Sharing intimacy in "open" intensive care units

Death Notification in Italian Critical Care Unites and Emergency Services. A Qualitative Study with Physicians, Nurses and Relatives

This qualitative study was conducted in critical care units and emergency services and was aimed at considering the death notification (DN) phenomenology among physicians (notifiers), patient relatives (receivers) and those who work between them (nurses). Through the qualitative method, a systemic perspective was adopted to recognise three different categories of representation: 23 clinicians, 13 nurses and 11 family members of COVID-19 victims were interviewed, totalling 47 people from all over Italy (25 females, mean age: 46,36; SD: 10,26). With respect to notifiers, the following themes emerged: the changes in the relational dimension, protective factors and difficulties related to DN. With respect to receivers, the hospital was perceived as a prison, bereavement between DN, lost rituals and continuing bonds. Among nurses, changes in the relational dimension, protective factors and the impact of the death. Some common issues between physicians and nurses were relational difficulties in managing distancing and empathy and the support of relatives and colleagues. The perspective of receivers showed suffering related to loss and health care professionals’ inefficacy in communication. Specifically, everyone considered DNs mismanaged because of the COVID-19 emergency. Some considerations inherent in death education for DN management among health professionals were presented.

Impact of Restricted Visitation Policies During the First Wave of the COVID-19 Pandemic on Communication Between Critically Ill Patients, Families and Clinicians: A Qualitative Interview Study

Rationale

Restricted visitation policies during the first wave of the coronavirus disease (COVID-19) pandemic have had a major impact on the ways that intensive care unit (ICU) clinicians communicated with patients and their families, requiring the use of innovative strategies to adapt to new communication structures.

Objectives

The purpose of this study is to describe the impact of restricted visitation policies on communication and to identify strategies that could be used to facilitate better communication within Canadian ICUs from the perspective of those affected.

Methods

We conducted semistructured individual interviews with critically ill patients, their families, and clinicians from 23 Canadian ICUs during the first wave of the COVID-19 pandemic between July 2020 and October 2020. We used inductive thematic analysis to identify relevant themes and subthemes.

Results

Forty-one interviews were conducted with 3 patients, 8 family members, 17 nurses, and 13 physicians. Five themes were identified from the analysis: 1) patient and family psychosocial and information needs; 2) communication tools; 3) quality of communication; 4) changing roles and responsibilities of patients and nurses/physicians; and 5) facilitators or barriers to implementing alternative communication. Participants identified strategies to leverage new videoconference technology and communication structures to preserve the quality of communication.

Conclusions

Our study identified challenges and opportunities related to communication between critically ill patients, families, and ICU clinicians due to the restricted hospital visitation policies during the first wave of the COVID-19 pandemic. The use of videoconference technology and changes to communication structure were important strategies to facilitate effective communication within the ICU.

How to communicate with families living in complete isolation

IMPORTANCE

During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.

OBJECTIVE

This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation.

EVIDENCE REVIEW

PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.

FINDINGS

Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.

CONCLUSIONS AND RELEVANCE

The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Implementation of a flexible visiting policy in intensive care unit: A randomized clinical trial

BACKGROUND

Visitation is one of the most critical needs of patients in intensive care units (ICUs). Clinicians should enable a more flexible visitation policy to prevent the adverse effects of a restricted approach.

AIM AND OBJECTIVES

This study aimed at investigating the relationship between increasing visitation time and patients' physiological parameters in intensive units. Additionally, nurses' beliefs and attitudes towards visiting is examined in this research.

DESIGN

Parallel randomized clinical trial.

METHODS

This study was conducted in four general medical ICUs in Iran. In total, 60 patients and 57 nurses participated in this study. The patients' physiological parameters were measured at particular times in both groups. Moreover, the nurses responded to the questionnaire on beliefs and attitudes towards visitation in intensive units before and after the intervention.

RESULTS

Among all the physiological parameters, systolic and diastolic blood pressure and heart rate had a significant decrease within the normal range 10 and 30 minutes after visiting in the intervention group (P < .05), and nurses' beliefs and attitudes score were at the middle of the survey scoring range (0-120). However, no significant difference was found between nurses' belief and attitude score and intervention in any groups (P > .05).

CONCLUSION

The findings indicate that increasing visitation times can lead to a positive effect on the stability and balance of patients' physiological parameters.

RELEVANCE TO CLINICAL PRACTICE

A more flexible visiting policy can provide a therapeutic environment where not only patients' physiological disorders are minimised as much as possible but also a higher level of patients' health and satisfaction are reached.

New perspectives on substituted relational autonomy for shared decision-making in critical care

In critical care when unconscious patients are assisted by machines, humanity is mainly ensured by respect for autonomy, realised through advance directives or, mostly, reconstructed by cooperation with relatives. Whereas patient-centred approaches are widely discussed and fostered, managing communication in complex, especially end-of-life, situations in open intensive care units is still a point of debate and a possible source of conflict and moral distress. In particular, healthcare teams are often sceptical about the growing role of families in shared decision-making and their ability to represent patients’ preferences. New perspectives on substituted relational autonomy are needed for overcoming this climate of suspicion and are discussed through recent literature in the field of medical ethics.

Association Between Clinical Nurse Specialist's Presence and Open Visitation in US Intensive Care Units

BACKGROUND

Current evidence shows that an open visitation policy can benefit patients and families during intensive care unit (ICU) stays. Therefore, an unrestricted visitation policy in the ICU has been proposed as part of patient-centered care.

PURPOSE

The purpose of this secondary analysis is to explore the likelihood of an ICU with a clinical nurse specialist (CNS) having an open visitation policy when compared with an ICU without a CNS.

DESIGN

This is a secondary analysis of a survey conducted between 2008 and 2009, describing the ICU visitation practices in more than 600 hospitals across the United States.

METHODS

χ Analysis was performed comparing the presence of CNS in the ICU with visitation policies, with P < 0.05 considered statistically significant.

RESULTS

There were data from 347 hospitals used in the analysis, with 47 hospitals (13.5%) having open visitation policies. There were 108 hospitals (31%) that had a CNS present in the ICU; 14 of the hospitals (13%) had open visitation policies. No significant correlation was found between a CNS being present in the ICU and open visitation policy (odds ratio, 0.93; P = .83), regardless of hospital geographic regions.

CONCLUSIONS

Although CNS presence was not associated with open visitation in this study, given the strong evidence to support the benefits to patients and the CNS role as a change agent in the hospital system, liberalization of visitation in the ICU is an area that could benefit from CNS advocacy.