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Choi HR, Ho MH, Lin CC. Navigating tensions when life-sustaining treatment is withdrawn: A thematic synthesis of nurses' and physicians' experiences. J Clin Nurs 2024; 33:2337-2356. [PMID: 38323726 DOI: 10.1111/jocn.17059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/18/2023] [Accepted: 01/23/2024] [Indexed: 02/08/2024]
Abstract
AIM To synthesise nurses' and physicians' experiences with withdrawing life-sustaining treatment in an intensive care unit. DESIGN The chosen methodology is thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing Transparency are used in Reporting the Synthesis of Qualitative Research Statement. METHODS AND DATA SOURCES A systematic search is conducted in APA PsycINFO, CINAHL Plus, EMBASE, PubMed and Web of Science following the inclusion and exclusion criteria in April 2023. Two reviewers independently screened and extracted the qualitative data. Subsequently, data analysis was conducted using thematic analysis of qualitative research. This study was not registered with any review registry due to the irrelevance of the data to health-related outcomes. RESULTS From the 16 articles, 267 quotes were extracted and analysed. The findings of the study revealed five analytical themes: (1) tensions between interdependent collaboration and hierarchical roles; (2) tensions between dignified dying or therapeutic perspectives; (3) family members' reflections of patient's wishes; (4) tensions in family members' positions; and (5) double-sidedness of distress. CONCLUSION This study contributes to nursing knowledge by providing a more nuanced understanding of this complex phenomenon of withdrawing life-sustaining treatment. The findings of this study have revealed significant variations globally in the practices surrounding the withdrawal of life-sustaining treatment in intensive care units, emphasising the need for further research to inform clinical practices that cater to diverse contexts. REPORTING METHOD Enhancing Transparency are used in Reporting the Synthesis of Qualitative Research Statement (ENTREQ statement). PATIENT OR PUBLIC CONTRIBUTION Since this study reported a potential collision between the patient's dignified dying and the family member's perceptions and interests, the family member's wishes should be carefully distinguished from the patient's quality of end of life in practice.
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Affiliation(s)
- Hye Ri Choi
- School of Nursing, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Mu-Hsing Ho
- School of Nursing, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chia-Chin Lin
- Alice Ho Miu Ling Nethersole Charity Foundation, School of Nursing, University of Hong Kong, Pok Fu Lam, Hong Kong
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Francoeur C, Silva A, Hornby L, Wollny K, Lee LA, Pomeroy A, Cayouette F, Scales N, Weiss MJ, Dhanani S. Pediatric Death After Withdrawal of Life-Sustaining Therapies: A Scoping Review. Pediatr Crit Care Med 2024; 25:e12-e19. [PMID: 37678383 PMCID: PMC10756696 DOI: 10.1097/pcc.0000000000003358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Evaluate literature on the dying process in children after withdrawal of life sustaining measures (WLSM) in the PICU. We focused on the physiology of dying, prediction of time to death, impact of time to death, and uncertainty of the dying process on families, healthcare workers, and organ donation. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and Web of Science. STUDY SELECTION We included studies that discussed the dying process after WLSM in the PICU, with no date or study type restrictions. We excluded studies focused exclusively on adult or neonatal populations, children outside the PICU, or on organ donation or adult/pediatric studies where pediatric data could not be isolated. DATA EXTRACTION Inductive qualitative content analysis was performed. DATA SYNTHESIS Six thousand two hundred twenty-five studies were screened and 24 included. Results were grouped into four categories: dying process, perspectives of healthcare professionals and family, WLSM and organ donation, and recommendations for future research. Few tools exist to predict time to death after WLSM in children. Most deaths after WLSM occur within 1 hour and during this process, healthcare providers must offer support to families regarding logistics, medications, and expectations. Providers describe the unpredictability of the dying process as emotionally challenging and stressful for family members and staff; however, no reports of families discussing the impact of time to death prediction were found. The unpredictability of death after WLSM makes families less likely to pursue donation. Future research priorities include developing death prediction tools of tools, provider and parental decision-making, and interventions to improve end-of-life care. CONCLUSIONS The dying process in children is poorly understood and understudied. This knowledge gap leaves families in a vulnerable position and the clinical team without the necessary tools to support patients, families, or themselves. Improving time to death prediction after WLSM may improve care provision and enable identification of potential organ donors.
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Affiliation(s)
- Conall Francoeur
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Amina Silva
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Laura Hornby
- Consultant, Canadian Blood Services, Hamilton, ON, Canada
| | - Krista Wollny
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Laurie A Lee
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Consultant, Canadian Blood Services, Hamilton, ON, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
- School of Nursing, Queen's University, Kingston, ON, Canada
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
- Dynamical Analysis Lab, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Transplant Québec, Montréal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | | | - Florence Cayouette
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
| | - Nathan Scales
- Dynamical Analysis Lab, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Matthew J Weiss
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
- Transplant Québec, Montréal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Sonny Dhanani
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
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Neto J, Casimiro HJ, Reis-Pina P. Palliative Extubation in Pediatric Patients in the Intensive Care Unit and at Home: A Scoping Review. Int J Pediatr 2023; 2023:6697347. [PMID: 38058590 PMCID: PMC10697771 DOI: 10.1155/2023/6697347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/15/2023] [Accepted: 10/13/2023] [Indexed: 12/08/2023] Open
Abstract
Aim This scoping review is aimed at systematically mapping the evidence on palliative extubation in the pediatric intensive care unit. Methods MEDLINE, EBSCO, and Cochrane databases were searched for articles published between January 2018 and December 2022, in English. Critical appraisal of sources of evidence was done using the Joanna Briggs Institute tools. PRISMA guidelines for scoping reviews were followed. Results Six studies were included, with 366 patients, from the USA (n = 4), Brazil (n = 1), and Germany (n = 1). Three were high-quality studies, two were moderate, and one was a low-quality study. Most studies were retrospective analysis; two were narrative approaches; two were evidence-based recommendation and quality improvement project; one study was a prospective intervention. Conclusion Symptom control is crucial pre- and postextubation. A checklist (symptom management and family support) and a postdebriefing template improve team communication and staff support postextubation. Critical care transports from the hospital are feasible to provide extubation at home. A framework addressing common planning challenges and resource management is recommended for extubation at home. The provision of pediatric palliative extubation is necessary since futile measures and prolongation of suffering violate the principle of nonmaleficence. Future research on this subject will result in more benefits for patients, parents, and professionals.
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Affiliation(s)
- Joana Neto
- Faculty of Medicine, University of Lisbon, Portugal
| | - Hugo Jorge Casimiro
- Faculty of Medicine, University of Lisbon, Portugal
- Hospital Palliative Care Team, Setúbal Hospital Centre, Setúbal, Portugal
| | - Paulo Reis-Pina
- Faculty of Medicine, University of Lisbon, Portugal
- Bento Menni's Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal
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Ortega-Chen C, Van Buren N, Kwack J, Mariano JD, Wang SE, Raman C, Cipta A. Palliative Extubation: A Discussion of Practices and Considerations. J Pain Symptom Manage 2023; 66:e219-e231. [PMID: 37023832 DOI: 10.1016/j.jpainsymman.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/27/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.
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Affiliation(s)
- Christina Ortega-Chen
- Department of Geriatrics and Palliative Medicine (COC), Kaiser Permanente Southern California, Panorama City, California, USA.
| | - Nicole Van Buren
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Joseph Kwack
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Jeffrey D Mariano
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine (JDM, AC), Pasadena, California, USA
| | - Susan Elizabeth Wang
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Charlene Raman
- Department of Graduate and Medical Education (CR), Kaiser Permanente Southern California Los Angeles Medical Center, Los Angeles, California, USA
| | - Andre Cipta
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine (JDM, AC), Pasadena, California, USA
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Francoeur C, Hornby L, Silva A, Scales NB, Weiss M, Dhanani S. Paediatric death after withdrawal of life-sustaining therapies: a scoping review protocol. BMJ Open 2022; 12:e064918. [PMID: 36123110 PMCID: PMC9486282 DOI: 10.1136/bmjopen-2022-064918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The physiology of dying after withdrawal of life-sustaining measures (WLSM) is not well described in children. This lack of knowledge makes predicting the duration of the dying process difficult. For families, not knowing this process's duration interferes with planning of rituals related to dying, travel for distant relatives and emotional strain during the wait for death. Time-to-death also impacts end-of-life care and determines whether a child will be eligible for donation after circulatory determination of death. This scoping review will summarise the current literature about what is known about the dying process in children after WLSM in paediatric intensive care units (PICUs). METHODS AND ANALYSIS This review will use Joanna Briggs Institute methodology for scoping reviews. Databases searched will include Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials via EBM Reviews Ovid, Ovid PsycINFO, CINAHL and Web of Science. Literature reporting on the physiology of dying process after WLSM, or tools that predict time of death in children after WLSM among children aged 0-18 years in PICUs worldwide will be considered. Literature describing the impact of prediction or timing of death after WLSM on families, healthcare workers and the organ donation process will also be included. Quantitative and qualitative studies will be evaluated. Two independent reviewers will screen references by title and abstract, and then by full text, and complete data extraction and analysis. ETHICS AND DISSEMINATION The review uses published data and does not require ethics review. Review results will be published in a peer-reviewed scientific journal.
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Affiliation(s)
- Conall Francoeur
- Department of Pediatrics, Centre de recherche du CHU de Quebec-Universite Laval, Quebec, Quebec, Canada
| | - Laura Hornby
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Amina Silva
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | | | - Matthew Weiss
- Department of Pediatrics, Centre de recherche du CHU de Quebec-Universite Laval, Quebec, Quebec, Canada
- Transplant Québec, Quebec, Québec, Canada
- Canadian Donation and Transplantation Research Program, Ottawa, Ontario, Canada
| | - Sonny Dhanani
- Canadian Donation and Transplantation Research Program, Ottawa, Ontario, Canada
- Critical Care, CHEO, Ottawa, Ontario, Canada
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