICUs of two private third-level clinics. The analysis procedure consisted of a microanalysis of the data and the process of open, axial, and selective coding of the information was continued.

RESULTS

We identified that the experience of relatives when they accompany their sick relative in the intensive care unit is represented in two categories: family disorganization which is characterized by generating a change and mismatch in family dynamics and, family reorganization in which a restoration of order is sought to cope with the situation.

CONCLUSIONS

The family in the intensive care unit develops a situational crisis characterized by intense, varied, and negative emotions and needs that wear down the relatives. Faced with this, family members undertake a reorganization process to restore the order of family dynamics to cope with the situation and overcome difficulties.

Family Members' Knowledge and Attitude Toward Life-Sustaining Treatment Decisions for Patients in the Intensive Care Unit

The decision to withhold or withdraw life-sustaining treatment (LST) lies sometimes in the hands of intensive care unit patients' families. Since 2018, family members of dying patients in South Korea have had the legal right to make decisions for the patients. This study aimed to examine knowledge and attitude toward LST among the family members of patients under intensive care since the foundation of the new legislation. Their perceptions of the roles of nurses were also explored. In this cross-sectional study, 89 participants completed survey questionnaires on demographic characteristics, relationship to patient, reason for admission, length of stay, awareness of the new legislation, knowledge and attitude toward LST, and perception of the role of nurses. The results indicated that knowledge was significantly associated with attitude and was, in fact, the only predictor of attitude toward LST (P = .021). Explaining the disease and prognosis in detail and relieving patients of their physical pain were the roles of nurses most valued by family members. The findings suggest that it is crucial for nurses to support family members and provide information about critical changes and medical options for collaborative decision making according to the patients' wishes during the dying process.

A qualitative study of bereaved relatives' end of life experiences during the COVID-19 pandemic

BACKGROUND

Meeting the needs of relatives when a family member is dying can help facilitate better psychological adjustment in their grief. However, end of life experiences for families are likely to have been deleteriously impacted by the COVID-19 crisis. Understanding how families' needs can be met during a global pandemic will have current/future relevance for clinical practice and policy.

AIM

To explore relatives' experiences and needs when a family member was dying during the COVID-19 pandemic.

DESIGN

Interpretative qualitative study using semi-structured interviews. Data were analysed thematically.

SETTING/PARTICIPANTS

A total of 19 relatives whose family member died during the COVID-19 pandemic in the United Kingdom.

RESULTS

In the absence of direct physical contact, it was important for families to have a clear understanding of their family member's condition and declining health, stay connected with them in the final weeks/days of life and have the opportunity for a final contact before they died. Health and social care professionals were instrumental to providing these aspects of care, but faced practical challenges in achieving these. Results are presented within three themes: (1) entering into the final weeks and days of life during a pandemic, (2) navigating the final weeks of life during a pandemic and (3) the importance of 'saying goodbye' in a pandemic.

CONCLUSIONS

Health and social care professionals can have an important role in mitigating the absence of relatives' visits at end of life during a pandemic. Strategies include prioritising virtual connectedness and creating alternative opportunities for relatives to 'say goodbye'.

The effect of professional education on medical and nursing students' attitudes toward death

This qualitative study aims to reveal the effect of professional education on medical and nursing students' attitudes toward death. The study was carried out with nursing and medical students (N = 197). Research data was collected through semi-structured interview questions and 23 focus group interviews. The data was assessed using thematic analysis method. The themes were evaluated within the context of perception of death, ethical dilemmas, and, death education. To achieve professional competency in attitudes toward death, it is imperative to form a common educational curriculum and practice that would help students develop a mutual language and value system about death.

Family and health professional experience with a nurse-led family support intervention in ICU: A qualitative evaluation study

OBJECTIVES

To investigate family and health professional experience with a nurse-led family support intervention in intensive care.

DESIGN

Qualitative evaluation study.

SETTING

A twelve-bed surgical intensive care unit in a 900-bed University Hospital in Switzerland.

MAIN OUTCOME MEASURES

Data were collected through 16 semi-structured interviews with families (n = 19 family members) and three focus group interviews with critical care staff (n = 19) and analysed using content analysis strategies.

FINDINGS

Four themes related to the new family support intervention were identified. First, families and staff described it as a valuable and essential part of ICU care. Second, it facilitated staff-family interaction and communication. Third, from staff perspective, it promoted the quality of family care. Fourth, staff believed that the family support intervention enabled them to better care for families through increased capacity for developing and sustaining relationships with families.

CONCLUSIONS

An advanced practice family nursing role coupled with a family support pathway is an acceptable, appreciated and beneficial model of care delivery in the inttensive care unit from the perspective of families and critical care staff. Further research is needed to investigate the intervention's effectiveness in the intensive care unit.

A qualitative meta-synthesis investigating the experiences of the patient's family when treatment is withdrawn in the intensive care unit

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.

Nurse-family relationship. Beyond the opening of doors and schedules

INTRODUCTION

Care in the Intensive Care Unit involves contemplating, among other dimensions of the patient, the family. For this, it is necessary for the nurse to establish relationships with the patient's relatives.

OBJECTIVE

To identify the way in which the nurse-family relationship is established in the adult ICU, as well as the conditions, elements and factors that favour or hinder it.

METHOD

Integrative narrative review of the scientific literature. The databases consulted were Ovid, PubMed, Science Direct, Scopus, Clinical Key, Google Scholar and Scielo. Articles in English and Spanish published between 2014 and 2018 were searched. The descriptors and formulas used were selected according to the acronym Population and their problems, Exposure and Outcomes or themes- PEO. The population comprised ICU nurses and the relatives of patients in critical condition; Adult Intensive Care Unit exposure or context; the expected results, and how they are related. For the methodological evaluation, the STROBE guide was used for observational articles, PRISMA for review articles, COREQ for qualitative articles and CASPe for articles derived from projects.

RESULTS

We identified 214 articles, of which 63 were selected to be included in the review. The central themes identified were: the ICU environment and its effects on the family, empathy as an indicator of relationship, interaction as a means of relating, communication as the centre of relationships and barriers to the establishment of relationships.

CONCLUSIONS

The nurse-family relationship in the Intensive Care Unit is based on interaction and communication amidst human, physical, regulatory and administrative barriers. Improving the nurse-family relationship contributes to the humanization of Adult Intensive Care Units.

End of life in acute hospital setting-A systematic review of families' experience of spiritual care

AIMS AND OBJECTIVES

To systematically review qualitative studies exploring families' experiences of spiritual care at the end of life in acute hospital settings.

BACKGROUND

Although there is a widespread belief that the consideration of spiritual and religious needs is outdated in the context of secularism, from a practical perspective patients and families appear to benefit from spiritual support at the end of life.

METHODS

Six key databases, CINAHL, MEDLINE, EMBASE, Global Health Library, Web of Science and Applied Social Sciences Index and Abstracts (ASSIA), were searched, and three reviewers independently extracted the data and coded them into themes and subthemes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used as a reporting framework.

RESULTS

Five main themes emerged: anticipating needs; honouring the family by honouring the patient; personal connection; lack of sensitivity; and making space for religious and spiritual practices.

CONCLUSIONS

Families experiencing end-of-life care in acute hospital settings may benefit from spiritual care. While this can also be considered as fundamental care, understanding this through the lenses of spiritual care allows for incorporation of religious and spiritual practices that many seek at this time, irrespective of their faith perspectives.

RELEVANCE TO CLINICAL PRACTICE

Although hospice care is well established internationally, many families experience end-of-life care in acute hospital settings. Nurses usually get to know families well during this time; however, the demands of the clinical environment place restrictions on family care and perceptions of lack of communication, limited support and/or limited sensitivity can compound families' suffering. Consideration of families' spiritual needs can help to support families during this time. Nurses are ideally placed for this and can anticipate and plan for patient and family needs in this regard, or refer to a specialist, such as the Healthcare Chaplain.

Spiritual care in the intensive care unit: An integrative literature research

PURPOSE

The aim of this study is to review the literature for three major domains in relation to spiritual care in the ICU, namely Quality of Life (QoL), Quality of Care (QoC), and Education (E).

METHOD

An integrative literature research.

RESULTS

The 113 selected articles reveal that spirituality is an essential component of QoL and that complementary and effective spiritual care (SC) relieves distress of patients and their relatives. Furthermore, the contribution of SC to quality of care is: 1) diagnosing and addressing spiritual and emotional needs among patients and their relatives; 2) offering spiritual comfort to the patient in distress; 3) increased spiritual well-being of both patients and their relatives; 4) increased family satisfaction in general and by shared decision-making. Finally, the literature reveals the necessity to improve SC knowledge and skills of ICU healthcare professionals (IC HCPs) through relevant training courses.

CONCLUSION

SC contributes to QoL and QoC. The literature indicates that IC HCPs acknowledge the need to improve their SC knowledge and skills to enhance complementary, effective SC. Further research on SC as an integrated part of daily ICU care is necessary to improve QoL and QoC of patients and their relatives.

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.

Challenges of older adults when a loved one was dying: Implications for nursing practice

AIMS

To explore the challenge of losing a loved one who was hospitalized at end of life and identify approaches deemed most helpful by older adult family members to resolve this challenge.

BACKGROUND

Nurses will be caring for a growing number of terminally ill older adults and their families. Research specific to older adults to address their needs when a loved one is dying is necessary to promote quality family-oriented care.

METHODS

A qualitative descriptive exploratory study was conducted with a purposive sample of 15 older adult family members during July-August 2015. Methods for data collection and analysis included story theory inquiry and theory-guided content analysis.

RESULTS

The dimensions of the challenge of losing a loved one include: moving from painful holding on to poignant letting go, uneasiness that permeates everyday living and precious memories, patterns of disconnect that breed discontent, and pervasive ambiguity that permeates perspectives about remaining time. Active engagement enabling exceptional care for loved ones, appreciating the rhythmic flow of everyday connecting and separating to get by, and embracing reality as situated in one's lifelong journey are the approaches to resolve this challenge.

CONCLUSIONS

Knowing a loved one was well cared for through nurses' compassionate caring was most important to older adults. Further research to address the self-care strategies of older adults as a loved one is dying is necessary. This study's nursing implications has the potential to enhance the quality of family-oriented care at end of life in diverse healthcare settings.

Family Outcomes and Perceptions of End-of-Life Care in the Intensive Care Unit: A Mixed-Methods Review

The purpose of this review was to evaluate end-of-life care (EOLC) in the intensive care unit (ICU) from the perspective of family members. Sandelowski's segregated approach from Joanna Briggs Institute (JBI) Mixed-Methods Systematic Reviews guided this review. A search was conducted in PubMed, CINAHL, PsycINFO, EMBASE, and ProQuest databases and identified 50 papers (33 quantitative, 15 qualitative, and 2 mixed-methodology studies). Five synthesized themes (distressing emotions, shared decision-making, proactive communication, personalized end-of- life care, and valuing of nursing care) were identified. For quantitative results, study methodologies and interventions were heterogeneous and did not always improve family members' perceived quality of care and family members' psychological distress. Configuration of qualitative and quantitative data revealed ICU end-of-life interventions were ineffective because they were not guided by family members' reported needs and perceptions. To fulfill the family members' needs for the patients' EOLC in the ICU, researchers should develop a theory to explicitly explain how the family members experience ICU EOLC and implement a theory-based intervention to improve family psychological outcomes.

Development of a Clinical Guide for Identifying Spiritual Distress in Family Members of Patients in the Intensive Care Unit

Background: Spirituality is important for many family members of patients in the intensive care unit (ICU). Clinicians without training in spiritual care experience difficulty identifying when family members are experiencing distress of a spiritual nature. Objective: The purpose of this study was to develop a guide to help clinicians working in the ICU identify family members who may benefit from specialized spiritual support. Design: Cross-sectional study. Setting/Subjects: A national sample of spiritual health practitioners, family members, and ICU clinicians. Subjects: A panel of 21 spiritual health practitioners participated in a modified Delphi process to achieve consensus on items that suggest spiritual distress among family members of patients in the ICU through three rounds of remote review followed by an in-person conference and a final round of panelist feedback. Feedback on the final set of items was obtained from an end-user group of four family members and six ICU clinicians. Measurements: Quantitative data were summarized with descriptive statistics. Content analysis was used to analyze written comments. Results: A total of 220 items were iteratively reviewed and rated by panelists. Forty-six items were identified as essential for inclusion and developed into a clinical guide, including an introduction (n = 1), definitions (n = 2), risk factors (n = 10), expressed concerns (n = 12), emotions (n = 7) and behaviors (n = 7) that may suggest spiritual distress, questions to identify spiritual needs (n = 6), and introducing spiritual support (n = 1). Conclusions: We have developed an evidence-informed clinical guide that may help clinicians in the ICU identify family members experiencing spiritual distress.

Staff perception of obstacles and facilitators when providing end of life care in critical care units of two teaching hospitals: A survey design

OBJECTIVE

To determine perceptions of Jordanian critical care staff about obstacles and facilitators to end-of-life care.

RESEARCH METHODOLOGY

The "National Survey of Critical Care Nurses' Perceptions of End-of-Life Care" was adapted and distributed to 143 critical care nurses (n = 110) and physicians (n = 33) in two Jordanian hospitals. Nurses and physicians completed items about perceived obstacles to end-of-life care. Nurses only completed items about facilitators to end-of-life care.

RESULTS

The overall response rate was 72.7% (n = 104/143). Seventy-six nurses (69.1%) and 28 physicians (84.5%) responded. Nurses and physicians agreed that the highest scoring obstacles were: 'family members who do not understand what life-saving measures mean' and the 'poor design of critical care units'. Other highly scoring obstacles related to clinicians' behaviours, characteristics and attitudes. Nurses perceived the highest scoring facilitator was 'family members who accepted that the patient was dying'.

CONCLUSION

There is a need to further explore the issues underlying perceptions about clinicians' behaviours, which were perceived to be key barriers to quality end-of-life care and to find acceptable solutions that fit with Islamic culture. It is the first time that the survey has been used to gather perceptions of doctors and nurses in a non-western culture.

Family members' experiences of waiting in intensive care: a concept analysis

AIM

The aim of this study was to explore the meaning of family members' experience of waiting in an intensive care context using Rodgers' evolutionary method of concept analysis.

METHOD

Systematic searches in CINAHL and PubMed retrieved 38 articles which illustrated the waiting experienced by family members in an intensive care context. Rodgers' evolutionary method of concept analysis was applied to the data.

FINDINGS

In total, five elements of the concept were identified in the analysis. These were as follows: living in limbo; feeling helpless and powerless; hoping; enduring; and fearing the worst. Family members' vigilance regarding their relative proved to be a related concept, but vigilance does not share the same set of attributes. The consequences of waiting were often negative for the relatives and caused them suffering. The references show that the concept was manifested in different situations and in intensive care units (ICUs) with various types of specialties.

CONCLUSIONS

The application of concept analysis has brought a deeper understanding and meaning to the experience of waiting among family members in an intensive care context. This may provide professionals with an awareness of how to take care of family members in this situation. The waiting is inevitable, but improved communication between the ICU staff and family members is necessary to reduce stress and alleviate the suffering of family members. It is important to acknowledge that waiting cannot be eliminated but family-centred care, including a friendly and welcoming hospital environment, can ease the burden of family members with a loved one in an ICU.

Critically ill patients' experiences of nursing care in the intensive care unit

BACKGROUND

Understanding critically ill patients' experiences of nursing care is an important aspect that can improve quality of care in the intensive care unit.

AIM

To elicit critically ill patients' experiences of nursing care in the adult intensive care units.

DESIGN

A qualitative descriptive design was utilized.

METHODS

Sixteen patients who had a predicted mortality risk of above 50% within the first 24 h of admission to the intensive care unit and had been discharged to the ward were purposively selected. The study was conducted at three academic affiliated, tertiary/quaternary specialist hospitals in South Africa. Individual semi-structured interviews were conducted with the selected participants until a point of data saturation was reached. Data were analysed using a conventional content analysis technique (Hsieh and Shannon, 2005). Lincoln and Guba's criteria for ensuring the trustworthiness of qualitative research were applied.

FINDINGS

Four major themes emerged: 'being in someone's shoes', 'communication', 'presence' and 'religion and spirituality'.

CONCLUSIONS

Even though some participants' responses reflected 'good' nursing care, the majority of the participants had negative experiences in relation to the nursing care they received while admitted in the selected intensive care units.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates critically ill patients' voices and preferences of intensive nursing care and describes some issues that require not only nurses' but also managerial improvements and interventions in order to ensure quality care and, eventually, patients' satisfaction with intensive nursing care.

Communication, the Key in Creating Dignified Encounters in Unexpected Sudden Death - With Stroke as Example

Aim:

The aim of this study was to illuminate the communication and its meaning in unexpected sudden death with stroke as example, as experienced by stroke team members and next of kin.

Subject and Methods:

The study has a qualitative design. Secondary analysis of data from four previous interview studies with stroke team members; physicians, registered nurses, and enrolled nurses from the stroke units (SU) and next of kin of patients who had died due to acute stroke during hospital stay were utilized.

Results:

Communication is revealed as the foundation for care and caring with the overarching theme foundation for dignified encounters in care built-up by six themes illuminating the meaning of communication in unexpected sudden death by stroke.

Conclusion:

Communication shown as the foundation for dignified encounters in care as experienced by stroke team members and next of kin enables the patient to come forth as a unique person and uphold absolute dignity in care. Acknowledging the next of kin's familiarity with the severely ill patient will contribute to personalizing the patient and in this way be the ground for a person centeredness in care despite the patients’ inability to defend their own interests. Through knowledge about the patient as a person, the foundation for dignified care is given, expressed through respect for the patient's will and desires and derived through conversations between carers and next of kin.

Family Members' Experiences With Bereavement in the Intensive Care Unit

BACKGROUND

Losing a loved one in the intensive care unit can be challenging for families. Providing bereavement support may assist in the grieving process.

OBJECTIVE

To describe family members' experiences with bereavement after the death of a loved one in the intensive care unit.

METHODS

This secondary analysis used an exploratory, descriptive design to study family members' experiences with bereavement. Family members of patients from 2 intensive care units in a tertiary medical center in the western United States participated. Audiotaped telephone interviews using a semistructured questionnaire were conducted. A qualitative, descriptive technique was used for data analysis. Two independent raters coded transcripts of audiotaped interviews with family members about their bereavement experiences.

RESULTS

Seventeen family members participated in the study. Most participants were female (n = 12; 71%) and spouses of deceased patients (n = 14; 82%), and their mean (SD) age was 62.4 (10.0) years. Three themes emerged: (1) bereavement was an individual experience; (2) situations occurring during the intensive care unit encounter remained significant for family members beyond a year after the death; and (3) social, cultural, spiritual, and religious events after the death hold importance for families of patients in the intensive care unit.

CONCLUSIONS

Bereavement is a challenging experience for families of deceased intensive care unit patients. The themes identified in this study add insight into the experiences of these family members. The results of this study may guide future interventions to help support bereaved families of intensive care unit patients.

[End-of-Life Care in Intensive Care Units: Nursing strategies of family involvement at the end of life]

Background: Family members of people dying in the intensive care unit (ICU) are exposed to many stress factors and they often do not experience involvement in End-of-Life (EoL) situations. For example, they criticize a low degree of participation in patients care, delayed or incomplete information and lack of privacy. Even nursing staff is facing various obstacles in EoL situations in ICUs. Aim: This study investigates strategies used by ICU nursing staff in German-speaking Switzerland to increase family members participation in situations at the end of life. Method: Data was collected by conducting 12 semi-structured interviews using an approach based on Grounded Theory. A model was developed to explain nursing strategies for family involvement in EoL situations in the ICU. Conclusions: Nurses provide personal space and tranquillity for family members and allow them to be present at any time. Against this background, they support family members and enable them to say goodbye consciously to a loved one. Subsequent work should examine the effectiveness of the strategies described, particularly in terms of stress reactions displayed by family members in the aftermath of EoL situations. In practice, family members should be provided space for privacy. The entire healthcare team is recommended to identify and pursue common values and objectives. Moreover, intradisciplinary exchange and mentoring need to be encouraged. In order to prepare future nursing staff for EoL situations in the ICU, recognizing and promoting their educational skills is mandatory.

Spiritual Care in the Intensive Care Unit: A Narrative Review

Spiritual care is an important component of high-quality health care, especially for critically ill patients and their families. Despite evidence of benefits from spiritual care, physicians and other health-care providers commonly fail to assess and address their patients' spiritual care needs in the intensive care unit (ICU). In addition, it is common that spiritual care resources that can improve both patient outcomes and family member experiences are underutilized. In this review, we provide an overview of spiritual care and its role in the ICU. We review evidence demonstrating the benefits of, and persistent unmet needs for, spiritual care services, as well as the current state of spiritual care delivery in the ICU setting. Furthermore, we outline tools and strategies intensivists and other critical care medicine health-care professionals can employ to support the spiritual well-being of patients and families, with a special focus on chaplaincy services.

Tough Conversations: Development of a Curriculum for Medical Students to Lead Family Meetings

Background:

Few educational interventions have been developed to teach Family Meeting (FM) communication skills at the undergraduate level. We developed an innovative curriculum to address this gap.

Methods:

Fourth year medical students during 2011-2013 (n = 674) completed training for conducting a FM. To assess the effectiveness of this training, students completed a FM Objective Structured Clinical Exam (OSCE) that included 15 domains rated on a 1-5 point Likert scale. Tasks included discussing prognosis, establishing goals of care and demonstrating conflict resolution skills. Students received one-to-one feedback from standardized family members and faculty observers. Group debriefings with faculty were held after the OSCE.

Results:

Analysis of faculty feedback narratives revealed four themes in which students required improvement: 1) Discussing prognosis, 2) Explaining palliative care/hospice, 3) Avoiding medical jargon, and 4) Discussing cultural/religious preferences. Evaluation total mean score was 28.2 (Min 15, Max 63; SD 7.57), and identified student’s need to; 1) Ask more about the degree of knowledge family members want, 2) Ask religious beliefs, and 3) Assess family members’ level of education ( p < 0.001). Qualitative analysis of group debriefings suggested that student perception of the OSCE experience was positive overall. Students found the case to be realistic and immediate feedback to be helpful.

Conclusions:

Conducting a FM is an advanced skill. This study shows that it is possible to train fourth year students to lead FMs and identify their strengths, needs using a FM OSCE.