In their own time: the family experience during the process of withdrawal of life-sustaining therapy

A cross-sectional study on advance care planning documentation attitudes during national advance care planning week in a South-East Asian country

BACKGROUND

Through advocacy initiatives such as roadshows during "National ACP Week", the Agency for Integrated Care (AIC) had increased advance care planning (ACP) engagement since 2011. Project Happy Apples (PHA), a community initiative project led by medical students from the National University of Singapore, also conducted a public exhibition to raise ACP awareness during this period. This study aimed to investigate and identify predictors of attitudes towards ACP documentation among 'ACP Week' respondents which may be used to formulate strategies to increase ACP documentation in Singapore.

METHODS

A cross-sectional study on ACP documentation attitudes of 262 respondents during local roadshows were conducted. Multiple logistic regression models were built to investigate the associations between demographic variables and attitudes toward ACP documentation.

RESULTS

The mean age was 43.5 years (SD = 17.4), 79 (30.15%) were males and 49 (18.7%) were healthcare professionals (HCP). 117 (44.66%) respondents had prior experience with serious illness and 116 (44.27%) had heard of ACP. Age was a significant predictor of readiness to sign official papers naming nominated healthcare spokesperson (NHS) (OR = 1.04, 95%CI: 1.02-1.07). Experience with serious illness was a significant predictor of readiness to discuss end-of-life (EOL) care with healthcare professionals (HCP) (OR = 3.65, 95%CI: 1.36-11.61). Being female was a significant predictor for readiness to speak to their nominated healthcare spokesperson about EOL care (OR = 7.33, 95%CI: 2.06-46.73). Subgroup analyses revealed that those aged 20-39 were less likely to speak to their healthcare professional about or sign official papers regarding EOL care. We also found that being a healthcare professional does not necessitate better or worse attitudes.

CONCLUSION

Advocacy programs tailored to targeting respondents of different age groups and prior experience with serious illness may improve the efficacy of advocacy efforts.

Lessons Learned Establishing the Palliative Care Research Cooperative's Qualitative Data Repository

Data sharing is increasingly an expectation in health research as part of a general move toward more open sciences. In the United States, in particular, the implementation of the 2023 National Institutes of Health Data Management and Sharing Policy has made it clear that qualitative studies are not exempt from this data sharing requirement. Recognizing this trend, the Palliative Care Research Cooperative Group (PCRC) realized the value of creating a de-identified qualitative data repository to complement its existing de-identified quantitative data repository. The PCRC Data Informatics and Statistics Core leadership partnered with the Qualitative Data Repository (QDR) to establish the first serious illness and palliative care qualitative data repository in the U.S. We describe the processes used to develop this repository, called the PCRC-QDR, as well as our outreach and education among the palliative care researcher community, which led to the first ten projects to share the data in the new repository. Specifically, we discuss how we co-designed the PCRC-QDR and created tailored guidelines for depositing and sharing qualitative data depending on the original research context, establishing uniform expectations for key components of relevant documentation, and the use of suitable access controls for sensitive data. We also describe how PCRC was able to leverage its existing community to recruit and guide early depositors and outline lessons learned in evaluating the experience. This work advances the establishment of best practices in qualitative data sharing.

Limitation of life sustaining therapy in disorders of consciousness: ethics and practice

Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.

Pediatric Death After Withdrawal of Life-Sustaining Therapies: A Scoping Review

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.

Life-Sustaining Treatment Decision in Palliative Care Based on Electronic Health Records Analysis

AIMS AND OBJECTIVES

This study sought to explore the present status of life-sustaining treatment decisions in a tertiary hospital to improve the life-sustaining treatment decision-making process.

BACKGROUND

Life-sustaining treatment decisions are crucial for palliative care because they encompass decisions to withdraw treatments when patients cannot articulate their values and preferences. However, surrogate decisions have settled many life-sustaining treatment cases in South Korea, and this trend is prevalent.

DESIGN

We conducted a retrospective, descriptive study employing a review of electronic health records.

METHODS

We extracted and analysed electronic health records of a tertiary hospital. Our inclusion criteria included adult patients who completed life-sustaining treatment forms in 2019. A total of 2,721 patients were included in the analysis. We analysed the decision-maker, the timing of the decision, and patients' health status a week before the decision. We followed the STROBE checklist.

RESULTS

Among 1,429 deceased patients, those whose families had made life-sustaining treatment decisions totalled 1,028 (70.6%). The median interval between life-sustaining treatment documentation completion to death was three days, more specifically, two days in the family decision group and 5.5 days in the patient decision group. As the decision day neared, there were marked changes in patients' vital signs and laboratory test results, and the need for nursing care increased.

CONCLUSIONS

Life-sustaining treatment decisions were made when death was imminent, suggesting that the time required to discuss end-of-life care was generally insufficient among patients, family, and healthcare professionals in Korea.

RELEVANCE TO CLINICAL PRACTICE

Monitoring changes in laboratory test results and symptoms could help screen the patients who need the life-sustaining treatment discussion. As improving the quality of death is imperative in palliative care, institutional efforts, such as clinical ethics support services, are necessary to improve the life-sustaining treatment decision-making process for patients, families, and healthcare providers.

Paediatric death after withdrawal of life-sustaining therapies: a scoping review protocol

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.

Neuroprognostication: a conceptual framework

Neuroprognostication, or the prediction of recovery from disorders of consciousness caused by severe brain injury, is as critical as it is complex. With profound implications for mortality and quality of life, neuroprognostication draws upon an intricate set of biomedical, probabilistic, psychosocial and ethical factors. However, the clinical approach to neuroprognostication is often unsystematic, and consequently, variable among clinicians and prone to error. Here, we offer a stepwise conceptual framework for reasoning through neuroprognostic determinations - including an evaluation of neurological function, estimation of a recovery trajectory, definition of goals of care and consideration of patient values - culminating in a clinically actionable formula for weighing the risks and benefits of life-sustaining treatment. Although the complexity of neuroprognostication might never be fully reducible to arithmetic, this systematic approach provides structure and guidance to supplement clinical judgement and direct future investigation.

Requests for Accommodation in Brain Death Cases: Emerging Role for Pediatric Palliative Care

Death by neurologic criteria is a diagnosis that has presented complexities since its inception and pediatric cases are no exception. While rare, families may request accommodation to deviate from the traditionally defined diagnostic pathway based on their beliefs, mistrust of the diagnosis, or other complex reasons. Palliative care consultation offers a unique clinical perspective to complement the work of intensivists to support families through the diagnosis and possible resolution around accommodation requests. With misinformation and high-profile cases widely visible to the public through the media, these requests require a thoughtful and informed clinical approach by all members of the interdisciplinary clinical team. Common themes in many of these cases are trauma, bias and their impact on caregivers. We use a case-based approach to explore these complexities and clinical tools.

Early Palliative Care Consultation in the Burn Unit: A Quality Improvement Initiative to Increase Utilization

Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended "triggers" for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (<72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived >24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.

The Situation of Life-Sustaining Treatment One Year After Enforcement of the Act on Decisions on Life-Sustaining Treatment for Patients at the End-of-Life in Korea: Data of National Agency for Management of Life-Sustaining Treatment

Purpose

The “Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End-of-Life” was enacted on February 3, 2016 and went into effect on February 4, 2018 in Korea. This study reviewed the first year of determination to life-sustaining treatment (LST) through data analysis of the National Agency for Management of Life-Sustaining Treatment.

Materials and Methods

The National Agency for Management of LST provided data between February 4, 2018 and January 31, 2019 anonymously from 33,549 patients. According to the forms patients were defined as either elf-determinants or family-determinants.

Results

The median age of the patient was 73 and the majority was male (59.9%). Cancer patients were 59% and self-determinants were 32.1%. Cancer patients had a higher rate of self-determinants than non-cancer (47.3% vs. 10.1%). Plan for hospice service was high in cancer patients among self-determinants (81.0% vs. 37.5%, p < 0.001). In comparison to family-determinants, self-determinants were younger (median age, 67 years vs. 75 years; p < 0.001) and had more cancer diagnosis (87.1% vs. 45.9%, p < 0.001). Decision of withholding or withdrawing of LSTs in cancer patients was higher than non-cancer patients in four items.

Conclusion

Cancer patients had a higher rate in self-determination and withholding or withdrawing of LSTs than non-cancer patients. Continued revision of the law and education of the public will be able to promote withdrawing or withholding the futile LSTs in patients at end-of-life. Further study following the revision of the law should be evaluated to change of end-of-life care.

The Concerns and Experience of Decision-Making Regarding Do-Not-Resuscitate Orders Among Caregivers in Hospice Palliative Care

A do-not-resuscitate (DNR) order is an important end-of-life decision. In Taiwan, family caregivers are also involved in this decision-making process. This study aimed to explore the concerns and experiences regarding DNR decisions among caregivers in Taiwan. Qualitative study was conducted. Convenience sampling was used, and 26 caregivers were recruited whose patients had a DNR order and had received hospice care or hospice home care. Semi-structured interviews were used for data collection, including the previous experiences of DNR discussions with the patients and medical staff and their concerns and difficulties in decision-making. The data analysis was based on the principle of thematic analysis. Four themes were identified: (1) Patients: The caregivers respected the patients’ willingness and did not want to make them feel like “giving up.” (2) Caregivers’ self: They did not want to intensify the patients’ suffering but sometimes found it emotionally difficult to accept death. (3) Other family members: They were concerned about the other family members’ opinions on DNR orders, their blame, and their views on filial impiety. (4) Medical staff: The information and suggestions from the medical staff were foundational to their decision-making. The caregivers needed the health care professionals’ supports to deal with the concerns from patients and other family members as well as their emotional reactions.

Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services

Importance

Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care.

Objectives

To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death.

Design, Setting, and Participants

This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019.

Exposure

Cessation of dialysis treatment before death.

Main Outcomes and Measures

Bereaved Family Survey ratings.

Results

Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001).

Conclusions and Relevance

This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.

Time-Limited Trials in the Intensive Care Unit to Promote Goal-Concordant Patient Care

Consider the hypothetical case of a 75-year-old patient admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure due to pneumonia and systolic heart failure. Although she suffers from a potentially treatable infection, her advanced age and chronic illness increase her risk of experiencing a poor outcome. Her family feels conflicted about whether the use of mechanical ventilation would be acceptable given what they understand about her values and preferences. In the ICU setting, clinicians, patients, and surrogate decision-makers frequently face challenges of prognostic uncertainty as well as uncertainty regarding patients' goals and values. Time-limited trials (TLTs) of life-sustaining treatments in the ICU have been proposed as one strategy to help facilitate goal-concordant care in the midst of a complex and high-stakes decision-making environment. TLTs represent an agreement between clinicians and patients or surrogate decision-makers to employ a therapy for an agreed-upon time period, with a plan for subsequent reassessment of the patient's progress according to previously-established criteria for improvement or decline. Herein, we review the concept of TLTs in intensive care, and explore their potential benefits, barriers, and challenges. Research demonstrates that, in practice, TLTs are conducted infrequently and often incompletely, and are challenged by system-level factors that diminish their effectiveness. The promise of TLTs in intensive care warrants continued research efforts, including implementation studies to improve adoption and fidelity, observational research to determine optimal timeframes for TLTs, and interventional trials to determine if TLTs ultimately improve the delivery of goal-concordant care in the ICU.

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

AIM

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

METHOD

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

FINDINGS

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

CONCLUSIONS

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

Family members' experiences in adult intensive care units: a systematic review

BACKGROUND

Admission to Intensive Care Units (ICU) exposures family members to a new environment, advanced monitoring systems and aggressive treatments. This is coupled with the critical condition of the patient being admitted in ICU. In such times of stress and crisis, families have varying experiences as they navigate the ICU journey. These happen more or less in chronological phases.

AIM

This review sought to describe the experiences of family members of patients admitted in adult ICUs.

DATA SOURCES

Four electronic databases (PubMed, Embase, Scopus and Web of Science) were searched, using keywords and free-text words.

METHODS

Curation of the review question involved problem identification, a scoping search, developing a search strategy, evaluation, data analysis, and reporting. Freehand search in reference lists of eligible articles was also done to obtain potentially eligible articles published in English language between 2007 and 2018. Studies were included if they reported on family members' experiences in adult ICUs. This review conforms to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA).

RESULTS

Upon completion of the screening process, 28 studies were included. Most studies were conducted in the United States while no study was identified from Africa. We report on 717 family members. Family members' experience of the ICU journey falls into three main themes: (i) Floating, (ii) Probing and (iii) Continuity or Closure.

CONCLUSION

As healthcare technology advances, the ICU environment consequently needs to evolve. As such, healthcare providers will need to adjust their practice, support and consider the patients' family as the other part of the patient and members of the care team in order to meet their expectations. Further research highlighting family members' experience of the ICU journey in Africa is needed.

Titrating Clinician Directiveness in Serious Pediatric Illness

Shared decision-making in pediatrics is based on a trusting partnership between parents, clinicians, and sometimes patients, wherein all stakeholders explore values and weigh options. Within that framework, clinicians often have an obligation to provide guidance. We describe a range of ethically justifiable clinician directiveness that could be appropriate in helping families navigate serious pediatric illness. The presentation of "default" options and informed nondissent as potential strategies are discussed. The degree of clinician directiveness may vary even for decisions that are equally "shared." A myriad of factors affect how directive a clinician can or should be. Some of the most important factors are the degree of prognostic certainty and the family's desire for guidance, but others are important as well, such as the urgency of the decision; the relationship between the clinician, patient, and family; the degree of team consensus; and the burdens and benefits of therapy. Directiveness should be considered an important tool in a clinician's armamentarium and is one that can be used to support families in stressful and emotionally difficult situations.

When a Child Dies in the PICU Despite Ongoing Life Support

OBJECTIVES

To examine the circumstance of death in the PICU in the setting of ongoing curative or life-prolonging goals.

DATA SOURCES

Multidisciplinary author group, international expert opinion, and use of current literature.

DATA SYNTHESIS

We describe three common clinical scenarios when curative or life-prolonging goals of care are pursued despite a high likelihood of death. We explore the challenges to providing high-quality end-of-life care in this setting. We describe possible perspectives of families and ICU clinicians facing these circumstances to aid in our understanding of these complex deaths. Finally, we offer suggestions of how PICU clinicians might improve the care of children at the end of life in this setting.

CONCLUSIONS

Merging curative interventions and optimal end-of-life care is possible, important, and can be enabled when clinicians use creativity, explore possibilities, remain open minded, and maintain flexibility in the provision of critical care medicine. When faced with real and perceived barriers in providing optimal end-of-life care, particularly when curative goals of care are prioritized despite a very poor prognosis, tensions and conflict may arise. Through an intentional exploration of self and others' perspectives, values, and goals, and working toward finding commonality in order to align with each other, conflict in end-of-life care may lessen, allowing the central focus to remain on providing optimal support for the dying child and their family.

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

BACKGROUND:

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

RESEARCH OBJECTIVES:

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

RESEARCH DESIGN:

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

PARTICIPANTS AND RESEARCH CONTEXT:

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

ETHICAL CONSIDERATIONS:

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

FINDINGS:

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

DISCUSSION:

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

CONCLUSION:

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

Palliative and End-of-Life Ethical Dilemmas in the Intensive Care Unit

Critical care nurses and advanced practice registered nurses frequently face bioethical dilemmas in clinical practice that are related to palliative and end-of-life care. Many of these dilemmas are associated with decisions made concerning continuing, limiting, or withdrawing life-sustaining treatments. The purpose of this article is to describe common ethical challenges through case study presentations and discuss approaches that critical care nurses and advanced practice registered nurses in collaboration with the interdisciplinary team can use to address these challenges. Resources that may be helpful in managing ethical dilemmas are identified.

A family nursing educational intervention supports nurses and families in an adult intensive care unit

The family experience of critical illness is filled with distress that may have a lasting impact on family coping and family health. A nurse can become a source of comfort that helps the family endure. Yet, nurses often report a lack of confidence in communicating with families and families report troubling relationships with nurses. In spite of strong evidence supporting nursing practice focused on the family, family nursing interventions often not implemented in the critical care setting. This pilot study examined the influence of an educational intervention on nurses' attitudes towards and confidence in providing family care, as well as families' perceptions of support from nurses in an adult critical care setting. An academic-clinical practice partnership used digital storytelling as an educational strategy. A Knowledge to Action Process Framework guided this study. Results of pre-intervention data collection from families and nurses were used to inform the educational intervention. A convenience sample of family members completed the Iceland Family Perceived Support Questionnaire (ICE-FPSQ) to measure perception of support provided by nurses. Video, voice, and narrative stories of nurses describing their experiences caring for family members during a critical illness and family members' experiences with a critically ill family member also guided education plans. When comparing the pre and post results of the Family Nurse Practice Scale (FNPS), nurses reported increased confidence, knowledge, and skill following the educational intervention. Qualitative data from nurses reported satisfaction with the educational intervention. Findings suggest that engaging nurses in educational opportunities focused on families while using storytelling methods encourages empathic understandings. Academic-clinician teams that drive directions show promise in supporting families and nurses in critical care settings. Plans are moving forward to use this study design and methods in other critical care settings.

Decision conflict and regret among surrogate decision makers in the medical intensive care unit

INTRODUCTION

Family members of critically ill patients in the intensive care unit face significant morbidity. It may be the decision-making process that plays a significant role in the psychological morbidity associated with being a surrogate in the ICU. We hypothesize that family members facing end-of-life decisions will have more decisional conflict and decisional regret than those facing non-end-of-life decisions.

METHODS

We enrolled a sample of adult patients and their surrogates in a tertiary care, academic medical intensive care unit. We queried the surrogates regarding decisions they had made on behalf of the patient and assessed decision conflict. We then contacted the family member again to assess decision regret.

RESULTS

Forty (95%) of 42 surrogates were able to identify at least 1 decision they had made on behalf of the patient. End-of-life decisions (defined as do not resuscitate [DNR]/do not intubate [DNI] or continuation of life support) accounted for 19 of 40 decisions (47.5%). Overall, the average Decision Conflict Scale (DCS) score was 21.9 of 100 (range 0-100, with 0 being little decisional conflict and 100 being great decisional conflict). The average DCS score for families facing end-of-life decisions was 25.5 compared with 18.7 for all other decisions. Those facing end-of-life decisions scored higher on the uncertainty subscale (subset of DCS questions that indicates level of certainty regarding decision) with a mean score of 43.4 compared with all other decisions with a mean score of 27.0. Overall, very few surrogates experienced decisional regret with an average DRS score of 13.4 of 100.

CONCLUSIONS

Nearly all surrogates enrolled were faced with decision-making responsibilities on behalf of his or her critically ill family member. In our small pilot study, we found more decisional conflict in those surrogates facing end-of-life decisions, specifically on the subset of questions dealing with uncertainty. Surrogates report low levels of decisional regret.

A Parent's Journey: Incorporating Principles of Palliative Care into Practice for Children with Chronic Neurologic Diseases

Rather than in conflict or in competition with the curative model of care, pediatric palliative care is a complementary and transdisciplinary approach used to optimize medical care for children with complex medical conditions. It provides care to the whole child, including physical, mental, and spiritual dimensions, in addition to support for the family. Through the voice of a parent, the following case-based discussion demonstrates how the fundamentals of palliative care medicine, when instituted early in the course of disease, can assist parents and families with shared medical decision making, ultimately improving the quality of life for children with life-limiting illnesses. Pediatric neurologists, as subspecialists who provide medical care for children with chronic and complex conditions, should consider invoking the principles of palliative care early in the course of a disease process, either through applying general facets or, if available, through consultation with a specialty palliative care service.

Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units

In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.

Resolving Communication Challenges in the Intensive Care Unit

Communication in the intensive care unit (ICU) is challenging because of complexity, high patient acuity, uncertainty, and ethical issues. Unfortunately, conflict is common, as several studies and reviews confirm. Three types of communication challenges are found in this setting: those within the ICU team, those between the ICU team and the patient or family, and those within the patient’s family. Although specific evidence-based interventions are available for each type of communication challenge, all hinge on clinicians being culturally competent, respectful, and good communicators/listeners. Critical care advanced practice nurses promote a positive team environment, increase patient satisfaction, and model good communication for other clinicians. All advanced practice nurses, however, also need to be adept at having difficult conversations, handling conflict, and providing basic palliative care, including emotional support.

Palliative and End-of-Life Ethical Dilemmas in the Intensive Care Unit

Critical care nurses and advanced practice registered nurses frequently face bioethical dilemmas in clinical practice that are related to palliative and end-of-life care. Many of these dilemmas are associated with decisions made concerning continuing, limiting, or withdrawing life-sustaining treatments. The purpose of this article is to describe common ethical challenges through case study presentations and discuss approaches that critical care nurses and advanced practice registered nurses in collaboration with the interdisciplinary team can use to address these challenges. Resources that may be helpful in managing ethical dilemmas are identified.

A scoping review of family experience and need during end of life care in intensive care

AIM

To scope systematically and collate qualitative studies on family experience and need during end of life care in intensive care, from the perspective of family members.

DESIGN

Scoping review of qualitative research.

METHODS

Standardized processes of study identification, data extraction and data synthesis were used. Multiple bibliographic databases were accessed during 2011 and updated in 2013.

RESULTS

From an initial 876 references, 16 studies were identified for inclusion. These were predominantly single site, North American studies that explored issues relating to the temporal stages in the end of life trajectory and the requirement for information and emotional support at end of life. With a strong focus on family need and experience during the transition from active treatment to end of life care, more work is required to understand how doctors and nurses can support families from treatment withdrawal through to death.

Post-Traumatic Stress Symptoms in Post-ICU Family Members: Review and Methodological Challenges

Family members of intensive care unit (ICU) patients are at risk for symptoms of post-traumatic stress disorder (PTSD) following ICU discharge. The aim of this systematic review is to examine the current literature regarding post-ICU family PTSD symptoms with an emphasis on methodological issues in conducting research on this challenging phenomenon. An extensive review of the literature was performed confining the search to English language studies reporting PTSD symptoms in adult family members of adult ICU patients. Ten studies were identified for review published from 2004 to 2012. Findings demonstrate a significant prevalence of family PTSD symptoms in the months following ICU hospitalization. However, there are several methodological challenges to the interpretation of existing studies and to the conduct of future research including differences in sampling, identification of risk factors and covariates of PTSD, and lack of consensus regarding the most appropriate PTSD symptom measurement tools and timing.

Self-described nursing roles experienced during care of dying patients and their families: a phenomenological study

BACKGROUND

Critical care nurses frequently care for dying patients and their families. Little is known about the roles experienced and perceived by bedside nurses as they care for dying patients and their families.

OBJECTIVES

The purpose of this study was to understand the experiences of critical care nurses and to understand their perceptions of activities and roles that they performed while caring for patients and families during the transition from aggressive life-saving care to palliative and end-of-life care.

METHODS

A descriptive, phenomenological study was conducted and a purposive sampling strategy was used to recruit 19 critical care nurses with experience caring for dying patients and their families. Individual interviews were conducted and audio-recorded. Coliazzi's method of data analysis was utilised to inductively determine themes, clusters and categories. Data saturation was achieved and methodological rigour was established.

RESULTS

Categories that evolved from the data included educating the family, advocating for the patient, encouraging and supporting family presence, managing symptoms, protecting families and creating positive memories and family support. Participants also identified the importance of teaching and mentoring novice clinicians.

CONCLUSIONS

The results of this study have important implications for clinical practice, education and research for optimal preparation in providing end-of-life care.

On ethical (in)decisions experienced by parents of infants in neonatal intensive care

This study was a phenomenological investigation of ethical decisions experienced by parents of newborns in neonatal intensive care. I explore the lived meanings of thematic events that speak to the variable ways that ethical situations may be experienced: a decision that was never a choice; a decision as looking for a way out; a decision as thinking and feeling oneself through the consequences; a decision as indecision; and a decision as something that one falls into. The concluding recommendations spell out the need for understanding the experiences of parents whose children require medical care and underscore the tactful sensitivities required of the health care team during moral-ethical decision making.

What is a good death? Health care professionals' narrations on end-of-life care

The present study explores how health professionals evaluate care at the end of life and what they consider to be a good death. We conducted four focus groups with 37 health professionals and used a grounded theory-based approach to analyze the transcripts of the discussions. A lack of organization, training, formalized procedures, and communication with dying persons and their families emerged. Difficulty in defining a good death derived from the ethical dilemmas that involved places to die, palliative care, and end-of-life decision making.

The culture of dysthanasia: attempting CPR in terminally ill children

Both dying children and their families are treated with disrespect when the presumption of consent to cardiopulmonary resuscitation (CPR) applies to all hospitalized children, regardless of prognosis and the likely efficacy of CPR. This "opt-out" approach to CPR fails to appreciate the nuances of the special parent-child relationship and the moral and emotional complexity of enlisting parents in decisions to withhold CPR from their children. The therapeutic goal of CPR is not merely to resume spontaneous circulation, but rather it is to provide circulation to vital organs to allow for treatment of the underlying proximal and distal etiologies of cardiopulmonary arrest. When the treating providers agree that attempting CPR is highly unlikely to achieve the therapeutic goal or will merely prolong dying, we should not burden parents with the decision to forgo CPR. Rather, physicians should carry the primary professional and moral responsibility for the decision and use a model of informed assent from parents, allowing for respectful disagreement. As emphasized in the palliative care literature, we recommend a directive and collaborative goal-oriented approach to conversations about limiting resuscitation, in which physicians provide explicit recommendations that are in alignment with the goals and hopes of the family and emphasize the therapeutic indications for CPR. Through this approach, we hope to help parents understand that "doing everything" for their dying child means providing medical therapies that ameliorate suffering and foster the intimacy of the parent-child relationship in the final days of a child's life, making the dying process more humane.

I don't want to be the one saying 'we should just let him die': intrapersonal tensions experienced by surrogate decision makers in the ICU

BACKGROUND

Although numerous studies have addressed external factors associated with difficulty in surrogate decision making, intrapersonal sources of tension are an important element of decision making that have received little attention.

OBJECTIVE

To characterize key intrapersonal tensions experienced by surrogate decision makers in the intensive care unit (ICU), and explore associated coping strategies.

DESIGN

Qualitative interview study.

PARTICIPANTS

Thirty surrogates from five ICUs at two hospitals in Pittsburgh, Pennsylvania, who were actively involved in making life-sustaining treatment decisions for a critically ill loved one.

APPROACH

We conducted in-depth, semi-structured interviews with surrogates, focused on intrapersonal tensions, role challenges, and coping strategies. We analyzed transcripts using constant comparative methods.

KEY RESULTS

Surrogates experience significant emotional conflict between the desire to act in accordance with their loved one's values and 1) not wanting to feel responsible for a loved one's death, 2) a desire to pursue any chance of recovery, and 3) the need to preserve family well-being. Associated coping strategies included 1) recalling previous discussions with a loved one, 2) sharing decisions with family members, 3) delaying or deferring decision making, 4) spiritual/religious practices, and 5) story-telling.

CONCLUSIONS

Surrogates' struggle to reconcile personal and family emotional needs with their loved ones' wishes, and utilize common coping strategies to combat intrapersonal tensions. These data suggest reasons surrogates may struggle to follow a strict substituted judgment standard. They also suggest ways clinicians may improve decision making, including attending to surrogates' emotions, facilitating family decision making, and eliciting potential emotional conflicts and spiritual needs.

Honoring patient care preferences: surrogates speak

A growing body of evidence has pointed to the stressful experience surrounding surrogate decision-making on behalf of incapacitated patients. This study (N = 59) asked surrogates to speak about their experiences immediately after having made a life-sustaining treatment decision. Grounded theory analysis revealed four themes: (1) the emotional impact of the decision-making process on the surrogate; (2) the difficulty of watching a loved one's health deteriorate; (3) the importance of having a Living Will (LW) or other written/verbal instructions; and (4) the reliance on spirituality as a means of coping with the surrogate experience. Findings of this study suggest that engaging surrogates at the time of patient admission may be essential in order to clarify patient preferences and strengthen communication between surrogates and the interdisciplinary healthcare team.

Family involvement in the end-of-life decisions of competent intensive care patients

In this article, we report the findings from a qualitative study that explored how relatives of terminally ill, alert and competent intensive care patients perceived their involvement in the end-of-life decision-making process. Eleven family members of six deceased patients were interviewed. Our findings reveal that relatives narrate about a strong intertwinement with the patient. They experienced the patients' personal individuality as a fragile achievement. Therefore, they viewed their presence as crucial with their primary role to support and protect the patient, thereby safeguarding his values and interests. However, their inclusion in decision making varied from active participation in the decision-making process to acceptance of the physicians' decision or just receiving information. We conclude that models of informed shared decision making should be utilised and optimised in intensive care, where nurses and physicians work with both the patient and his or her family and regard the family as partners in the process.

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

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

Family management after the sudden death of a family member

Although more is known about how individuals within families make decisions and manage more discrete issues when a family member is dying, less is known about how families as a unit manage after the sudden death of a family member. The article discusses an investigation that was conducted to better understand how families respond to the life-threatening illness or injury and eventual death of a family member. The purpose of the study was to define Family Management Styles (FMSs) and determine distinctive characteristics of each FMS used by families after the death of a family member who had life-sustaining therapy withdrawn as a result of an unexpected, life-threatening illness or injury. Interviews are conducted with 8 families (22 family members) 1 to 2 years after the death of their family members. A modified typology of FMSs based on a directed analysis that was then inductively modified includes: progressing, accommodating, maintaining, struggling, and floundering. Understanding FMSs and how FMSs may change over time, reflecting the changing focus of family work, will further aid in the development of family-focused interventions as well as develop FMSs within the context of end of life.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

PARTICIPANTS

Health care clinicians, patients, and family members.

RESULTS

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

CONCLUSIONS

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