Agreement among family members in their assessment of the Quality of Dying and Death

Family Members' Feedback on the "Quality of Death" of Adult Patients Who Died in Intensive Care Units and the Factors Affecting the Death Quality: A Systematic Review and Meta-Analysis

Intensive care units (ICUs) are designed for critically ill patients who often experience high mortality rates owing to the severity of their conditions. Although the primary goal is patient recovery, it is crucial to understand the quality of death in the ICU setting. Nevertheless, there is a notable lack of systematic reviews on measured death quality and its associated factors. This study aims to conduct a quantitative synthesis of evidence regarding the quality of death in the ICU and offers a comprehensive overview of the factors influencing this quality, including its relationship with the post-intensive care syndrome-family (PICS-F). A thorough search without any language restrictions across MEDLINE, CINAHL, PsycINFO, and Igaku Chuo Zasshi databases identified relevant studies published until September 2023. We aggregated the results regarding the quality of death care for patients who died in the ICU across each measurement tool and calculated the point estimates and 95% confidence intervals. The quantitative synthesis encompassed 19 studies, wherein the Quality of Dying and Death-single item (QODD-1) was reported in 13 instances (Point estimate: 7.0, 95% CI: 6.93-7.06). Patient demographic data, including age and gender, as well as the presence or absence of invasive procedures, such as life support devices and cardiopulmonary resuscitation, along with the management of pain and physical symptoms, were found to be associated with a high quality of death. Only one study reported an association between quality of death and PICS-F scores; however, no significant association was identified. The QODD-1 scale emerged as a frequently referenced and valuable metric for evaluating the quality of death in the ICU, and factors associated with the quality of ICU death were identified. However, research gaps persist, particularly regarding the variations in the quality of ICU deaths based on cultural backgrounds and healthcare systems. This review contributes to a better understanding of the quality of death in the ICU and emphasises the need for comprehensive research in this critical healthcare domain.

Psychometric Properties of the Brazilian Version of the Quality of Dying and Death for Adult Family Members of ICU Patients

Death is a complex, subjective phenomenon that requires an understanding of experiences to be qualified to provide care during the end-of-life process. This study aimed to analyze the psychometric properties of the Portuguese version (Brazil) of the Quality of Dying and Death (QODD) scale on family members of patients who died in adult intensive care units. A methodological study was conducted with 326 family members of patients that died in three ICUs of public hospitals in the state of São Paulo, Brazil. For this study, the QODD 3.2a (25 items and six domains) was administered during the period from December 2020 to March 2022. The analysis was performed using the classic theory of the tests and the goodness of fit of the model was tested using confirmatory factor analysis. We have used Spearman's correlation coefficients between the scores of the overall scale and domains. Cronbach's alpha coefficient and the intraclass correlation coefficient (ICC) were used for the evaluation of internal consistency and temporal stability, respectively. The Horn's parallel analysis indicated two factors that were not confirmed in the exploratory factor analysis. A single factor retained 18 of the initial 25 items and the analysis of the goodness of fit to the unidimensional model resulted in the following: CFI = 0.7545, TLI = 0.690, chi-squared = 767.33, df = 135, RMSEA = 0.121 with 90%CI, and p = 5.04409. The inter-item correlations indicated a predominance of weak correlations among the items of the instrument. The items with the largest number of moderate correlations were questions 13b, 9b, and 10b and a strong correlation was found between questions 15b and 16b. Cronbach's alpha coefficient was 0.8 and the ICC was 0.9. The Quality of Dying and Death-Version 3.2a (intensive therapy) in Brazilian Portuguese has a unidimensional structure and acceptable reliability. However, it did not obtain a good fit to the proposed factorial model.

Translation and Cultural Adaptation into Portuguese of the Quality of Dying and Death Scale for Family Members of Patients in Intensive Care Units

The translation and cultural adaptation of the Quality of Dying and Death in Brazil may provide a reliable and reproducible scale for collecting and analyzing data on the process of dying and death, given the absence of Brazilian studies that have produced or used scales in this topic. The purpose of this study was to perform the translation and cultural adaptation of the Quality of Dying and Death (QODD 3.2a) scale for intensive care patients' relatives into Portuguese (Brazil). This methodological study was carried out in a public university of the São Paulo State University (UNESP) medical school, São Paulo, Brazil, in three stages: translation and back-translation by two native-speaking independent professionals, analysis by a committee of specialists, and a pre-test phase. The final version was created by seven experts after making semantic, idiomatic, and cultural changes to 16 items. The results indicated a satisfactory content validation index (CVI ≥ 0.80). This version was applied on 32 relatives of patients who were hospitalized in a public hospital in the interior of São Paulo. No item was excluded from the instrument. The content and face validity were achieved to a satisfactory standard, in addition to reaching the minimum parameters recommended in the literature. The Portuguese version of QODD 3.2a for relatives of deceased patients in intensive care is appropriate and culturally adapted for use in Brazil.

Good death and bereavement in a lung cancer patient following meaning-centered couples psychotherapy by a cancer nursing specialist

OBJECTIVE

There are many terminally ill cancer patients who are struggling with the meaning of life, but it cannot be said that their concerns are being adequately addressed.

METHOD

From a series of cancer patients undergoing end-of-life care, the case of a patient, who developed incurable lung cancer and, together with his wife, lost the meaning of life and underwent meaning-centered couples psychotherapy once every two weeks to have them consider the meaning of life together, is presented.

RESULTS

The patient was a 70-year-old man who had been diagnosed with lung cancer and pleural dissemination 14 months earlier. The meaning-centered psychotherapy (MCP) sessions were conducted with the patient and his 70-year-old wife by a cancer nursing specialist who had received extensive training in MCP and had also received 7-year on-going supervision from a Japanese MCP-enlightened psychologist. At the same time, palliative treatment of physical distress was performed. The patient was able to discover the meaning of life as a result of MCP performed by a cancer nursing specialist for him and his spouse who had lost any notion of the meaning of life after being informed that he had terminal cancer at the time of the initial diagnosis.

SIGNIFICANCE OF RESULTS

Meaning-centered psychotherapy provided to terminal cancer patients by cancer nurses can help patients and their families express their gratitude, thereby achieving a good death for the bereaved family. Nurses are likely to increasingly perform MCP in the future.

Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol

Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).

Predictors of Family Dissatisfaction with Support During Neurocritical Care Shared Decision-Making

BACKGROUND

There is a critical need to improve support for families making difficult shared decisions about patient care with clinicians in the neuroscience ICU (neuro-ICU). The aim of this study is to identify patient- and family-related factors associated with dissatisfaction with shared decision-making support among families of neuro-critically ill patients.

METHODS

We conducted a retrospective observational cohort study using survey data that had been collected from a consecutive sample of family members of patients in the neuro-ICU (one family member per patient) at two US academic centers. Satisfaction with shared decision-making support on ICU discharge had been measured among family members using one specific Likert scale item on the Family Satisfaction in the ICU 24 survey, a validated survey instrument for families of patients in the ICU. We dichotomized top-box responses for this particular item as an outcome variable and identified available patient- and family-related covariates associated with dissatisfaction (i.e., less than complete satisfaction) via univariate and multivariate analyses.

RESULTS

Among 355 surveys, 180 (49.5%) of the surveys indicated dissatisfaction with support during decision-making. In a multivariate model, no preexisting characteristics of families or patients ascertainable on ICU admission were predictive of dissatisfaction. However, among family factors determined during the ICU course, experiencing three or fewer formal family meetings (odds ratio 1.93 [confidence interval 1.13-3.31]; p = 0.01) was significantly predictive of dissatisfaction with decisional support in this cohort with an average patient length of stay of 8.6 days (SD 8.4). There was also a trend toward a family's decision to keep a patient as full code, without treatment limitations, being predictive of dissatisfaction (odds ratio 1.80 [confidence interval 0.93-3.51]; p = 0.08).

CONCLUSIONS

Family dissatisfaction with neuro-ICU shared decision-making support is not necessarily predicted by any preexisting family or patient variables but appears to correlate with participating in fewer formal family meetings during ICU admission. Future studies to improve family satisfaction with neurocritical care decision-making support should have broad inclusion criteria for participants and should consider promoting frequency of family meetings as a core strategy.

Assessing physicians' and nurses' experience of dying and death in the ICU: development of the CAESAR-P and the CAESAR-N instruments

Background

As an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting. Most of these studies are centered on the patient’s and/or the relatives’ experience. Our study aimed to develop an instrument designed to assess the experience of physicians and nurses of patients who died in the ICU, using a mixed methodology and validated in a prospective multicenter study.

Methods

Physicians and nurses of patients who died in 41 ICUs completed the job strain and the CAESAR questionnaire within 24 h after the death. The psychometric validation was conducted using two datasets: a learning and a reliability cohort.

Results

Among the 475 patients included in the main cohort, 398 nurse and 417 physician scores were analyzed. The global score was high for both nurses [62/75 (59; 66)] and physicians [64/75 (61; 68)]. Factors associated with higher CAESAR-Nurse scores were absence of conflict with physicians, pain control handled with physicians, death disclosed to the family at the bedside, and invasive care not performed. As assessed by the job strain instrument, low decision control was associated with lower CAESAR score (61 (58; 65) versus 63 (60; 67), p = 0.002).

Factors associated with higher CAESAR-Physician scores were room dedicated to family information, information delivered together by nurse and physician, families systematically informed of the EOL decision, involvement of the nurse during implementation of the EOL decision, and open visitation. They were also higher when a decision to withdraw or withhold treatment was made, no cardiopulmonary resuscitation was performed, and the death was disclosed to the family at the bedside.

Conclusion

We described and validated a new instrument for assessing the experience of physicians and nurses involved in EOL in the ICU. This study shows important areas for improving practices.

Palliative medicine family conferences and caregiver psychological distress during prolonged mechanical ventilation

OBJECTIVES

Little is known about the experience of family caregivers of patients who require prolonged mechanical ventilation (PMV). We examined the perspectives of caregivers of patients who died after PMV to explore the role of palliative care and the quality of dying and death (QODD) in patients and understand the psychological symptoms of these caregivers.

METHODS

A longitudinal study was performed in five hospitals in Taipei, Taiwan. Routine palliative care family conferences and optional consultation with a palliative care specialist were provided, and family caregivers were asked to complete surveys.

RESULTS

In total, 136 family caregivers of 136 patients receiving PMV were recruited and underwent face-to-face baseline interviews in 2016-2017. By 2018, 61 (45%) of 136 patients had died. We successfully interviewed 30 caregivers of patients' death to collect information on the QODD of patients and administer the Impact of Event Scale (IES), Hospital Anxiety and Depression Scale (HADS) and Center for Epidemiologic Studies Depression (CES-D) scale to caregivers. We observed that more frequent palliative care family conferences were associated with poorer QODD in patients (coefficients: -44.04% and 95% CIs -75.65 to -12.44), and more psychological symptoms among caregivers (coefficient: 9.77% and 95% CI 1.63 to 17.90 on CES-D and coefficient: 7.67% and 95% CI 0.78 to 14.55 on HADS). A higher caregiver burden at baseline correlated with lower psychological symptoms (coefficient: -0.35% and 95% CI -0.58 to -0.11 on IES and coefficient: -0.22% and 95% CI -0.40 to -0.05 on CES-D) among caregivers following the patients' death. Caregivers' who accepted the concept of palliative care had fewer psychological symptoms after patients' death (coefficient: -3.29% and 95% CI -6.32 to -0.25 on IES and coefficient: -3.22% and 95% CI -5.24 to -1.20 on CES-D).

CONCLUSIONS

Palliative care conferences were more common among family members with increased distress. Higher caregiver burden and caregiver acceptance of palliative care at baseline both predicted lower levels of caregiver distress after death.

Translation, Cultural, and Age-Related Adaptation and Psychometric Properties of Persian Version of "Quality of Dying and Death" in Nurses Working in Neonatal Intensive Care Units

Background:

Death and dying care is an area with less attention in nursing. This even is evidenced as more challenging in some populations such as neonates. Neonatal intensive care unit (NICU) nurses should be aware of the quality of care they provide for dying neonates and their families to find the areas which need attention.

Objective:

The aim of this study was to assess the psychometric features of the Quality of Dying and Death (QODD) questionnaire in NICU nurses in Tehran, the capital city of Iran.

Methods:

This methodological study was conducted in 2017. For this purpose, using census method, 130 NICU nurses working in selected hospitals participated. After the backward–forward translation, based on the method proposed by the International Test Commission, the psychometric properties of the Persian QODD were examined through the assessment of the face, content and construct validity, internal consistency, and stability.

Results:

Final Persian QODD's content and face validity were accepted through a qualitative method. In the confirmatory factor analysis, the original version of QODD was not confirmed. Subsequently, an exploratory factor analysis was carried out in which phrases were included in three dimensions (symptom control, preparation for death of neonate, and professional attention) that explained 75% of the variance. Cronbach's alpha values ranged from 0.82 to 0.88 for these three dimensions. The intraclass correlation coefficient (ICC) was ICC = 0.94 between two tests performed with a 2-week interval on twenty eligible nurses.

Conclusions:

The Persian version of QODD has acceptable psychometric properties in nurses working with the neonatal population and can be used to investigate the NICU nurses' opinion on the QODD provided in NICU patients.

Assessing Symptoms, Concerns, and Quality of Life in Noncancer Patients at End of Life: How Concordant Are Patients and Family Proxy Members?

CONTEXT

It has become commonplace to use family caregivers as proxy responders where patients are unable to provide information about their symptoms and concerns to health care providers.

OBJECTIVES

The objective of this study was to determine the degree of concordance between patients' and family members' reports of patient symptoms and concerns at end of life.

METHODS

Sample dyads included a mix of patients residing at home, in a nursing home, in a long-term care facility, or in hospice. Diagnoses included patients with amyotrophic lateral sclerosis (n = 75), chronic obstructive pulmonary disease (n = 52), end-stage renal disease (n = 42), and institutionalized, cognitively intact frail elderly (n = 49). Dyads completed the Patient Dignity Inventory (PDI), the modified Structured Interview Assessment of Symptoms and Concerns in Palliative Care, and Graham and Longman's two-item Quality of Life Scale.

RESULTS

Concordance was less than 70% for seven of the 25 PDI items, with the lowest concordance (65.1%) for the item "not being able to continue with my usual routines." For all but one PDI item, discordance was in the direction of family members reporting that the patient was worse off than the patient had indicated. Where discordance was observed on the Structured Interview Assessment of Symptoms and Concerns in Palliative Care and Quality of Life Scales, the trend toward family members overreporting patient distress and poor quality of life continued.

CONCLUSION

Understanding discordance between patients and family member reports of symptoms and concerns is a valuable step toward minimizing patient and family burden at end of life.

The quality of dying and death measurement instruments: A systematic psychometric review

AIMS

To identify instruments that could assess the quality of dying and death and their psychometric properties. To assess the methodological quality of studies on measurement properties.

BACKGROUND

A high quality of death is regarded as a goal at the end of life and, therefore, an assessment of the end of life experience is essential. Many instruments have been developed to evaluate the quality of dying and death. The selection of the most appropriate measure to be used in clinical and research settings is crucial.

DESIGN

Psychometric systematic review.

DATA SOURCES

We systematically searched ProQuest Medline, SciELO and ProQuest PsycINFO from 1970 - May 2016.

REVIEW METHODS

Identification and evaluation of instruments that assessed quality of dying and death. Papers were evaluated by two independent reviewers according to the COSMIN checklist with a 4-point scale.

RESULTS

A total of 19 studies were included in this review. Seven instruments were found that were specifically designed for assessing quality of dying and death. A retrospective carer proxy report to evaluate this construct was used in most of the papers. The methodological quality of the studies was fair for most of the psychometric characteristics analyzed.

CONCLUSION

Many instruments have been developed to assess the quality of dying and death. The Quality of Dying and Death Questionnaire is the best available measure of the quality of dying and death. It is the only questionnaire identified in this review where all psychometric properties according to the COSMIN checklist have been evaluated.

Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief

CONTEXT

Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level.

OBJECTIVES

The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation.

METHODS

We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain.

RESULTS

We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools.

CONCLUSION

Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.

Measuring Patient-Centeredness of Care for Seriously Ill Individuals: Challenges and Opportunities for Accountability Initiatives

Patient- and family-centeredness of care is particularly important for individuals with serious illness. In this article, we describe methodological challenges of using measures of patient- and family-centeredness in accountability initiatives such as public reporting and pay for performance. We begin with background on measuring patient- and family-centered care using standardized surveys, describe evidence of the use of these measures for quality improvement, and highlight methodological challenges in the development and implementation of these measures for use in accountability. To ensure that patient- and family-centeredness is the cornerstone of public and private accountability initiatives designed to promote high-quality care to seriously ill patients, we recommend development of (1) a nationally endorsed survey instrument that assesses patient and family experiences of serious illness care across the full range of patient trajectories and care settings in which this care is provided; (2) administrative data infrastructure that allows for identification and outreach to the most knowledgeable respondents for the survey, regardless of the patient's setting of care; and (3) a broad toolkit of quality improvement approaches to ensure that as the emphasis on accountability grows, providers across settings have access to tools that can help them improve patient- and family-centeredness of care for the seriously ill.

The role of psychosomatic medicine in intensive care units

Critically ill patients, their relatives, and intensive care staff are consistently exposed to stress. The principal elements of this exceptional burden are confrontation with a life-threatening disease, specific environmental conditions at the intensive care unit, and the social characteristics of intensive care medicine. The short- and long-term consequences of these stressors include a feeling of helplessness, distress, anxiety, depression, and even posttraumatic stress disorders. Not only the patients, but also their relatives and intensive care staff are at risk of developing such psychopathologies. The integration of psychosomatic medicine into the general concept of intensive care medicine is an essential step for the early identification of fear and anxiety and for understanding biopsychosocial coherence in critically ill patients. Preventive measures such as the improvement of individual coping strategies and enhancing the individual's resistance to stress are crucial aspects of improving wellbeing, as well as the overall outcome of disease. Additional stress-reducing measures reported in the published literature, such as hearing music, the use of earplugs and eye-masks, or basal stimulation, have been successful to a greater or lesser extent.

Validation of the Spanish Version of the Quality of Dying and Death Questionnaire (QODD-ESP) in a Home-Based Cancer Palliative Care Program and Development of the QODD-ESP-12

CONTEXT

Improving quality of death (QOD) is a key goal in palliative care (PC). To our knowledge, no instruments to measure QOD have been validated in Spanish.

OBJECTIVES

The goals of this study were to validate the Spanish version of the quality of dying and death (QODD) questionnaire and to develop and validate a shortened version of this instrument by phone interview.

METHODS

We enrolled caregivers (CGs) of consecutive deceased cancer patients who participated in a single PC clinic. CGs were contacted by phone between 4 and 12 weeks after patients' death and completed the Spanish QODD (QODD-ESP). A question assessing quality of life during last week of life was included. A 12-item QODD (QODD-ESP-12) was developed. Reliability, convergent validity, and construct validity were estimated for both versions.

RESULTS

About 150 (50%) of 302 CGs completed the QODD-ESP. Patient's mean age (SD) was 67 (14); 71 (47%) were females, and 131 (87%) died at home. CGs' mean age (SD) was 51 (13); 128 (85%) were females. Mean QODD-ESP score was 69 (range 35-96). Kaiser-Meyer-Olkin measure of sampling adequacy was 0.322, not supporting the use of factorial analysis to assess the existence of an underlying construct. Mean QODD-ESP-12 score was 69 (range 31-97). Correlation with last week quality of life was 0.306 (P < 0.01). Confirmatory factorial analysis of QODD-ESP-12 showed that data fitted well Downey's four factors; Chi-square test = 6.32 (degrees of freedom = 60), P = 0.394 comparative fit index = 0.988; Tucker-Lewis Index = 0.987, and root mean square error of approximation = 0.016 (95% CI 0-0.052).

CONCLUSION

QODD-ESP-12 is a reliable and valid instrument with good psychometric properties and can be used to assess QOD in a Spanish-speaking cancer PC population by phone interview.

Exploring end of life priorities in Saudi males: usefulness of Q-methodology

Background

Quality end-of-life care depends on understanding patients’ end-of-life choices. Individuals and cultures may hold end-of-life priorities at different hierarchy. Forced ranking rather than independent rating, and by-person factor analysis rather than averaging may reveal otherwise masked typologies.

Methods

We explored Saudi males’ forced-ranked, end-of-life priorities and dis-priorities. Respondents (n = 120) rank-ordered 47 opinion statements on end-of-life care following a 9-category symmetrical distribution. Statements’ scores were analyzed by averaging analysis and factor analysis (Q-methodology).

Results

Respondents’ mean age was 32.1 years (range, 18–65); 52 % reported average religiosity, 88 and 83 % ≥ very good health and life-quality, respectively, and 100 % ≥ high school education. Averaging analysis revealed that the extreme five end-of-life priorities were to, be at peace with God, be able to say the statement of faith, maintain dignity, resolve conflicts, and have religious death rituals respected, respectively. The extreme five dis-priorities were to, die in the hospital, not receive intensive care if in coma, die at peak of life, be informed about impending death by family/friends rather than doctor, and keep medical status confidential from family/friends, respectively. Q-methodology classified 67 % of respondents into five highly transcendent opinion types. Type-I (rituals-averse, family-caring, monitoring-coping, life-quality-concerned) and Type-V (rituals-apt, family-centered, neutral-coping, life-quantity-concerned) reported the lowest and highest religiosity, respectively. Type-II (rituals-apt, family-dependent, monitoring-coping, life-quantity-concerned) and Type-III (rituals-silent, self/family-neutral, avoidance-coping, life-quality & quantity-concerned) reported the best and worst life-quality, respectively. Type-I respondents were the oldest with the lowest general health, in contrast to Type-IV (rituals-apt, self-centered, monitoring-coping, life-quality/quantity-neutral). Of the extreme 14 priorities/dis-priorities for the five types, 29, 14, 14, 50, and 36 %, respectively, were not among the extreme 20 priorities/dis-priorities identified by averaging analysis for the entire cohort.

Conclusions

1) Transcendence was the extreme end-of-life priority, and dying in the hospital was the extreme dis-priority. 2) Quality of life was conceptualized differently with less emphasize on its physiological aspects. 3) Disclosure of terminal illness to family/close friends was preferred as long it is through the patient. 4) Q-methodology identified five types of constellations of end-of-life priorities and dis-priorities that may be related to respondents’ demographics and are partially masked by averaging analysis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0064-5) contains supplementary material, which is available to authorized users.

Validation of the German Version of the Quality of Dying and Death Questionnaire for Informal Caregivers (QODD-D-Ang)

CONTEXT

The quality of dying and death (QOD) influences end-of-life care for patients and their relatives. To the best of our knowledge, there are currently no validated standard instruments for evaluating the QOD of patients in palliative care units (PCUs) in Germany.

OBJECTIVES

This study aimed to validate the German version of the multidimensional questionnaire "Quality of Dying and Death" for informal caregivers (QODD-Deutsch-Angehörige [QODD-D-Ang]) and provide a detailed report on its validity and reliability.

METHODS

The QODD was forward/backward translated following the European Organization for Research and Treatment of Cancer guidelines. Data collected in two German palliative care units (N = 226) with the QODD-D-Ang were used to calculate the QODD-D-Ang total score (TS) and to define reliability and validity, as well as acceptance and burden for informal caregivers. Frequencies, means, and SDs of various patient data related to care and disease were calculated to describe the study population and to look at group differences.

RESULTS

The mean TS of 175 participants was 75.72 (range 38-99; minimum 0 to maximum 100; higher scores indicate better QOD). The QODD-D-Ang showed good internal consistency for 27 items (Cronbach's alpha 0.852). Factors extracted by factor analysis could not be usefully interpreted. The TS of the QODD-D-Ang correlated substantially with the Palliative care Outcome Scale (r = 0.540), indicating good convergent validity. The QODD-D-Ang TS was stable for various demographic and clinical dimensions except for the amount of days on which informal caregivers visited patients, and, therefore, provided good discriminant validity.

CONCLUSION

Analyses of validity and reliability of the QODD-D-Ang showed satisfactory to good psychometric properties, meaning that the QODD can be recommended for standard implementation in German hospices and palliative care institutions to measure the QOD. Feasibility could be improved by adapting the instrument so that it may be administered with minimal demands on staff. When interpreting the results, it should be kept in mind that the QODD-D-Ang does not measure quality of care but the quality of the dying process as estimated by bereaved relatives.

Assessing the Quality of Death and Dying in an Integrated Health Care System in Rural Pennsylvania

CONTEXT

With growing emphasis on improving the value of health care, there is increased scrutiny of quality outcomes and high health expenditures during the final months of life.

OBJECTIVES

The purpose of this project is to answer 1) how do next of kin (NOK) perceive the quality of their loved ones' dying and death; 2) are there patient and NOK characteristics that predict lower quality; and 3) are there structural aspects of care associated with lower quality?

METHODS

A mailed survey was administered to a stratified random sample of NOK of Geisinger Health System patients who had died in the past year. The Quality of Death and Dying, the General Anxiety Disorder seven-item scale, the Patient Health Questionnaire eight-item depression scale, and selected questions from the Toolkit of Instruments to Measure End of Life Care were used.

RESULTS

There were 672 respondents. Significant predictors of Quality of Death and Dying score were number of doctors involved in care (P = 0.0415), location of death (P < 0.0001), frequency of receiving confusing or contradictory information (P < 0.0001), illness progression (P = 0.0343), Patient Health Questionnaire-2 score (P = 0.0148), and General Anxiety Disorder seven-item scale score (P < 0.0070).

CONCLUSION

Several findings suggest that factors such as NOK depression and anxiety, prolonged illness, dying in the hospital, receipt of conflicting information, and confusion around the doctor in charge are associated with lower quality of the dying and death experience for NOK. Further investigation is warranted to facilitate high-quality measurement and the use of measurement results to improve care.

Measuring Experience With End-of-Life Care: A Systematic Literature Review

CONTEXT

Increasing interest in end-of-life care has resulted in many tools to measure the quality of care. An important outcome measure of end-of-life care is the family members' or caregivers' experiences of care.

OBJECTIVES

To evaluate the instruments currently in use to inform next steps for research and policy in this area.

METHODS

We conducted a systematic review of PubMed, PsycINFO, and PsycTESTS(®) for all English-language articles published after 1990 using instruments to measure adult patient, family, or informal caregiver experiences with end-of-life care. Survey items were abstracted and categorized into content areas identified through an iterative method using three independent reviewers. We also abstracted information from the most frequently used surveys about the identification of proxy respondents for after-death surveys, the timing and method of survey administration, and the health care setting being assessed.

RESULTS

We identified 88 articles containing 51 unique surveys with available content. We characterized 14 content areas variably present across the 51 surveys. Information and care planning, provider care, symptom management, and overall experience were the most frequent areas addressed. There was also considerable variation across the surveys in the identification of proxy respondents, the timing of survey administration, and in the health care settings and services being evaluated.

CONCLUSION

This review identified several comprehensive surveys aimed at measuring the experiences of end-of-life care, covering a variety of content areas and practical issues for survey administration. Future work should focus on standardizing surveys and administration methods so that experiences of care can be reliably measured and compared across care settings.

Dying in the hospital: what happens and what matters, according to bereaved relatives

CONTEXT

Most deaths in Western countries occur in hospital, but little is known about factors determining the quality of dying (QOD).

OBJECTIVES

The aim was to assess the QOD in hospital as experienced by relatives and identify factors related to QOD.

METHODS

A cross-sectional study on 18 wards of a university hospital in The Netherlands was conducted, including relatives of patients who died after an admission of more than six hours, from June 2009 to March 2011. Relatives' perceptions of QOD and quality of care and the relation between dimensions of QOD and overall QOD scores were assessed.

RESULTS

Two hundred forty-nine relatives participated (51%) and rated overall QOD at 6.3 (SD 2.7; range 0-10). According to relatives, patients suffered from 7.0 (SD 5.8) of 22 symptoms and were at peace with imminent death in 37%. Patients had been aware of imminent death in 26%, and relatives were aware in 49%. Furthermore, 39% of patients and 50% of relatives had said good-bye, and 77% of patients died in the presence of a relative. Symptom alleviation was sufficient in 53%, and in 75%, sufficient efforts had been made to relieve symptoms. Characteristics of QOD and quality of care could be summarized in nine domains, explaining 34% of the variation of QOD scores. Medical, personalized, and supportive care were most strongly related to QOD.

CONCLUSION

Relatives rated QOD as sufficient. A majority of patients and relatives were not sufficiently prepared for imminent death, and relatives experienced many problems. QOD appears to be a multidimensional construct, strongly affected by medical care and staff attentiveness.

EMPOWER: an intervention to address barriers to pain management in hospice

CONTEXT

Concerns about pain medications are major barriers to pain management in hospice, but few studies have focused on systematic methods to address these concerns.

OBJECTIVES

The objective of this study was to test the preliminary efficacy of the Effective Management of Pain: Overcoming Worries to Enable Relief (EMPOWER) intervention, which included hospice staff education, staff screening of barriers to pain management at admission, and discussion about misunderstandings regarding pain management with family caregivers and patients.

METHODS

We conducted a pilot, cluster randomized, controlled trial with four hospices. One hundred twenty-six family caregivers (55 interventions and 71 controls) were interviewed at two weeks after admission. If patients survived three months after admission, caregivers were reinterviewed.

RESULTS

At two weeks, caregivers in the intervention group reported better knowledge about pain management (P = 0.001), fewer concerns about pain and pain medications (P = 0.008), and lower patient pain over the past week (P = 0.014) and trended toward improvement in most other areas under study. Exploratory analyses suggest that EMPOWER had a greater effect for black subjects (vs. whites) on reducing concern about stigma. At three months, the intervention group trended better on most study outcomes.

CONCLUSION

EMPOWER is a promising model to reduce barriers to pain management in hospice.

Measuring the quality of dying and death in the pediatric intensive care setting: the clinician PICU-QODD

CONTEXT

In the pediatric intensive care setting, an accurate measure of the dying and death experience holds promise for illuminating how critical care nurses, physicians, and allied psychosocial staff can better manage end-of-life care for the benefit of children and their families, as well as the caregivers.

OBJECTIVES

The aim was to assess the reliability and validity of a clinician measure of the quality of dying and death (Pediatric Intensive Care Unit-Quality of Dying and Death 20 [PICU-QODD-20]) in the pediatric intensive care setting.

METHODS

In a retrospective cohort study, five types of clinicians (primary nurse, bedside nurse, attending physician, and the psychosocial clinician and critical care fellow most involved in the case) were asked to complete a survey for each of the 94 children who died over a 12 month period in the pediatric intensive care units of two children's hospitals in the northeast U.S. Analyses were conducted within type of clinician.

RESULTS

In total, 300 surveys were completed by 159 clinicians. Standard item analyses and substantive review led to the selection of 20 items for inclusion in the PICU-QODD-20. Cronbach alpha for the PICU-QODD-20 ranged from 0.891 for bedside nurses to 0.959 for attending physicians. For each type of clinician, the PICU-QODD-20 was significantly correlated with the quality of end-of-life care and with meeting the family's needs. In addition, when patient/family or team barriers were encountered, the PICU-QODD-20 score tended to be significantly lower than for cases in which the barrier was not encountered.

CONCLUSION

The PICU-QODD-20 shows promise as a valid and reliable measure of the quality of dying and death in pediatric intensive care.

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.

Perception by family members and ICU staff of the quality of dying and death in the ICU: a prospective multicenter study in The Netherlands

OBJECTIVE

Admission to the ICU is a major event in a patient’s life and also for family members. We tried to elucidate how family members and ICU caregivers experience the dying process of their patients.

METHODS

The prospective study took place in three Dutch ICUs. Patients who had stayed . 48 h and died in the ICU were eligible. The Quality of Dying and Death (QODD) questionnaire was used, with addition of items pertaining to the patient’s autonomy. Values indicate median and interquartile range.

RESULTS

We included 100 consecutive patients. ICU stay before death was 8 (3-16) days. APACHE (Acute Physiology and Chronic Health Evaluation) II score at admission was 24 (19-31). Family response rate was 89%. Families were satisfied with overall QODD (score, 8 [7-9]) and felt supported by the ICU caregivers (8 [7-9]). Pain control was scored lower by family members (8 [5.75- 8.25]) than by nurses and physicians (9 [8-10], P 5 .024) Almost always, physicians discussed the patient’s end-of-life wishes with family members, although families rated the quality of the discussion lower (7 [5.5-8.5]) than physicians (9 [6.5-10]) ( P 5 .045). The majority of the families (89%) felt included in the decision-making process. More than one-half of the family members (57%) believed that the physician made the fi nal decision alone after giving information, whereas 36.8% believed they had participated in making the decision. Family members rated the QODD questionnaire as difficult (6 [5-8]), and several items were not answered by a majority of family members.

CONCLUSIONS

Quality of dying and death is generally perceived to be good by family members and caregivers of patients who die in Dutch ICUs. There is a need for modification of the QODD questionnaire for the European ICU population.

Improving the quality of palliative and terminal care in the hospital by a network of palliative care nurse champions: the study protocol of the PalTeC-H project

BACKGROUND

The quality of care of patients dying in the hospital is often judged as insufficient. This article describes the protocol of a study to assess the quality of care of the dying patient and the contribution of an intervention targeted on staff nurses of inpatient wards of a large university hospital in the Netherlands.

METHODS/DESIGN

We designed a controlled before and after study. The intervention is the establishment of a network for palliative care nurse champions, aiming to improve the quality of hospital end-of-life care. Assessments are performed among bereaved relatives, nurses and physicians on seven wards before and after introduction of the intervention and on 11 control wards where the intervention is not applied. We focus on care provided during the last three days of life, covered in global ratings of the quality of life in the last three days of life and the quality of dying, and various secondary endpoints of treatment and care affecting quality of life and dying.

DISCUSSION

With this study we aim to improve the understanding of and attention for patients' needs, and the quality of care in the dying phase in the hospital and measure the impact of a quality improvement intervention targeted at nurses.

Identifying elements of ICU care that families report as important but unsatisfactory: decision-making, control, and ICU atmosphere

BACKGROUND

One in fi ve deaths in the United States occurs in the ICU, and many of these deaths are experienced as less than optimal by families of dying people. The current study investigated the relationship between family satisfaction with ICU care and overall ratings of the quality of dying as a means of identifying targets for improving end-of-life experiences for patients and families.

METHODS

This multisite cross-sectional study surveyed families of patients who died in the ICU in one of 15 hospitals in western Washington State. Measures included the Family Satisfaction in the ICU (FS-ICU) and the Single-Item Quality of Dying (QOD-1) questionnaires. Associations between FS-ICU items and the QOD-1 were examined using multivariate linear regression controlling for patient and family demographics and hospital site.

RESULTS

Questionnaires were returned for 1,290 of 2,850 decedents (45%). Higher QOD-1 scores were significantly associated (all P < .05) with (1) perceived nursing skill and competence (β= 0.15), (2) support for family as decision-makers ( β= 0.10), (3) family control over the patient’s care( β= 0.18), and (4) ICU atmosphere (β= 0.12). FS-ICU items that received low ratings and correlated with higher QOD-1 scores (ie, important items with room for improvement) were (1) support of family as decision-maker, (2) family control over patient’s care, and (3) ICU atmosphere.

CONCLUSIONS

Increased support for families as decision-makers and for their desired level of control over patient care along with improvements in the ICU atmosphere were identified as aspects of the ICU experience that may be important targets for quality improvement.

TRIAL REGISTRY

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

Survey burden for family members surveyed about end-of-life care in the intensive care unit

CONTEXT

Family surveys are an important source of information about quality of end-of-life care in the intensive care unit (ICU). The burden associated with completing such surveys is not well studied.

OBJECTIVES

1) To assess the predictors of burden that families report with completing surveys for patients who died in the ICU and 2) to examine associations between quality-of-care ratings and survey burden.

METHODS

Data were collected from 14 hospitals as part of a cluster randomized trial to integrate palliative care into the ICU. Survey questions included demographics, quality of dying, satisfaction with care, and overall level of burden associated with survey completion. Patient characteristics were identified from chart abstraction and death certificates. Multivariable linear regression with robust SEs was used to examine associations between survey burden, subject characteristics, and family ratings of quality of care.

RESULTS

Of the families surveyed, 62% rated the survey to be no or low burden. Family members of older patients reported less survey burden (P = 0.016), and those who lived with the patient reported higher survey burden (P = 0.043). Family members reporting lower ratings of satisfaction with care and quality of dying reported higher survey burden (P < 0.001).

CONCLUSION

Most families reported no to low burden. Family members who live with their loved one are particularly vulnerable to survey burden and those of older patients report less burden. The association between low quality-of-care ratings and survey burden suggests that the response bias in this type of research is toward overestimating quality of care.

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.

Understanding bereaved caregiver evaluations of the quality of dying and death: an application of cognitive interviewing methodology to the quality of dying and death questionnaire

CONTEXT

To increase the interpretability of quality of dying and death measures, research is needed to understand potential sources of response variation.

OBJECTIVES

The aim of this study was to understand how bereaved caregivers assess the quality of dying and death experience with the Quality of Dying and Death questionnaire (QODD) by exploring the cognitive processes that underlie their evaluations.

METHODS

Bereaved caregivers of former metastatic cancer patients were asked to take part in a cognitive interview protocol after formulating the 31 quality ratings that contribute to the total QODD score. Qualitative content analysis was applied to transcribed interviews, with a specific focus on the information retrieved, the judgment strategies used, and any difficulties participants reported.

RESULTS

Twenty-two bereaved caregivers were interviewed with the protocol. Information that formed the basis of quality ratings referred to the perspective of the patient, the caregiver, other family/friends, or a combination of perspectives. Quality rating judgment strategies were generally comparative, and the most common standards of comparison were to "a hoped for or ideal dying experience," "a state before the dying phase," "a state of distress/no distress," or "normalcy/humanness." All respondents relied on multiple perspectives and standards of comparison when answering the QODD.

CONCLUSION

These results suggest that the quality of dying and death is a complex construct based on multiple perspectives and standards of comparison. These findings have implications for clinical care, which, if it aspires to improve how dying and death are evaluated, must ensure that the family is the unit of care and aid in preparation for the dying and death experience.

Measuring family satisfaction with care and quality of dying in the intensive care unit: does patient age matter?

RATIONALE

Few studies have examined the role of patient age on family experiences of end-of-life care.

OBJECTIVES

To assess measurement characteristics of two family-assessed questionnaires across three patient age groups.

METHODS

Four hundred and ninety-six patients who died in an intensive care unit (ICU) at a single hospital were identified and one family member per patient was sent two questionnaires: 1) Family Satisfaction in the ICU (FS-ICU); and 2) Quality of Dying and Death (QODD). Two hundred and seventy-five surveys were returned (55.4%). We analyzed three age groups: <35, 35-64, and ≥65 years. Differences were evaluated using χ(2) tests to evaluate ceiling, floor, and missing responses; Kruskal-Wallis tests to compare median scores on items and total scores; and linear regression controlling for patient sex, race, diagnosis, and family-member sex, race, education, and relationship to provide adjusted comparisons of total and subscale scores.

RESULTS

Measurement characteristics varied by age groups for both questionnaires. Missing values and floor endorsements were more common for the younger age groups for six items and one overall rating score. Ceiling endorsements were more common for the older group for 11 items. Fifteen items and four total scores were significantly higher in the older group.

CONCLUSIONS

The FS-ICU and QODD questionnaires performed differently across patient age groups. Assessments of family satisfaction and quality of dying and death were higher in the oldest group, particularly in the area of clinician-family communication. Studies of the dying experience of older adults may not generalize to patients of other ages, and study instruments should be validated among different age groups.

Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial

RATIONALE

Because of high mortality, end-of-life care is an important component of intensive care.

OBJECTIVES

We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care.

METHODS

We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics.

MEASUREMENTS AND MAIN RESULTS

All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81).

CONCLUSIONS

We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

End-of-life communication in the intensive care unit

OBJECTIVE

Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life (EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current research and recommendations for ICU EOL communication.

DESIGN

For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent bibliographies and cross-referenced known EOL ICU communication researchers.

RESULTS

Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency.

CONCLUSIONS

Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality of ICU palliative care and EOL communication.

End-of-life concerns and care preferences: congruence among terminally ill elders and their family caregivers

This study examined the end-of-life challenges, concerns, and care preferences of terminally ill elders and their family caregivers, with a focus on areas of congruence and incongruence. Ten elders and 10 family caregivers participated in separate, semi-structured, face-to-face interviews. Data analysis included team coding and thematic analysis, guided by an a priori set of categories based on the study questions. Shared challenges and concerns included experiencing decline, managing pain and discomfort, and living with uncertainty. There was also congruence regarding end-of-life care preferences, specifically the importance of quality care, treatment with dignity and respect, and avoiding unnecessary life-sustaining treatment. Areas of incongruence included the elders' difficulties in accepting dependence, their fears of becoming a burden, and desire to be prepared for death. Family caregivers were most concerned with providing adequate care to meet the elders' physical and spiritual care needs. Open family communication was associated with greater congruence. The authors discuss implications of these findings for research and intervention.

Review: the quality of dying and death: a systematic review of measures

To determine whether modern medicine is facilitating 'good' deaths, appropriate measures of the quality of dying and death must be developed and utilized. The purpose of this paper is to identify quality of dying and death measurement tools and to determine their quality. MEDLINE (1950-2008), Healthstar (1966-2008), and CINAHL (1982-2008) were searched using keyword terms 'quality of dying/death' and 'good/bad death'. Papers that described a quality of dying and death measure or that aimed to measure the quality of dying and death were selected for review. The evaluation criteria included a description of the measure development (validated or ad hoc), the provision of a definition of quality of dying and death, an empirical basis for the measure, the incorporation of multiple domains and the subjective nature of the quality of dying and death construct, and responsiveness to change. Eighteen measures met the selection criteria. Six were published with some description of the development process and 12 were developed ad hoc. Less than half were based on an explicit definition of quality of dying and death and even fewer relied on a conceptual model that incorporated multidimensionality and subjective determination. The specified duration of the dying and death phase ranged from the last months to hours of life. Of the six published measures reviewed, the Quality of Dying and Death questionnaire (QODD) is the most widely studied and best validated. Strategies to measure the quality of dying and death are becoming increasingly rigorous. Further research is required to understand the factors influencing the ratings of the quality of dying and death.

Assessing burden in families of critical care patients

OBJECTIVE

To provide critical care clinicians with information on validated instruments for assessing burden in families of critical care patients.

DATA SOURCES

PubMed (1979-2009).

STUDY SELECTION

We included all quantitative studies that used a validated instrument to evaluate the prevalence of, and risk factors for, burden on families.

DATA EXTRACTION AND SYNTHESIS

We extracted the descriptions of the instruments used and the main results. Family burden after critical illness can be detected reliably and requires preventive strategies and specific treatments. Using simple face-to-face interviews, intensivists can learn to detect poor comprehension and its determinants. Instruments for detecting symptoms of anxiety, depression, or stress can be used reliably even by physicians with no psychiatric training. For some symptoms, the evaluation should take place at a distance from intensive care unit discharge or death. Experience with families of patients who died in the intensive care unit and data from the literature have prompted studies of bereaved family members and the development of interventions aimed at decreasing guilt and preventing complicated grief.

CONCLUSIONS

We believe that burden on families should be assessed routinely. In clinical studies, using markers for burden measured by validated tools may provide further evidence that effective communication and efforts to detect and to prevent symptoms of stress, anxiety, or depression provide valuable benefits to families.

Exploring the quality of dying of patients with chronic obstructive pulmonary disease in the intensive care unit: a mixed methods study

RATIONALE FOR THE STUDY

Improving the quality of end-of-life (EOL) care in critical care settings is a high priority. Patients with advanced chronic obstructive pulmonary disease (COPD) are frequently admitted to and die in critical care units. To date, there has been little research examining the quality of EOL care for this unique subpopulation of critical care patients.

AIMS

The aims of this study were (a) to examine critical care clinician perspectives on the quality of dying of patients with COPD and (b) to compare nurse ratings of the quality of dying and death between patients with COPD with those who died from other illnesses in critical care settings.

DESIGN AND SAMPLE

A sequential mixed method design was used. Three focus groups provided data describing the EOL care provided to patients with COPD dying in the intensive care unit (ICU). Nurses caring for patients who died in the ICU completed a previously validated, cross-sectional survey (Quality of Dying and Death) rating the quality of dying for 103 patients.

DATA ANALYSIS

Thematic analysis was used to analyse the focus group data. Total and item scores for 34 patients who had died in the ICU with COPD were compared with those for 69 patients who died from other causes.

RESULTS

Three primary themes emerged from the qualitative data are as follows: managing difficult symptoms, questioning the appropriateness of care and establishing care priorities. Ratings for the quality of dying were significantly lower for patients with COPD than for those who died from other causes on several survey items, including dyspnoea, anxiety and the belief that the patient had been kept alive too long. The qualitative data allowed for in-depth explication of the survey results.

CONCLUSIONS

Attention to the management of dyspnoea, anxiety and treatment decision-making are priority concerns when providing EOL care in the ICU to patients with COPD.

Shared priorities for the end-of-life period

This study investigated end-of-life priorities of terminally ill patients and their intimate associates. A primary goal was to reduce the number of items in an existing instrument measuring survivors' evaluations of the quality of dying and death. Three Seattle-area patient samples (chronic obstructive pulmonary disease patients, hospice patients, and participants in an efficacy trial of complementary comfort care) and their significant others provided priority rankings of 26 experiences at end of life. Two items represented top priorities for all subgroups: time with family/friends and pain control. Clustered multivariate probit regression models suggested only a few significant differences between participant groups in priority rankings: higher education increased the priority placed on having available means to hasten death, cancer patients and persons in the hospice sample (likely those experiencing disproportionate pain) assigned pain control higher priority than other groups, persons in the clinical trial (which included massage as an intervention) assigned higher priority to human touch, and racial/ethnic minorities emphasized the importance of having funeral arrangements made. In the clinical trial sample (the most recently interviewed), the importance attributed to taking care of health care costs increased over time. If researchers were to use a reduced set of the 17 items mentioned among the top five priorities by at least 10% of the sample, none of the items that varied significantly between subgroups or over time would be eliminated. This change would reduce respondent burden in future investigations, simplify analyses aimed at identifying domains underlying the dying-and-death experience, and exclude the top-priority item of fewer than 4% of respondents.

Nationwide veterans affairs quality measure for cancer: the family assessment of treatment at end of life

The Veterans Affairs (VA) health care system has created a national initiative to measure quality of care at the end of life. This article describes the first phase of this national initiative, the Family Assessment of Treatment at End of Life (FATE), in evaluating the quality of end-of-life care for veterans dying with cancer. In the initial phase, next of kin of patients from five VA Medical Centers were contacted 6 weeks after patients' deaths and invited to participate in a telephone interview, and surrogates for 262 cancer patients completed FATE interviews. Decedents were 98% male with an average age of 72 years. There was substantial variation among sites. Higher FATE scores, consistent with family reports of higher satisfaction with care, were associated with palliative care consultation and hospice referral and having a Do Not Resuscitate order at the time of death, whereas an intensive care unit death was associated with lower scores. Early experience with FATE suggests that it will be a helpful tool to characterize end-of-life cancer care and to identify targets for quality improvement.

Evaluation of End-of-Life Cancer Care From the Perspective of Bereaved Family Members: The Japanese Experience

Surveying bereaved family members could enhance the quality of end-of-life cancer care in inpatient palliative care units (PCUs). We systematically reviewed nationwide postbereavement studies of PCUs in Japan and attempts to develop measures for evaluating end-of-life care from the perspective of bereaved family members. The Care Evaluation Scale (CES) for evaluating the structures and processes of care, and the Good Death Inventory (GDI) for evaluating the outcomes of care were considered suitable methods. We applied a shortened version of the CES to three nationwide surveys from 2002 to 2007. We developed the CES as an instrument to measure the structures and processes of care and the GDI as an outcomes measure for end-of-life cancer care from the perspective of bereaved family members. We conducted three nationwide surveys in 1997, 2001, and 2007 (n = 850, 853, and 5,301, respectively). Although six of the 10 areas of the CES showed significant improvements between the two time points investigated, we identified considerable potential for further progress. Feedback from surveys of bereaved family members might help to improve the quality of end-of-life cancer care in inpatient PCUs. However, the effectiveness of feedback procedures remains to be confirmed. Furthermore, there is a need to extend the ongoing evaluation process to home care hospices and general hospitals, including cancer centers, identify the limitations of end-of-life care in all settings, and develop strategies to overcome them.

Integrating palliative and critical care: evaluation of a quality-improvement intervention

RATIONALE

Palliative care in the intensive care unit (ICU) is an important focus for quality improvement.

OBJECTIVES

To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU.

METHODS

We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results.

MEASUREMENTS AND MAIN RESULTS

There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01).

CONCLUSIONS

We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Good death inventory: a measure for evaluating good death from the bereaved family member's perspective

The aim of this study was to develop a measure for evaluating good death from the bereaved family member's perspective, and to examine the validity and reliability of the assessment. A cross-sectional anonymous questionnaire was administered to bereaved family members of cancer patients who had died in a regional cancer center from September 2004 to February 2006. We measured the Good Death Inventory (GDI), Care Evaluation Scale, and an overall care satisfaction scale. A retest was conducted one month after sending the questionnaire. Of the 344 questionnaires sent to bereaved family members, 189 responses were analyzed (57%). A factor analysis of the responses to the GDI identified 10 core domains: "environmental comfort," "life completion," "dying in a favorite place," "maintaining hope and pleasure," "independence," "physical and psychological comfort," "good relationship with medical staff," "not being a burden to others," "good relationship with family," and "being respected as an individual." Eight optional domains also were identified: "religious and spiritual comfort," "receiving enough treatment," "control over the future," "feeling that one's life is worth living," "unawareness of death," "pride and beauty," "natural death," and "preparation for death." The GDI had sufficient concurrent validity with the Care Evaluation Scale and overall care satisfaction, sufficient internal consistency (alpha=0.74-0.95), and acceptable test-retest reliability (ICC=0.38-0.72). Finally, we developed a short version of the GDI. The GDI is a valid scale to measure end-of-life care comprehensive outcomes from the bereaved family member's perspective in Japan.

Can the death of a child be good?

Fifty-four thousand children die each year despite the advances in care for children with acute and chronic illnesses. Demands for improved palliative and end-of-life care for children exist. Good death is a concept frequently used in the adult hospice movement. However, how can the death of a child be good? Analysis of good death can assist pediatric nurses to understand the concept and provide a framework for nurses in the clinical and research arenas to work together to develop and provide evidence-based, developmentally appropriate care for dying children and their families.

Using the medical record to evaluate the quality of end-of-life care in the intensive care unit

RATIONALE

We investigated whether proposed "quality markers" within the medical record are associated with family assessment of the quality of dying and death in the intensive care unit (ICU).

OBJECTIVE

To identify chart-based markers that could be used as measures for improving the quality of end-of-life care.

DESIGN

A multicenter study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hrs of being transferred from an ICU.

SETTING

ICUs at ten hospitals in the northwest United States.

PATIENTS

Overall, 356 patients who died in the ICU or within 24 hrs of transfer from an ICU.

MEASUREMENTS

The 22-item family assessed Quality of Dying and Death (QODD-22) questionnaire and a single item rating of the overall quality of dying and death (QODD-1).

ANALYSIS

The associations of chart-based quality markers with QODD scores were tested using Mann-Whitney U tests, Kruskal-Wallis tests, or Spearman's rank-correlation coefficients as appropriate.

RESULTS

Higher QODD-22 scores were associated with documentation of a living will (p = .03), absence of cardiopulmonary resuscitation performed in the last hour of life (p = .01), withdrawal of tube feeding (p = .04), family presence at time of death (p = .02), and discussion of the patient's wish to withdraw life support during a family conference (p < .001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p < or = .05).

CONCLUSIONS

We identified chart-based variables associated with higher QODD scores. These QODD scores could serve as targets for measuring and improving the quality of end-of-life care in the ICU.

A 'pain-free' death

BACKGROUND

The time around a patient's death is often filled with sadness, but good medical and nursing care can provide comfort to patients and their carers at this critical time. For many, a 'pain-free' death is a priority although there are other aspects to providing good care at the end of life. Honest, open discussion with patients and carers about their wishes is an essential prerequisite to individualized care.

SOURCES OF DATA

Relevant literature was reviewed with regards to policy, education and delivery of end of life care.

AREAS OF AGREEMENT

Pain management must be tailored to the individual with due regard to the route of analgesic administration in those unable to swallow, and consideration to the other circumstances surrounding a person's care. All staff caring for dying patients should address pain as a priority in managing end of life care, to promote the best possible death for patients and prevent undue distress for carers and staff.

AREAS OF CONTROVERSY

This review has approached patient care at the end of life within current UK legislation, outlining what can be done to promote a 'pain-free' death. Debate continues about the role of euthanasia within end of life care and the use of analgesics and sedatives in pain management in terminal care.

GROWING POINTS

There is a range of tools available to help staff to care for dying patients, such as the Liverpool Care Pathway (LCP) for the Dying. It is most effective when introduced as part of a wider system of staff education in relation to terminal care.

AREAS TIMELY FOR DEVELOPING RESEARCH

Research into care of the dying will continue to be challenging. Priorities include; whether the use of tools such as the LCP improve the care patients receive, and the development of routine outcome measures including validated reports from patients and proxies.

Dialysis discontinuation: quo vadis?

Approximately 1 in 4 deaths of patients maintained on dialysis in the United States is preceded by a decision to discontinue treatment. Once considered to be a form of suicide, dialysis discontinuation is now increasingly common in most countries that are fortunate enough to offer renal replacement therapies. Given an aging and progressively sicker chronic kidney disease patient population, the rate of terminating dialysis is likely to increase. The literature on dialysis discontinuation includes studies principally from Canada, the United Kingdom, and the United States. The research is reviewed, critiqued, and examined to determine its relevance to practice. Future issues include the need to explore variability in dialysis practice as well as employment of a more patient-centered approach that is consistent with modern palliative medicine.

A systematic review of measures of end-of-life care and its outcomes

OBJECTIVE

To identify psychometrically sound measures of outcomes in end-of-life care and to characterize their use in intervention studies.

DATA SOURCES

English language articles from 1990 to November 2005 describing measures with published psychometric data and intervention studies of end-of-life care.

STUDY DESIGN

Systematic review of end-of-life care literature.

EXTRACTION METHODS

Two reviewers organized identified measures into 10 major domains. Eight reviewers extracted and characterized measures from intervention studies.

PRINCIPAL FINDINGS

Of 24,423 citations, we extracted 200 articles that described 261 measures, accepting 99 measures. In addition to 35 measures recommended in a prior systematic review, we identified an additional 64 measures of the end-of-life experience. The most robust measures were in the areas of symptoms, quality of life, and satisfaction; significant gaps existed in continuity of care, advance care planning, spirituality, and caregiver well-being. We also reviewed 84 intervention studies in which 135 patient-centered outcomes were assessed by 97 separate measures. Of these, 80 were used only once and only eight measures were used in more than two studies.

CONCLUSIONS

In general, most measures have not undergone rigorous development and testing. Measure development in end-of-life care should focus on areas with identified gaps, and testing should be done to facilitate comparability across the care settings, populations, and clinical conditions. Intervention research should use robust measures that adhere to these standards.

Measuring outcomes in randomized prospective trials in palliative care

Palliative care aims to improve the quality of life of patients and their families and reduce suffering from life-threatening illness. In assessing palliative care efficacy, researchers must consider a broad range of potential outcomes, including those experienced by the patient's family/caregivers, clinicians, and the health care system. The purpose of this article is to summarize the discussions and recommendations of an Outcomes Working Group convened to advance the palliative care research agenda, particularly in the context of randomized controlled trials. These recommendations address the conceptualization of palliative care outcomes, sources of outcomes data, application of outcome measures in clinical trials, and the methodological challenges to outcome measurement in palliative care populations. As other fields have developed and refined methodological approaches that address their particular research needs, palliative care researchers must do the same to answer important clinical questions in rigorous and credible ways.