Intensive care unit cultures and end-of-life decision making

Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure

Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.

Interprofessional clinical decision-making process in health: A scoping review

AIMS

To describe the key elements of the interprofessional decision-making process in health, based on published scientific studies. To describe the authors, reviews and subject matter of those publications.

DESIGN

Scoping review of the literature.

DATA SOURCES

MEDLINE, APA Psycinfo OpenGrey, Lissa and Cochrane databases were searched in December 2019 and January 2023.

REVIEW METHODS

References were considered eligible if they (i) were written in French or English, (ii) concerned health, (iii) studied a clinical decision-making process, (iv) were performed in an interprofessional context. 'PRISMA-scoping review' guidelines were respected. The eligible studies were analysed and classified by an inductive approach RESULTS: We identified 1429 sources of information, 145 of which were retained for the analysis. Based on these studies, we identified five key elements of interprofessional decision-making in health. The process was found to be influenced by group dynamics, the available information and consideration of the unique characteristics of the patient. An organizational framework and specific training favoured improvements in the process.

CONCLUSION

Decision-making can be based on a willingness of the healthcare organization to promote models based on more shared leadership and to work on professional roles and values. It also requires healthcare professionals trained in the entire continuum of collaborative practices, to meet the unique needs of each patient. Finally, it appears essential to favour the sharing of multiple sources of accessible and structured information. Tools for knowledge formalization should help to optimize interprofessional decision-making in health.

IMPACT

The quality of a team decision-making is critical to the quality of care. Interprofessional decision-making can be structured and improved through different levels of action. These improvements could benefit to patients and healthcare professionals in every settings of care involving care collaboration.

IMPACT STATEMENT

Interprofessional decision-making in health is an essential lever of quality of care, especially for the most complex patients which are a contemporary challenge. This scoping review article offers a synthesis of a large corpus of data published to date about the interprofessional clinical decision-making process in healthcare. It has the potential to provide a global vision, practical data and a list of references to facilitate the work of healthcare teams, organizations and teachers ready to initiate a change.

Palliative care integration in the intensive care unit: healthcare professionals' perspectives - a qualitative study

OBJECTIVES

The complex care needs and high mortality of critically ill patients in intensive care unit (ICU) warrants a team approach. While studies have affirmed the integral role of palliative care teams in ICU, little is known about the ICU healthcare professional's perception on how this integration affects the care of the critically ill.This study examines their perception of how integration of palliative care into ICU practice affects interprofessional collaborative practices and relationships in the delivery of care.

METHODS

A qualitative study was conducted in 13 focus group discussions with 54 ICU healthcare professionals recruited through purposive sampling. Data were analysed using a qualitative descriptive approach reflecting uninterpreted participants' description of their experiences in its most unbiased manner.

RESULTS

ICU clinicians perceived that palliative care integration into the ICU enhanced care of patients and team dynamics in three areas: (1) bridging care, (2) cultural shift and (3) empowering, advocating and enhancing job satisfaction. Enhanced collaborative efforts between disciplines led to improved mutual understanding, shared-decision making and alignment of care goals. There was a shift in perception of dying as a passive process, to an active process of care where various healthcare professionals could work together to optimise symptom control and support grieving families. Team members felt empowered to advocate for patients, improving their sense of job fulfilment.

CONCLUSIONS

Palliative care integration enhanced perception of collaborative practices in caring for the dying. Future studies could use empirical methods to measure collaboration and patient outcomes to further understand team dynamics.

What Affects Adoption of Specialty Palliative Care in Intensive Care Units: A Qualitative Study

CONTEXT

Although many patients with critical illness may benefit from involvement of palliative care specialists, adoption of these services in the intensive care unit (ICU) is variable.

OBJECTIVE

To characterize reasons for variable buy-in for specialty palliative care in the ICU, and identify factors associated with routine involvement of specialists in appropriate cases.

METHODS

Qualitative study using in-depth, semi-structured interviews with ICU attendings, nurses, and palliative care clinicians, purposively sampled from eight ICUs (medical, surgical, cardiothoracic, neurological) with variable use of palliative care services within two urban, academic medical centers. Interviews were transcribed and coded using an iterative and inductive approach with constant comparison.

RESULTS

We identified three types of specialty palliative care adoption in ICUs, representing different phases of buy-in. The "nascent" phase was characterized by the need for education about palliative care services and clarification of which patients may be appropriate for involvement. During the key "transitional" phase, use of specialists depended on development of "comfort and trust", which centered on four aspects of the ICU-palliative care clinician relationship: 1) increasing familiarity between clinicians; 2) navigating shared responsibility with primary clinicians; 3) having a collaborative approach to care; and 4) having successful experiences. In the "mature" phase, ICU and palliative care clinicians worked to strengthen their existing collaboration, but further adoption was limited by the availability and resources of the palliative care team.

CONCLUSION

This conceptual framework identifying distinct phases of adoption may assist institutions aiming to foster sustained adoption of specialty palliative care in an ICU setting.

Managerial and organisational prerequisites for the integration of palliative care in the intensive care setting: A qualitative study

AIM

To explore the association of organizational structures when integrating palliative care in intensive care units.

BACKGROUND

Palliative care within intensive care settings has been widely recognized as an area requiring improvement when caring for patients and their families. Despite this, intensive care units continue to struggle to integrate palliative care.

METHODS

A qualitative descriptive methodology was used. Data were collected through research interviews with 15 managers and 36 health care professionals working in intensive care. The data were analysed adopting constant comparative analysis.

RESULTS

This study provides insight into a diverse range of perspectives on organizational structure in the context of facilitation and the challenges posed. Three themes were identified: Do not resuscitate policy as a gateway to palliative care, facilitating family members to enable participation and support and barriers for palliative care in intensive care unit as a result of intensive care organization.

CONCLUSIONS

In fostering a sustainable organizational culture and practice development in intensive care, the findings indicate the need for specific palliative care policies and implementation strategies tailored according to context.

IMPLICATIONS FOR NURSING MANAGEMENT

Management has a responsibility to facilitate dialogue within any multidisciplinary team regarding palliative care and, in particular, to focus on 'do not resuscitate' policies as a gateway into this conversation.

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

OBJECTIVES

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

RESEARCH DESIGN

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

SETTING

General adult intensive care unit at a tertiary referral hospital.

RESULTS

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

CONCLUSION

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

Comparison of Geriatric Versus Non-geriatric Trauma Patients With Palliative Care Consultations

BACKGROUND

Palliative care in trauma patients is still evolving. The goal was to compare characteristics, outcomes, triggers and timing for palliative care consultations (PCC) in geriatric (≥65 y.o.) and non-geriatric trauma patients.

MATERIALS AND METHODS

Retrospective study included 432 patients from two level 1 trauma centers who received PCC between December 2012 and January 2019. Non-geriatric (n = 61) and geriatric (n = 371) groups were compared for: mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Score (GCS), Do-Not-Resuscitate (DNR) orders, futile interventions (FI), duration of mechanical ventilation (DMV), ICU admissions, ICU and hospital lengths of stay (ICULOS; HLOS), timing to PCC, and mortality. Further propensity matching (PM) analysis compared 59 non-geriatric to 59 Geriatric patients matched by ISS, GCS, and DNR.

RESULTS

Geriatric patients were older (85.2 versus 49.7), with falls as predominant MOI. Non-geriatric patients comprised 14.1% of all patients with PCC and were more severely injured than Geriatrics: with statistically higher ISS (24.1 versus 18.5), lower RTS (5.4 versus 7.0), GCS (7.1 versus 11.5), with predominant MOI being traffic accidents, all P < 0.01. Non-Geriatrics had more ICU admissions (96.7% versus 88.1%), longer ICULOS (10.2 versus 4.7 days), DMV (11.1 versus 4.1 days), less DNR (57.4% versus 73.9%), higher in-hospital mortality (12.5% versus 2.6%), but double the time admission-PCC (11.3 versus 4.3 days) compared to Geriatrics, all P < 0.04. In PM comparison, despite same injury severity, Non-geriatrics had triple the time to PCC, five times the HLOS of geriatrics, and more FI (25.4% versus 3.4%), all P < 0.001.

CONCLUSIONS

PCC remains underutilized in non-geriatric trauma patients. Despite higher injury severity, non-geriatrics received more aggressive treatment, and had three times longer time to PCC, resulting in higher rate of FI than in Geriatrics.

Do It to Them, Not to Me: Doctors' and Nurses' Personal Preferences Versus Recommendations for End-of-Life Care

BACKGROUND

The emotional toll and financial cost of end-of-life care can be high. Existing literature suggests that medical providers often choose to forego many aggressive interventions and life-prolonging therapies for themselves. To further investigate this phenomenon, we compared how providers make medical decisions for themselves versus for relatives and unrelated patients.

METHODS

Between 2016 and 2019, anonymous surveys were emailed to physicians (attendings, fellows, and residents), nurse practitioners, physician assistances, and nurses at two multifacility tertiary medical centers. Participants were asked to decide how likely they would offer a tracheostomy and feeding gastrostomy to a hypothetical patient with a devastating neurological injury and an uncertain prognosis. Participants were then asked to reconsider their decision if the patient was their own family member or if they themselves were the patient. The Kruskal-Wallis H, Mann-Whitney U, and Tukey tests were used to compare quantitative data. Statistical significance was set at P < 0.05.

RESULTS

Seven hundred seventy-three surveys were completed with a 10% response rate at both institutions. Regardless of professional identity, age, or gender, providers were significantly more likely to recommend a tracheostomy and feeding gastrostomy to an unrelated patient than for themselves. Professional identity and age of the respondent did influence recommendations made to a family member.

CONCLUSIONS

We demonstrate that medical practitioners make different end-of-life care decisions for themselves compared with others. It is worth investigating further why there is such a discrepancy between what medical providers choose for themselves compared with what they recommend for others.

[Family's Perception of Proxy Decision Making to Authorize Do Not Resuscitate Order of Elderly Patients in Long Term Care Facility: A Q-Methodological Study]

PURPOSE

This study aimed to distinguish and describe the types of perceptions of do not resuscitate (DNR) proxy decisions among families of elderly patients in a long-term care facility.

METHODS

This exploratory study applied Q-methodology, which focuses on individual subjectivity. Thirty-four Q-statements were selected from 130 Q-populations formed based on the results of in-depth interviews and literature reviews. The P-samples were 34 families of elderly patients in a long-term care hospital in Busan, Korea. They categorized the Q-statements using a 9-point scale. Using the PC-QUANL program, factor analysis was performed with the P-samples along an axis.

RESULTS

The families' perceptions of the DNR proxy decision were categorized into three types. Type I, rational acceptance, valued consensus among family members based on comprehensive support from medical staff. Type II, psychological burden, involved hesitance in making a DNR proxy decision because of negative emotions and psychological conflict. Type III, discreet decisions, valued the patients' right to self-determination and desire for a legitimate proxy decision. Type I included 18 participants, which was the most common type, and types II and III each included eight participants.

CONCLUSION

Families' perceptions of DNR proxy decisions vary, requiring tailored care and intervention. We suggest developing and providing interventions that may psychologically support families.

Type of Intensive Care Unit Matters: Variations in Palliative Care for Critically Ill Patients with Chronic, Life-Limiting Illness

Background: It is not clear whether use of specialty palliative care consults and "comfort measures only" (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p < 0.001) as well as presence of CMO order set at time of death (p < 0.001). Compared with medical ICUs, odds of palliative care consultation were highest in the cardiothoracic ICU and trauma ICU. Odds of CMO order set in place at time of death were highest in the neurology/neurosurgical ICU. Conclusion: Utilization of specialty palliative care consultations and CMO order sets varies across types of ICUs. Examining this variability within institutions may provide an opportunity to improve end-of-life care for patients with chronic, life-limiting illnesses who die in the ICU.

Impact of Workplace Climate on Burnout Among Critical Care Nurses in the Veterans Health Administration

BACKGROUND

Burnout is a maladaptive response to work-related stress that is associated with negative consequences for patients, clinicians, and the health care system. Critical care nurses are at especially high risk for burnout. Previous studies of burnout have used survey methods that simultaneously measure risk factors and outcomes of burnout, potentially introducing common method bias.

OBJECTIVES

To evaluate the frequency of burnout and individual and organizational characteristics associated with burnout among critical care nurses across a national integrated health care system using data from an annual survey and methods that avoid common method bias.

METHODS

A 2017 survey of 2352 critical care nurses from 94 sites. Site-level workplace climate was assessed using 2016 survey data from 2191 critical care nurses.

RESULTS

Overall, one-third of nurses reported burnout, which varied significantly across sites. In multilevel analysis, workplace climate was the strongest predictor of burnout (odds ratio [OR], 2.20; 95% CI, 1.50-3.22). Other significant variables were overall hospital quality (OR, 1.44; 95% CI, 1.05-1.99), urban location (OR, 1.93; 95% CI, 1.09-3.42), and nurse tenure (OR, 2.11; 95% CI, 1.44-3.10). In secondary multivariable analyses, workplace climate subthemes of perceptions of workload and staffing, supervisors and senior leadership, culture of teamwork, and patient experience were each significantly associated with burnout.

CONCLUSIONS

Drivers of burnout are varied, yet interventions frequently target only the individual. Results of this study suggest that in efforts to reduce burnout, emphasis should be placed on improving local workplace climate.

Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

Background

While a palliative approach is generally perceived to be an integral part of the intensive care unit (ICU), the provision of palliative care in this setting is challenging. This review aims to identify factors (barriers and facilitators) influencing a palliative approach in intensive care settings, as perceived by health care professionals.

Method

A systematic mixed-methods review was conducted. Multiple electronic databases were used, and the following search terms were utilized: implementation, palliative care, and intensive care unit. In total, 1843 articles were screened, of which 24 met the research inclusion/exclusion criteria. A thematic synthesis method was used for both qualitative and quantitative studies.

Results

Four key prerequisite factors were identified: (a) organizational structure in facilitating policies, unappropriated resources, multi-disciplinary team involvement, and knowledge and skills; (b) work environment, including physical and psychosocial factors; (c) interpersonal factors/barriers, including family and patients’ involvement in communication and participation; and (d) decision-making, e.g., decision and transition, goal conflict, multidisciplinary team communication, and prognostication.

Conclusion

Factors hindering the integration of a palliative approach in an intensive care context constitute a complex interplay among organizational structure, the care environment and clinicians’ perceptions and attitudes. While patient and family involvement was identified as an important facilitator of palliative care, it was also recognized as a barrier for clinicians due to challenges in shared goal setting and communication.

Influence of nurse's involvement on practices during end-of-life decisions within stroke units

OBJECTIVES

Decision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions.

PATIENTS AND METHODS

This secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision.

RESULTS

Among the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03).

CONCLUSION

The involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.

Critical emancipatory reflection on a practice-based issue in relation to the working relationship between doctors and nurses in China

Objective

Reflection is viewed as the most significant skill and should be advocated for lifelong learning. In order to grasp the process of reflection and embrace the reflective skill, one of the authors of this paper reflects on a practice-based issue in relation to the communication between doctors and nurses, to gain new understanding and thus improve the authors’ clinical practice.

Methods

Smyth’s framework with four stages is utilized as an ideal framework to guide the author’s reflection on the practice-based issue to free the author from her entrenched assumptions and the oppressive forces that limit her practice.

Results

The espoused and enacted theory, together with the critical reflection theory, are used to explore the values and beliefs that essentially govern the author’s practice and how these are distinct from the author’s worldviews. Following this, critical emancipatory reflection is undertaken to explore the dominant power structures within the author’s workplace. Furthermore, given the hegemonic and chaotic working context of this issue, hegemony and symbolic interaction theory are applied to unearth the various hidden constraining and oppressive forces. Additionally, socialization theory is utilized to help the author achieve professional identity.

Conclusions

Reconstructing the practice-based issue empowers the author to realize that in the future, she should act as a reflective practitioner, creating a daily habit, staying alert to practice, seeing things freshly, finding support systems, improving communication skills, conducting reflective research, and reifying reflective practice. Ultimately, the author will be sufficiently equipped to be able to transform her practice and change its outcomes.

A Model for Promoting Occupational Safety and Health in Taiwan's Hospitals: An Integrative Approach

Advocating for improving workplace safety and health has gained substantial support in recent years. The medical industry is a high-risk industry and receives considerable public attention. This study used an integrative approach as a starting point and combined the contextual factors of an organization: perceived organizational support, safety climate, social influence, and shared decision making. Subsequently, the effects of these factors on preventive action and safety satisfaction were investigated. This study surveyed employees of two hospitals, one in Northern Taiwan and one in Eastern Taiwan, collecting valid data from 468 respondents. Structural equation modeling (SEM) was used to verify our research framework. The finding indicates that (1) All hypotheses proposed in this study were supported. (2) The overall goodness of fit of the model was excellent, and the explained variance of the outcome variables was high. (3) Safety climate had the strongest total effects on preventive action and safety satisfaction simultaneously, whereas preventive action had the strongest direct effect on safety satisfaction. The objective of this study was to obtain empirical conclusions and make suggestions for academic theory and clinical practice. The findings may serve as a reference for future research and for scholars and practitioners, enabling the creation of healthy workplaces and, thus, a brighter future.

Improving end-of-life care in an intensive care unit: a collaborative quality improvement project

BACKGROUND

The shift from curative to palliative care is one of the most challenging situations in intensive care units.

AIMS

The purpose of this collaborative project was to develop and implement a pilot intervention aimed at improving end-of-life care for patients in an open intensive care unit in Quebec City, Canada.

METHODS

Individual and group interviews were first conducted to identify strengths and needs for improvement in care. After the main needs for improvement were determined, interventions were implemented in a concerted manner. These included training in end-of-life care as well as the adaptation of tools to promote communication with the patient and his or her family, or to facilitate interdisciplinary work.

RESULTS

Preliminary results obtained through individual interviews indicate participant satisfaction with the project, but additional data need to be gathered to evaluate improvements in practice.

CONCLUSIONS

Other collaborative quality improvement projects need to be implemented to improve end-of-life practices in intensive care units.

What do hospitalists experience as barriers and helpful factors for having ACP conversations? A systematic qualitative evidence synthesis

BACKGROUND:

Hospitalists seem to struggle with advance care planning implementation. One strategy to help them is to understand which barriers and helpful factors they may encounter.

AIMS:

This review aims to give an overview on what hospitalists experience as barriers and helpful factors for having advance care planning conversations.

METHOD:

A systematic synthesis of the qualitative literature was conducted.

DATA SOURCES:

A bibliographic search of English peer-reviewed publications in PubMed, Embase, CINAHL, Central, PsycINFO, and Web of Science was undertaken.

RESULTS:

Hospitalists report lacking communication skills which lead to difficulties with exploring values and wishes of patients, dealing with emotions of patients and families and approaching the conversation about letting a patient die. Other barriers are related to different interpretations of the concept advance care planning, cultural factors, like being lost in translation, and medicolegal factors, like fearing prosecution. Furthermore, hospitalists report that decision-making is often based on irrational convictions, and it is highly personal. Physician and patient characteristics, like moral convictions, experience, and personality play a role in the decision-making process. Hospitalists report that experience and learning from more experienced colleagues is helpful. Furthermore, efficient multidisciplinary co-operation is helping.

CONCLUSION:

This systematic review shows that barriers are often related to communication issues and the convictions of the involved hospitalist. However, they seem to be preventable by creating a culture where experienced professionals can be consulted, where convictions can be questioned, and where co-operation within and between organizations is encouraged. This knowledge can serve as a basis for implementation.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool

Background

Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU).

Objectives

To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates.

Methods

Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups.

Results

Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner.

Conclusions

The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

Changes in professionals' beliefs following a palliative care implementation programme at a surgical department: a qualitative evaluation

BACKGROUND

One ambition regarding palliative care is that it should be more accessible to patients and families regardless of care setting. Previous studies show many difficulties and shortcomings in the care of patients with palliative care needs in acute care facilities, but also challenges regarding efforts to implement palliative care. The aim of this study is to evaluate how the implementation of palliative care, using a combination of integration and consultation strategies, can change beliefs regarding palliative care among professionals in a surgical department.

METHOD

In order to explore professionals' experiential outcome of an educational implementation strategy, a before-after qualitative design was used. The study was based on three focus group discussions. Two discussions were conducted before introducing the implementation strategy and one was conducted after. The participants consisted of five nurses and two specialist surgeons from a surgical department in Sweden. The focus group discussions revealed a variety of different attitudes and beliefs, which were analysed using qualitative systematic text condensation.

RESULTS

Beliefs regarding palliative care were identified in seven areas; the importance of palliative care, working methods in palliative care, team collaboration in palliative care, collegial support, discussions about diagnosis, symptoms at the end of life, and families of patients in palliative care. Changes in beliefs were seen in all areas except one: team collaboration in palliative care.

CONCLUSION

It is possible to change the beliefs of health care professionals in a surgical department regarding palliative care through the implementation of palliative knowledge. Beliefs were changed from an individual to a collective development where the group initiated a shared palliative working method. The changes observed were palliative care being described as more complex and participants differentiating between surgical care and palliative care.

Sense of responsibility in ICU end-of-life decision-making: Relatives' experiences

BACKGROUND:

Relatives of intensive care unit patients who lack or have reduced capacity to consent are entitled to information and participation in decision-making together with the patient. Practice varies with legislation in different countries. In Norway, crucial decisions such as withdrawing treatment are made by clinicians, usually morally justified to relatives with reference to the principle of non-maleficence. The relatives should, however, be consulted about whether they know what the patient would have wished in the situation.

RESEARCH OBJECTIVES:

To examine and describe relatives' experiences of responsibility in the intensive care unit decision-making process.

RESEARCH DESIGN:

A secondary analysis of interviews with bereaved relatives of intensive care unit patients was performed, using a narrative analytical approach.

PARTICIPANTS AND RESEARCH CONTEXT:

In all, 27 relatives of 21 deceased intensive care unit patients were interviewed about their experiences from the end-of-life decision-making process. Most interviews took place in the participants' homes, 3-12 months after the patient's death.

ETHICAL CONSIDERATIONS:

Based on informed consent, the study was approved by the Data Protection Official of the Norwegian Social Science Data Services and by the Regional Committee for Medical and Health Research Ethics.

FINDINGS:

The results show that intensive care unit relatives experienced a sense of responsibility in the decision-making process, independently of clinicians' intention of sparing them. Some found this troublesome. Three different variants of participation were revealed, ranging from paternalism to a more active role for relatives.

DISCUSSION:

For the study participants, the sense of responsibility reflects the fact that ethics and responsibility are grounded in the individual's relationship to other people. Relatives need to be included in a continuous dialogue over time to understand decisions and responsibility.

CONCLUSION:

Nurses and physicians should acknowledge and address relatives' sense of responsibility, include them in regular dialogue and help them separate their responsibility from that of the clinicians.

Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life care

PURPOSE

This study critically examines the available policy guidelines on integration of palliative and end-of-life care in Indian intensive care units to appraise their congruence with Indian reality.

MATERIALS AND METHODS

Six position statements and guidelines issued by the Indian Society for Critical Care Medicine and the Indian Association of Palliative Care from 2005 till 2015 were examined. The present study reflects upon the recommendations suggested by these texts.

RESULT

Although the policy documents conform to the universally set norms of introducing palliative and end-of-life care in intensive care units, they hardly suit Indian reality. The study illustrates local complexities that are not addressed by the policy documents. This include difficulties faced by intensivists and physicians in arriving at a consensus decision, challenges in death prognostication, hurdles in providing compassionate care, providing "culture-specific" religious and spiritual care, barriers in effective communication, limitations of documenting end-of-life decisions, and ambiguities in defining modalities of palliative care. Moreover, the policy documents largely dismiss special needs of elderly patients.

CONCLUSION

The article suggests the need to reexamine policies in terms of their attainability and congruence with Indian reality.

Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians

BACKGROUND

Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions.

AIM

Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents.

DESIGN

We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis.

SETTING/PARTICIPANTS

We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender.

RESULTS

The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit-burden considerations. Physicians' individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus.

CONCLUSION

The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians' feelings to improve the transparency of the decision-making process and reduce bias.

Patient and family involvement in adult critical and intensive care settings: a scoping review

BACKGROUND

Despite international bodies calling for increased patient and family involvement, these concepts remain poorly defined within literature on critical and intensive care settings.

OBJECTIVE

This scoping review investigates the extent and range of literature on patient and family involvement in critical and intensive care settings. Methodological and empirical gaps are identified, and a future agenda for research into optimizing patient and family involvement is outlined.

METHODS

Searches of MEDLINE, CINAHL, Social Work Abstracts and PsycINFO were conducted. English-language articles published between 2003 and 2014 were retrieved. Articles were included if the studies were undertaken in an intensive care or critical care setting, addressed the topic of patient and family involvement, included a sample of adult critical care patients, their families and/or critical care providers. Two reviewers extracted and charted data and analysed findings using qualitative content analysis.

FINDINGS

A total of 892 articles were screened, 124 were eligible for analysis, including 61 quantitative, 61 qualitative and 2 mixed-methods studies. There was a significant gap in research on patient involvement in the intensive care unit. The analysis identified five different components of family and patient involvement: (i) presence, (ii) having needs met/being supported, (iii) communication, (iv) decision making and (v) contributing to care.

CONCLUSION

Three research gaps were identified that require addressing: (i) the scope, extent and nature of patient involvement in intensive care settings; (ii) the broader socio-cultural processes that shape patient and family involvement; and (iii) the bidirectional implications between patient/family involvement and interprofessional teamwork.

Advancing palliative and end-of-life science in cardiorespiratory populations: The contributions of nursing science

Nursing science has a critical role to inform practice, promote health, and improve the lives of individuals across the lifespan who face the challenges of advanced cardiorespiratory disease. Since 1997, the National Institute of Nursing Research (NINR) has focused attention on the importance of palliative and end-of-life care for advanced heart failure and advanced pulmonary disease through the publication of multiple funding opportunity announcements and by supporting a cadre of nurse scientists that will continue to address new priorities and future directions for advancing palliative and end-of-life science in cardiorespiratory populations.

ICU Bedside Nurses' Involvement in Palliative Care Communication: A Multicenter Survey

CONTEXT

Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses.

OBJECTIVES

To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication.

METHODS

A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S.

RESULTS

The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%).

CONCLUSION

ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions.

Balancing professional tension and deciding upon the status of death: Making end-of-life decisions in intensive care units

This study investigated how intensivists make decisions regarding withholding and withdrawing treatment for patients at the end of their lives. This involved completing in-depth interviews from two sites of the South of England, United Kingdom by twelve intensivists. The data collected by these intensivists were analysed using thematic analysis. This resulted in the identification of three themes: intensivists' role, treatment effectiveness, and patients' best interest. Transcending these were two overarching themes relating to the balance between quantity and quality of life, and the intensivists' sense of responsibility versus burden. The results are considered in terms of making sense of death and the role of beliefs in the decision-making process.

Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review

INTRODUCTION

Although many terminally ill people are admitted to an intensive care unit (ICU) at the end of life, their care is often inadequate because of poor communication by physicians and lack of patient- and family-centred care. The aim of this systematic literature review was to describe physician-related barriers to adequate communication within the team and with patients and families, as well as barriers to patient- and family-centred decision-making, towards the end of life in the ICU. We base our discussion and evaluation on the quality indicators for end-of-life care in the ICU developed by the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup.

METHOD

Four electronic databases (MEDLINE, Embase, CINAHL and PsycINFO) were searched, using controlled vocabulary and free text words, for potentially relevant records published between 2003 and 2013 in English or Dutch. Studies were included if the authors reported on physician-related and physician-reported barriers to adequate communication and decision-making. Barriers were categorized as being related to physicians' knowledge, physicians' attitudes or physicians' practice. Study quality was assessed using design-specific tools. Evidence for barriers was graded according to the quantity and quality of studies in which the barriers were reported.

RESULTS

Of 2,191 potentially relevant records, 36 studies were withheld for data synthesis. We determined 90 barriers, of which 46 were related to physicians' attitudes, 24 to physicians' knowledge and 20 to physicians' practice. Stronger evidence was found for physicians' lack of communication training and skills, their attitudes towards death in the ICU, their focus on clinical parameters and their lack of confidence in their own judgment of their patient's true condition.

CONCLUSIONS

We conclude that many physician-related barriers hinder adequate communication and shared decision-making in ICUs. Better physician education and palliative care guidelines are needed to enhance knowledge, attitudes and practice regarding end-of-life care. Patient-, family- and health care system-related barriers need to be examined.

Utilization and determinants of palliative care in the trauma intensive care unit: results of a national survey

BACKGROUND

There is a paucity of data evaluating utilization of palliative care in trauma intensive care units.

AIM

We sought to determine current indications and determinants of palliative care consultation in the trauma intensive care units.

DESIGN

Using a cross-sectional assessment, we surveyed trauma surgeons to understand indications, benefits, and barriers trauma surgeons perceive when consulting palliative care.

SETTING/PARTICIPANTS

A total of 1232 surveys were emailed to all members of the Eastern Association for the Surgery of Trauma.

RESULTS

A total of 362 providers responded (29% response rate). Majority of respondents were male (n = 287, 80.2%) and practiced in Level 1 (n = 278, 77.7%) trauma centers. Most common indicators for referral to palliative care were expected survival 1 week to 1 month, multisystem organ dysfunction >3 weeks, minimal neurologic responsiveness >1 week, and referral to hospice. In post hoc analysis, there was a significant difference in frequency of utilization of palliative care when respondents had access to board-certified palliative care physicians (χ(2) = 56.4, p < 0.001). Although half of the respondents (n = 199, 55.6%) reported palliative care consults beneficial all or most of the time, nearly still half (n = 174, 48.6%) felt palliative care was underutilized. Most frequent barriers to consultation included resistance from families (n = 144, 40.2%), concerns that physicians were "giving up" (n = 109, 30.4%), and miscommunication of prognosis (n = 98, 27.4%) or diagnosis (n = 58, 16.2%) by the palliative care physician.

CONCLUSION

Although a plurality of trauma surgeons reported palliative care beneficial, those surveyed indicate that palliative care is underutilized. Barriers identified provide important opportunities to further appropriate utilization of palliative care services.

Differences in end-of-life care in the ICU across patients cared for by medicine, surgery, neurology, and neurosurgery physicians

BACKGROUND

Some of the challenges in the delivery of high-quality end-of-life care in the ICU include the variability in the characteristics of patients with certain illnesses and the practice of critical care by different specialties.

METHODS

We examined whether ICU attending specialty was associated with quality of end-of-life care by using data from a clustered randomized trial of 14 hospitals. Patients died in the ICU or within 30 h of transfer and were categorized by specialty of the attending physician at time of death (medicine, surgery, neurology, or neurosurgery). Outcomes included family ratings of satisfaction, family and nurse ratings of quality of dying, and documentation of palliative care in medical records. Associations were tested using multipredictor regression models adjusted for hospital site and for patient, family, or nurse characteristics.

RESULTS

Of 3,124 patients, the majority were cared for by an attending physician specializing in medicine (78%), with fewer from surgery (12%), neurology (3%), and neurosurgery (6%). Family satisfaction did not vary by attending specialty. Patients with neurology or neurosurgery attending physicians had higher family and nurse ratings of quality of dying than patients of attending physicians specializing in medicine (P &lt; .05). Patients with surgery attending physicians had lower nurse ratings of quality of dying than patients with medicine attending physicians (P &lt; .05). Chart documentation of indicators of palliative care differed by attending specialty.

CONCLUSIONS

Patients cared for by neurology and neurosurgery attending physicians have higher family and nurse ratings of quality of dying than patients cared for by medicine attending physicians and have a different pattern of indicators of palliative care. Patients with surgery attending physicians had fewer documented indicators of palliative care. These findings may provide insights into potential ways to improve the quality of dying for all patients.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.

Learning through observation: the role of ethnography in improving critical care

PURPOSE OF REVIEW

To determine the conditions under which ethnographic research is a useful tool for reflexive self-learning and enhanced performance in critical care units.

RECENT FINDINGS

The focus of studies using qualitative methods to investigate the organization of work in critical care units largely remains the investigation of the stresses and strains for staff, patients, and families managing communication at the end of life. A more recent focus of research has been on safety and quality improvement. Iterative feedback between researchers and clinicians is likely a useful tool for self-reflexive learning and change.

SUMMARY

Qualitative researchers have long been involved in the study of critical care. There is a new emphasis on using ethnographic methods as a tool for behavioural change through the process of iterative feedback.

End-of-life care decisions in the PICU: roles professionals play

OBJECTIVE

Describe the roles and respective responsibilities of PICU healthcare professionals in end-of-life care decisions faced by PICU parents.

DESIGN

Retrospective qualitative study.

SETTING

University-based tertiary care children's hospital.

PARTICIPANTS

Eighteen parents of children who died in the pediatric ICU and 48 PICU healthcare professionals (physicians, nurses, social workers, child-life specialists, chaplains, and case managers).

INTERVENTIONS

In depth, semi-structured focus groups and one-on-one interviews designed to explore experiences in end-of-life care decision making.

MEASUREMENTS AND MAIN RESULTS

We identified end-of-life care decisions that parents face based on descriptions by parents and healthcare professionals. Participants described medical and nonmedical decisions addressed toward the end of a child's life. From the descriptions, we identified seven roles healthcare professionals play in end-of-life care decisions. The family supporter addresses emotional, spiritual, environmental, relational, and informational family needs in a nondirective way. The family advocate helps families articulate their views and needs to healthcare professionals. The information giver provides parents with medical information, identifies decisions or describes available options, and clarifies parents' understanding. The general care coordinator helps facilitate interactions among healthcare professionals in the PICU, among healthcare professionals from different subspecialty teams, and between healthcare professionals and parents. The decision maker makes or directly influences the defined plan of action. The end-of-life care coordinator organizes and executes functions occurring directly before, during, and after dying/death. The point person develops a unique trusting relationship with parents.

CONCLUSIONS

Our results describe a framework for healthcare professionals' roles in parental end-of-life care decision making in the pediatric ICU that includes directive, value-neutral, and organizational roles. More research is needed to validate these roles. Actively ensuring attention to these roles during the decision-making process could improve parents' experiences at the end of a child's life.

Communication by nurses in the intensive care unit: qualitative analysis of domains of patient-centered care

BACKGROUND

High-quality communication is a key determinant and facilitator of patient-centered care. Nurses engage in most of the communication with patients and patients' families in the intensive care unit.

OBJECTIVE

To perform a qualitative analysis of nurses' communications.

METHODS

Ethnographic observations of 315 hours of interactions and 53 semistructured interviews with 33 nurses were conducted in a 26-bed cardiac-medical intensive care unit in an academic hospital and a 26-bed general intensive care unit in a Veterans Affairs hospital in Portland, Oregon. Communication interactions were categorized into 5 domains of patient-centered care. Interviews were analyzed to identify major themes in nurses' roles and preferences for communicating with patients and patients' families within the domains.

RESULTS

Most communication occurred in the domains of biopsychosocial information exchange, patient as person, and clinician as person. Nurses endorsed the importance of the domains of shared power and responsibility and therapeutic alliance but had relatively few communication interactions in these areas. Communication behaviors were strongly influenced by the nurses' roles as translators of information between physicians and patients and the patients' families and what the nurses were and were not willing to communicate to patients and patients' families.

CONCLUSIONS

Critical care, including communication, is a collaborative effort. Understanding how nurses engage in patient-centered communication in the intensive care unit can guide future interventions to improve patient-centered care.

End-of-life practices in Danish ICUs: development and validation of a questionnaire

Background

Practices for withholding or withdrawing therapy vary according to professional, cultural and religious differences. No Danish-validated questionnaire examining withholding and withdrawing practices exists, thus the aim of this study was to develop and validate a questionnaire for surveying the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the ICU.

Methods

A questionnaire was developed on the basis of literature, focus group interviews with intensive care nurses and intensivists, and individual interviews with primary physicians. The questionnaire was validated in the following 3 phases: a qualitative test with 17 participants; a quantitative pilot test with 60 participants; and a survey with 776 participants. The validation process included tests for face and content validity (by interviewing participants in the qualitative part of the pilot study), reliability (by assessing the distribution of responses within the individual response categories), agreement (by conducting a test-retest, evaluated by paired analyses), known groups’ validity (as a surrogate test for responsiveness, by comparing two ICUs with a known difference in end-of-life practices), floor and ceiling effect, and missing data.

Results

Face and content validity were assessed as good by the participants in the qualitative pilot test; all considered the questions relevant and none of the participants found areas lacking. Almost all response categories were used by the participants, thus demonstrating the questionnaires ability to distinguish between different respondents, agreement was fair (the average test-retest agreement for the Likert scale responses was 0.54 (weighted kappa; range, 0.25-0.73), and known groups’ validity was proved by finding significant differences in level of satisfaction with interdisciplinary collaboration and in experiences of withdrawal decisions being unnecessarily postponed. Floor and ceiling effect was in accordance with other questionnaires, and missing data was limited to a range of 0-7% for all questions.

Conclusions

The validation showed good and fair areas of validity of the questionnaire. The questionnaire is considered a useful tool to assess the perceptions of collaboration and other aspects of withholding and withdrawing therapy practices in Danish ICUs amongst nurses, intensivists, and primary physicians.

Life-sustaining treatment decisions in the ICU for patients with ESLD: a prospective investigation

We conducted a prospective study in the ICU of life-sustaining treatment and comfort care decisions over time in patients with end-stage liver disease (ESLD) from the perspectives of patients, family members, and healthcare professionals. Six patients with ESLD, 19 family members, and 122 professionals participated. The overarching theme describing the decision-making process was "on the train." Four sub-themes positioned patients and family members as passengers with limited control, unable to fully understand the decision-making process. Findings suggest that including patients and family members in non-immediate life-saving decisions and verifying early on their understanding may help to improve the decision-making process.

Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care

OBJECTIVE

Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit.

DATA SOURCES

We searched the MEDLINE database from inception to May 2011 for all English language articles using the term "surgical palliative care" or the terms "surgical critical care," "surgical ICU," "surgeon," "trauma" or "transplant," and "palliative care" or "end-of- life care" and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report.

DATA EXTRACTION AND SYNTHESIS

We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families.

CONCLUSIONS

Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. "Consultative," "integrative," and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and "culture" in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit.

Who is attending? End-of-life decision making in the intensive care unit

PURPOSE

Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM.

METHODS

Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units.

RESULTS

The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer.

CONCLUSIONS

Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.

Family members' informal roles in end-of-life decision making in adult intensive care units

BACKGROUND

To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process.

OBJECTIVE

To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units.

METHODS

Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit.

PARTICIPANTS

Health care clinicians, patients, and family members.

RESULTS

Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains.

CONCLUSIONS

These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.

Palliative medicine referral in patients undergoing continuous renal replacement therapy for acute kidney injury

BACKGROUND

Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied.

METHODS

We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury.

RESULTS

Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15-25) days compared with 12.5 days (95% CI = 9-17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9-15) days vs. 7.0 (95% CI = 6-9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4-8) vs. 3.0 (95% CI = 3-4) days; p < 0.01].

CONCLUSIONS

PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, "triggered" referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.

Nursing Roles and Strategies in End-of-Life Decision Making in Acute Care: A Systematic Review of the Literature

The objective of this paper is to analyze the literature concerning nurses' roles and strategies in EOL decision making in acute care environments, synthesize the findings, and identify implications for future research. We conducted searches in CINAHL and PubMed, using a broad range of terms. The 44 articles retained for review had quantitative and qualitative designs and represented ten countries. These articles were entered into a matrix to facilitate examining patterns, themes, and relationships across studies. Three nursing roles emerged from the synthesis of the literature: information broker, supporter, and advocate, each with a set of strategies nurses use to enact the roles. Empirical evidence linking these nursing roles and strategies to patients and family members outcomes is lacking. Understanding how these strategies and activities are effective in helping patients and families make EOL decisions is an area for future research.

Withholding or withdrawing therapy in intensive care units: an analysis of collaboration among healthcare professionals

PURPOSE

The purpose of the study was to determine the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the intensive care unit (ICU).

METHODS

A questionnaire survey was conducted in seven hospitals in the Region of Southern Denmark, including six regional and four university ICUs. Four hundred ninety-five nurses, 135 intensivists, and 146 primary physicians participated in the study. The primary physicians came from two regional hospitals.

RESULTS

The unified response rate was 84%. "Futile therapy" and "Patient's wish" were for all participants the main reasons for considering withholding or withdrawing therapy. Of primary physicians 63% found their general experience of collaboration very or extremely satisfactory compared to 36% of intensivists and 27% of nurses. Forty-three percent of nurses, 29% of intensivists, and 2% of primary physicians found that decisions regarding withdrawal of therapy were often, very often, or always unnecessarily postponed. Intensivists with ICU as their main workplace were more satisfied with the collaboration and more rarely found that end-of-life decisions were changed or postponed compared to intensivists who did not have ICU as their main workplace.

CONCLUSION

Nurses, intensivists and primary physicians differ in their perception of collaboration and other aspects of withholding and withdrawing therapy practises at the ICU. Multi-disciplinary patient conferences, nurse involvement in the decision-making process, and guidelines for withholding and withdrawing therapy are recommended.

The end-of-life family meeting in intensive care part I: Indications, outcomes, and family needs

This is a three-part article that reviews the literature on end-of-life family meetings in intensive care, focused on situations when the patient cannot participate. Family meetings in end-of-life care, especially when conducted prophylactically or proactively, have been shown to be effective procedures for improving family and staff satisfaction and even reducing resource utilization. The first part of the article outlines the family needs that should be addressed in such meetings, including clinician availability, consistent information sharing (especially of prognosis), empathic communication and support, facilitation of bereavement, and trust. The second part addresses family-centered, shared decision making and sources of conflict, as well as related communication and negotiation skills and how to end the meeting. Families and clinicians differ in 1) their understanding of the patient's condition and prognosis; 2) the emotional impact of the illness, particularly the personal meaning of pursuing recovery or limiting supports; and 3) their views of how to make decisions about life-prolonging treatments. The final part draws on the previous two sections to present a structured format and guide for communication skills in conflictual meetings. Ten steps for a humane and effective meeting are suggested, illustrated with sample conversations.

Issues in cross-cultural comparative research

It is the purpose of this article to describe the methodological issues when designing qualitative cultural comparative studies, which may be used to address health disparities. Overall, two broad types of comparative studies were found: primary and secondary comparative studies. Methodological issues to consider when designing primary studies were reviewed. The main areas discussed in this article relate to sampling and study purpose, sample boundaries, theoretical context, concept development, analogous comparisons, and systematic comparisons. Nurses are in a prime position to pose the qualitative research questions needed to address health disparities within their clinical settings. It is suggested that awareness of the method types and issues might inspire further qualitative comparative work.