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Chen RY, Li YC, Hsueh KC, Wang FW, Chen HJ, Huang TY. Factors influencing terminal cancer patients' autonomous DNR decision: a longitudinal statutory document and clinical database study. BMC Palliat Care 2022; 21:149. [PMID: 36028830 PMCID: PMC9419392 DOI: 10.1186/s12904-022-01037-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Much of our knowledge of patient autonomy of DNR (do-not-resuscitate) is derived from the cross-sectional questionnaire surveys. Using signatures on statutory documents and medical records, we analyzed longitudinal data to understand the fact of terminal cancer patients’ autonomous DNR decision-making in Taiwan. Methods Using the medical information system database of one public medical center in Taiwan, we identified hospitalized cancer patients who died between Jan. 2017 and Dec. 2018, collected their demographic and clinical course data and records of their statutory DNR document types, letter of intent (DNR-LOI) signed by the patient personally and the consent form signed by their close relatives. Results We identified 1,338 signed DNR documents, 754 (56.35%) being DNR-LOI. Many patients had the first DNR order within their last week of life (40.81%). Signing the DNR-LOI was positively associated with being under the care of a family medicine physician prior to death at last hospitalization and having hospice palliative care and negatively associated with patient age ≥ 65 years, no formal education, having ≥ 3 children, having the first DNR order to death ≤ 29 days, and the last admission in an intensive care unit. Conclusions A substantial proportion of terminal cancer patients did not sign DNR documents by themselves. It indicates they may not know their actual terminal conditions and lose the last chance to grasp time to express their life values and wishes. Medical staff involving cancer patient care may need further education on the legal and ethical issues revolving around patient autonomy and training on communicating end-of-life options with the patients. We suggest proactively discussing DNR decision issues with terminal cancer patients no later than when their estimated survival is close to 1 month.
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Affiliation(s)
- Ru-Yih Chen
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC.,Department of Business Management, Institute of Health Care Management, National Sun Yat-Sen University, No. 70. Lianhai Rd, Kaohsiung, Taiwan, ROC
| | - Ying-Chun Li
- Department of Business Management, Institute of Health Care Management, National Sun Yat-Sen University, No. 70. Lianhai Rd, Kaohsiung, Taiwan, ROC.
| | - Kuang-Chieh Hsueh
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Fu-Wei Wang
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Hong-Jhe Chen
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Tzu-Ya Huang
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
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2
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Bunin J, Shohfi E, Meyer H, Ely EW, Varpio L. The burden they bear: A scoping review of physician empathy in the intensive care unit. J Crit Care 2021; 65:156-163. [PMID: 34157584 DOI: 10.1016/j.jcrc.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/03/2021] [Accepted: 05/25/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Research shows that physician empathy can improve patients' reporting of symptoms, participation in care, compliance, and satisfaction; however, success in harnessing these advantages in the ICU hinges on a myriad of contextual factors. This study describes the current state of knowledge about intensivists' empathy. METHODS A scoping review was conducted across six databases and grey literature to clarify intensivists' experiences of empathy and identify directions of future inquiries. The search had no date limits and was specific to empathy, intensivists, and ICU environments. Results were blindly and independently reviewed by authors. RESULTS The search yielded 628 manuscripts; 45 met inclusion criteria. Three overarching themes connected the manuscripts: (1) the risks and benefits of empathy, (2) the spectrum of connection and distance of intensivists from patients/families, and (3) the facilitators and barriers to empathy's development. CONCLUSION Empathy among intensivists is not a dichotomous phenomenon. It instead exists on continua. Four steps are recommended for optimizing empathy in the ICU: clearly defining empathy, addressing risks and benefits transparently, providing education regarding reflective practice, and developing supportive environments. Overall, this review revealed that the state of knowledge about empathy as experienced by intensivists still has room to grow and be further explored.
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Affiliation(s)
- Jessica Bunin
- Department of Medicine, Uniformed Services University of the Health Sciences, USA; Walter Reed National Military Medical Center, USA.
| | - Emily Shohfi
- Walter Reed National Military Medical Center, USA
| | - Holly Meyer
- Department of Medicine, Uniformed Services University of the Health Sciences, USA
| | | | - Lara Varpio
- Department of Medicine, Uniformed Services University of the Health Sciences, USA
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3
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Nogi M, Wong LC, Yamanaka AB, Richardson K, Ng-Osorio J, Arndt RG, Petrov S, Ganitano E. An evaluation of an interprofessional simulation training session on end-of-life-care conversations in the intensive care unit. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.xjep.2020.100357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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4
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Holt Clemmensen T, Hein Lauridsen H, Andersen-Ranberg K, Kaae Kristensen H. Informal carers' support needs when caring for a person with dementia - A scoping literature review. Scand J Caring Sci 2020; 35:685-700. [PMID: 32781496 DOI: 10.1111/scs.12898] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/26/2020] [Accepted: 07/14/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Informal carers of people with dementia report having unmet needs for support and few supportive interventions have been shown to be effective. There is a need to develop needs assessment instruments and supportive interventions with a holistic and person-centred approach to meet the various and complex needs of carers. The aim of this study was to provide an overview of carers' support needs when caring for people with dementia with the objectives to map and synthesise knowledge on key concepts of carers' support needs. METHODS A scoping review methodology was used. A literature search was conducted in PsycINFO, CINAHL, PubMed and EMBASE between January 2007 and October 2019. Three authors independently selected articles meeting the inclusion criteria, and data were extracted using a matrix developed for that purpose. Inductive content analysis was used to synthesise key concepts of carers' support needs. RESULTS The search identified 2748 articles after removing duplicates, and 122 articles were included in the mapping of carers' support needs. Synthesising carers' support needs indicated that the full extent of support needs emerges in the interaction between the carer and the person cared for and that it is possible to categorise support needs into four key concepts related to: 1) the carer as a person, 2) managing being a carer, 3) providing care, and 4) knowledge of dementia. CONCLUSION The findings of this study help to map a framework describing carers' support needs that may guide the development of future needs assessment instruments and supportive interventions.
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Affiliation(s)
- Trine Holt Clemmensen
- Health Sciences Research Centre, UCL University College, Odense, Denmark.,Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Henrik Hein Lauridsen
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Karen Andersen-Ranberg
- Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Hanne Kaae Kristensen
- Health Sciences Research Centre, UCL University College, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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5
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Wang A, Thomas K, Weil J, Hudson P. Characteristics of family meetings for patients with advanced disease in an Australian metropolitan tertiary hospital. BMJ Support Palliat Care 2020:bmjspcare-2020-002250. [PMID: 32718937 DOI: 10.1136/bmjspcare-2020-002250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/08/2020] [Accepted: 06/14/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Family meetings (FMs) between clinicians, patients and family are recommended as a valuable communication and care planning method in the delivery of palliative care. However, there is a dearth of knowledge regarding FM characteristics, with few studies describing the prevalence, circumstances and content of FMs. The aims of this study were to: (1) measure the prevalence of FMs, (2) examine circumstance and timing of FMs, and (3) explore the content of FMs. METHODS A retrospective medical record audit was conducted of 200 patients who died in an Australian hospital of an expected death from advanced disease. Details of FMs were collected using an audit tool, along with patient demographics and admission data. RESULTS 33 patients (16.5%) had at least one FM during their inpatient stay. The majority of FMs occurred for patients admitted to an inpatient palliative care unit (59.5%) and were most commonly facilitated by doctors (81.0%). Patient attendance was frequent (40.5%). FM content fell into six categories: medical information, supportive communication behaviours of clinicians, psychosocial support for patients and families, end-of-life discussions, discharge planning and administrative arrangements. CONCLUSIONS Despite the benefits FMs confer, FMs appear to be infrequently used at the end of life. When FMs are used, there is a strong medical focus on both facilitation and content. Available FM documentation tools also appear to be underused. Clinicians are encouraged to have a greater understanding of FMs to optimise their use and adopt a proactive and structured approach to the conduct and documentation of FMs.
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Affiliation(s)
- Amy Wang
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
| | - Kristina Thomas
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Jennifer Weil
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
- Vrije University Brussels, Brussels, Belgium
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6
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Ganz FD. Improving Family Intensive Care Unit Experiences at the End of Life: Barriers and Facilitators. Crit Care Nurse 2020; 39:52-58. [PMID: 31154331 DOI: 10.4037/ccn2019721] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Experiencing the end of life of a family member in the intensive care unit is clearly difficult. An important role of critical care nurses is to help family members through this challenging period. This article highlights a few clinically significant barriers and facilitators related to improving family experiences at the patient's end of life that have received less attention in the literature thus far. Facilitators include specific aspects of communication, the nurse's role as the coordinator of care, bereavement care, promoting a "good death," and caring for health care providers. Barriers include medical uncertainty and differences in values and culture.
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Affiliation(s)
- Freda DeKeyser Ganz
- Freda DeKeyser Ganz is Department Chair, Hadassah-Hebrew University School of Nursing, Jerusalem, Israel.
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7
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Orr S. The Acceptability and Feasibility of Using Mortality Prediction Scores for Initiating End-of-Life Goals-of-Care Communication in the Adult Intensive Care Unit. J Pain Symptom Manage 2020; 59:121-129. [PMID: 31546001 DOI: 10.1016/j.jpainsymman.2019.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Uncertainties in prognosis remain a barrier to end-of-life (EOL) communication in the intensive care unit (ICU), thus strategies are needed for increasing the precision of prognosis and timeliness of EOL goals-of-care communication. Use of mortality prediction scores offers one approach to this issue. OBJECTIVES This study evaluated the acceptability and feasibility of providers' use of patient mortality prediction scores as part of routine practice to increase prognosis precision and timeliness of EOL communication as well as providers' intentions to change practice related to EOL goals-of-care communication based on awareness of the scores. METHODS An explanatory mixed-methods approach was used to provide Sequential Organ Failure Assessment (SOFA) patient mortality prediction scores to ICU providers, who then completed an acceptability and feasibility questionnaire and participated in follow-up interviews conducted to further understand questionnaire responses and gain insight into their perceptions based on having SOFA scores. RESULTS Providers reported that using SOFA scores was acceptable and feasible, although there was some disagreement about effectiveness of SOFA scores for determining mortality risk. Providers with limited ICU experience were eager, and accepting of the scores while those with more experience found the scores to be an adjunct to their own intuition, although all acknowledged the benefit of looking at score trends. An important finding was the need to consider SOFA scores in relation to patient clinical context. CONCLUSION Use of SOFA scores as a means to potentially increase EOL goals-of-care communication emerged as most beneficial and acceptable to providers with limited ICU experience.
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Affiliation(s)
- Shelly Orr
- Virginia Commonwealth University School of Nursing, Richmond, Virginia, USA.
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8
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Van Keer RL, Deschepper R, Huyghens L, Bilsen J. Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study. PATIENT EDUCATION AND COUNSELING 2019; 102:2199-2207. [PMID: 31272799 DOI: 10.1016/j.pec.2019.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 06/14/2019] [Accepted: 06/18/2019] [Indexed: 05/28/2023]
Abstract
OBJECTIVE During critical care, physicians are frequently confronted with bad-news communication because of patients' frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context. METHODS Ethnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients' medical records. Data were thematically analysed. RESULTS Bad-news communication was primarily dominated by physicians. Patients' and relatives' input and other professionals' involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out. CONCLUSION Delivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved. PRACTICE IMPLICATIONS The challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol.
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Affiliation(s)
- Rose-Lima Van Keer
- Mental Health and Wellbeing Research Group (MENT), Department of Public Health, Faculty of Medicine and Pharmacy,Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Reginald Deschepper
- Mental Health and Wellbeing Research Group (MENT), Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Luc Huyghens
- Critical Care Department/Service of Intensive Care Medicine, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.
| | - Johan Bilsen
- Mental Health and Wellbeing Research Group (MENT), Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel Brussels, Belgium.
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9
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Schwartz DB, Pavic-Zabinski K, Tull K. Role of the Nutrition Support Clinician on a Hospital Bioethics Committee. Nutr Clin Pract 2019; 34:869-880. [PMID: 31464002 DOI: 10.1002/ncp.10378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hospital bioethics committees comprise a diverse group of healthcare professionals to deal with ethical issues within the institution that arise during patient care. The nutrition support clinicians (NSCs) have an important role on a bioethics committee because of their knowledge and expertise of different nutrition routes and the benefits vs burdens and risks of these modalities, both enteral and parenteral nutrition. Ethics expertise is built on an understanding of ethical principles, when applied in clinical ethics, using critical thinking to prevent ethical dilemmas and to assist in healthcare decision making with a focus on patient-centered care. The NSCs have the opportunity to address ethics during direct patient care with their participation in the intensive care unit interprofessional rounds, family meetings, and surrogate meetings. Evident in ethical dilemmas is often the lack of advance care planning by patients and their family members concerning healthcare wishes for when the individual is unable to communicate their preferences for life-sustaining therapies, including nutrition support. NSCs, as hospital bioethics committee members, are able to support the initiative of National Healthcare Decisions Day to help educate other healthcare clinicians and the public about the importance of advance care planning with communication of healthcare wishes and completion of an advance directive. Components addressed in the article are incorporated into a comprehensive ethics case study, highlighting the role of NSCs.
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Affiliation(s)
| | | | - Katherine Tull
- Providence Saint Joseph Medical Center, Burbank, California, USA
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10
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Van Keer RL, Deschepper R, Huyghens L, Bilsen J. Preventing Conflicts Between Nurses and Families of a Multi-ethnic Patient Population During Critical Medical Situations in a Hospital. J Transcult Nurs 2019; 31:250-256. [DOI: 10.1177/1043659619859049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Little is known about how to avoid intercultural nurse–family conflicts in critical care settings. In this article, strategies are discussed that may be useful to prevent or mitigate intercultural nurse–family conflicts during critical medical situations in hospital. Method: Strategies are based on an ethnographic study by Van Keer et al., other literature, and expert opinion. Results: Sufficient structural measures are needed. First, institutions must create appropriate ward policies, such as including nurses in end-of-life communication. Second, nurses should be coached in the workplace. Third, institutions must provide adapted, visual, ward information to families. Additionally, education and research are needed. These measures should be actively stimulated by nurse managers and reflect a multicultural program supported by the hospital. Discussion: Intercultural nurse–family conflict prevention or mitigation should take into account organizational aspects, on hospital units and in hospital as a whole, and the crucial role of education and research.
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Affiliation(s)
| | | | - Luc Huyghens
- Vrije Universiteit Brussel, Brussels, Belgium
- Universitair Ziekenhuis Brussel, Brussels, Belgium
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11
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Death in Trauma: The Role of the ACNP in Patient Advocacy and Familial Support in End-of-Life Care Decision-Making. J Trauma Nurs 2018; 25:171-176. [PMID: 29742629 DOI: 10.1097/jtn.0000000000000363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The trauma acute care nurse practitioner (ACNP) participates in the care of critically-ill patients by utilizing his or her advanced clinical skills at the bedside and through communication with the interdisciplinary team, the patient, and the patient's family. Although the incidence of morbidity is decreasing in trauma, death can occur shortly after arrival to hospital, or in the days after initial injury, leading to the need for the unexpected conversation of end-of-life wishes with a patient or the patient's family. It is within the scope of the ACNP to facilitate these conversations, and it is recommended that ACNPs engage patients and their families in these conversations for overall improved patient outcomes. Many techniques exist to aid in this difficult decision-making process and may be useful to the trauma ACNP when having end-of-life discussions.
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13
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Smith MA, Clayman ML, Frader J, Arenson M, Haber-Barker N, Ryan C, Emanuel L, Michelson K. A Descriptive Study of Decision-Making Conversations during Pediatric Intensive Care Unit Family Conferences. J Palliat Med 2018; 21:1290-1299. [PMID: 29920145 DOI: 10.1089/jpm.2017.0528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Little is known about how decision-making conversations occur during pediatric intensive care unit (PICU) family conferences (FCs). OBJECTIVE Describe the decision-making process and implementation of shared decision making (SDM) during PICU FCs. DESIGN Observational study. SETTING/SUBJECTS University-based tertiary care PICU, including 31 parents and 94 PICU healthcare professionals involved in FCs. MEASUREMENTS We recorded, transcribed, and analyzed 14 PICU FCs involving decision-making discussions. We used a modified grounded theory and content analysis approach to explore the use of traditionally described stages of decision making (DM) (information exchange, deliberation, and determining a plan). We also identified the presence or absence of predefined SDM elements. RESULTS DM involved the following modified stages: information exchange; information-oriented deliberation; plan-oriented deliberation; and determining a plan. Conversations progressed through stages in a nonlinear manner. For the main decision discussed, all conferences included a presentation of the clinical issues, treatment alternatives, and uncertainty. A minority of FCs included assessing the family's understanding (21%), assessing the family's need for input from others (28%), exploring the family's desired decision-making role (35%), and eliciting the family's opinion (42%). CONCLUSIONS In the FCs studied, we found that DM is a nonlinear process. We also found that several SDM elements that could provide information about parents' perspectives and needs did not always occur, identifying areas for process improvement.
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Affiliation(s)
- Michael A Smith
- 1 Department of Pediatrics, University of California San Francisco , San Francisco, California
| | - Marla L Clayman
- 2 Health and Social Development, American Institutes for Research , Washington, DC
| | - Joel Frader
- 3 Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago , Chicago, Illinois.,4 Department of Pediatrics, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Melanie Arenson
- 5 Department of Psychology, University of Maryland , College Park, Maryland
| | - Natalie Haber-Barker
- 6 Department of Sociology, Iron Workers Local 395 Apprenticeship School, Ivy Tech College , Lake Station, Indiana
| | - Claire Ryan
- 7 Department of Orthopedics, University of Texas at Austin Dell Medical School , Austin, Texas
| | - Linda Emanuel
- 8 Department of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine , Chicago, Illinois.,9 Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Kelly Michelson
- 4 Department of Pediatrics, Northwestern University Feinberg School of Medicine , Chicago, Illinois.,10 Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago , Chicago, Illinois
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Glajchen M, Goehring A. The Family Meeting in Palliative Care: Role of the Oncology Nurse. Semin Oncol Nurs 2017; 33:489-497. [PMID: 29107531 DOI: 10.1016/j.soncn.2017.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To describe the family meeting in palliative and end-of-life care, highlighting the role of the oncology nurse. Specific strategies will be provided for pre-meeting preparation, communication, and follow-up activities. DATA SOURCES A conceptual framework drawn from family and communication theory, and best practices from the clinical, research, nursing, and palliative care literature. CONCLUSION Working with patients and families is complex, but the family meeting is a promising tool and a potential quality indicator in palliative care. IMPLICATIONS FOR NURSING PRACTICE The nurse is well positioned to participate fully in every aspect of the family meeting.
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15
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Michelson K, Clayman ML, Ryan C, Emanuel L, Frader J. Communication During Pediatric Intensive Care Unit Family Conferences: A Pilot Study of Content, Communication, and Parent Perceptions. HEALTH COMMUNICATION 2017; 32:1225-1232. [PMID: 27612506 DOI: 10.1080/10410236.2016.1217450] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
While there is a robust literature describing family conferences (FCs) in adult intensive care units (ICUs), less information exists about FCs in pediatric ICUs (PICUs). We conducted a pilot study to describe the focus of discussion, communication patterns of health care team members (HTMs) and parents, and parents' perspectives about clinician communication during PICU FCs. We analyzed data from 22 video- or audiorecorded PICU FCs and post-FC questionnaire responses from 27 parents involved in 18 FCs. We used the Roter Interaction Analysis System (RIAS) to describe FC dialogue content. Our questionnaire included the validated Communication Assessment Tool (CAT). FCs were focused on care planning (n = 5), decision making (n = 6), and updates (n = 11). Most speech came from HTMs (mean 85%; range, 65-94%). Most HTM utterances involved medical information. Most parent utterances involved asking for explanations. The mean overall CAT score was 4.62 (using a 1-5 scale where 5 represents excellent and 1 poor) with a mean of 73.02% "excellent" responses. Update and care-planning FCs had lower CAT scores compared to decision-making FCs. The lowest scoring CAT items were "Involved me in decisions as much as I wanted," "Talked in terms I could understand," and "Gave me as much information as I wanted." These findings suggest that while health care providers spend most of their time during FCs relaying medical information, more attention should be directed at providing information in an understandable manner. More work is needed to improve communication when decision making is not the main focus of the FC.
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Affiliation(s)
- Kelly Michelson
- a Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics , Northwestern University Feinberg School of Medicine
| | | | | | - Linda Emanuel
- d The Buehler Center on Aging, Health & Society, Department of General Internal Medicine and Geriatrics, and Department of Psychiatry and Behavioral Sciences , Northwestern University Feinberg School of Medicine
| | - Joel Frader
- e Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics , Northwestern University Feinberg School of Medicine
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16
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Challenges in the implementation of strategies to increase communication and enhance patient and family centered care in the ICU. Med Intensiva 2017; 41:365-367. [DOI: 10.1016/j.medin.2017.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/13/2017] [Indexed: 11/19/2022]
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17
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Miller N, Shuler J, Hayley D, He J, Porter-Williamson K, Kalender-Rich J. Across the Continuum: How Inpatient Palliative Care Consultations Are Reported in Hospital Discharge Summaries. J Palliat Med 2017; 21:85-88. [PMID: 28723252 DOI: 10.1089/jpm.2016.0539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inpatient Palliative Care (PC) consultations help develop a patient-centered and quality-of-life-focused plan of care for patients with serious illness. Discharge summaries (DSs) are an essential tool to maintain continuity of these care plans across multiple locations and providers. METHODS We conducted a retrospective chart review of selected DSs of patients who received inpatient PC consultations at the University of Kansas Hospital from July 2011 to May 2015. The study included patients 18 years or older, patients who were discharged alive, and patients who were not discharged with hospice care. Code words and their related phrases, developed by an expert panel of geriatric medicine and palliative medicine physicians, were used to evaluate the DSs. They were categorized into PC, symptom management, hospice and palliative home health, decision making, and plan of care. We also identified whether there was communication between the primary team and PC team, as well as family meeting status in the PC consultation and notes. RESULTS Of the 961 chart reviews, no code words were found in 22.8% of the DSs. PC was mentioned in only 63.3% and was the only code word in 5.3%. CONCLUSION More than one in five DSs lacked any code words of the completed PC consultation and more than one in three DSs lacked mention of PC. As DSs are the main source of provider communication, it is critical they reflect the key discussion points from the PC consultation, which will improve the transition of care and provider communication.
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Affiliation(s)
- Nikki Miller
- 1 Department of Internal Medicine, University of Kansas School of Medicine , Kansas City, Kansas
| | - John Shuler
- 2 Department of Internal Medicine, Oregon Health and Science University , Portland, Oregon
| | - Deon Hayley
- 1 Department of Internal Medicine, University of Kansas School of Medicine , Kansas City, Kansas.,3 Landon Center on Aging, University of Kansas School of Medicine , Kansas City, Kansas
| | - Jianghua He
- 4 Department of Biostatistics, University of Kansas School of Medicine , Kansas City, Kansas
| | - Karin Porter-Williamson
- 1 Department of Internal Medicine, University of Kansas School of Medicine , Kansas City, Kansas
| | - Jessica Kalender-Rich
- 1 Department of Internal Medicine, University of Kansas School of Medicine , Kansas City, Kansas.,3 Landon Center on Aging, University of Kansas School of Medicine , Kansas City, Kansas
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COMmunication with Families regarding ORgan and Tissue donation after death in intensive care (COMFORT): protocol for an intervention study. BMC Health Serv Res 2017; 17:42. [PMID: 28095838 PMCID: PMC5240419 DOI: 10.1186/s12913-016-1964-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 12/17/2016] [Indexed: 11/14/2022] Open
Abstract
Background Discussing deceased organ donation can be difficult not only for families but for health professionals who initiate and manage the conversations. It is well recognised that the methods of communication and communication skills of health professionals are key influences on decisions made by families regarding organ donation. Methods This multicentre study is being performed in nine intensive care units with follow-up conducted by the Organ and Tissue Donation Service in New South Wales (NSW) Australia. The control condition is pre-intervention usual practice for at least six months before each site implements the intervention. The COMFORT intervention consists of six elements: family conversations regarding offers for organ donation to be led by a “designated requester”; family offers for donation are deferred to the designated requester; the offer of donation is separated from the end-of-life discussion that death is inevitable; it takes place within a structured family donation conversation using a “balanced” approach. Designated requesters may be intensivists, critical care nurses or social workers prepared by attending the three-day national “Family Donation Conversation” workshops, and the half-day NSW Simulation Program. The design is pre-post intervention to compare rates of family consent for organ donation six months before and under the intervention. Each ICU crosses from using the control to intervention condition after the site initiation visit. The primary endpoint is the consent rate for deceased organ donation calculated from 140 eligible next of kin families. Secondary endpoints are health professionals’ adherence rates to core elements of the intervention; identification of predictors of family donation decision; and the proportion of families who regret their final donation decision at 90 days. Discussion The pragmatic design of this study may identify ‘what works’ in usual clinical settings when requesting organ donation in critical care areas, both in terms of changes in practice healthcare professionals are willing and able to adopt, and the effect this may have on desired outcomes. The findings of this study will be indicative of the potential benefits of the intervention and be relevant and transferrable to clinical settings in other states and countries. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000815763 (24 July 2013). ClinicalTrials.gov: NCT01922310 (14 August 2013) (retrospectively registered). Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1964-7) contains supplementary material, which is available to authorized users.
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Lotz JD, Jox RJ, Meurer C, Borasio GD, Führer M. Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians. Palliat Med 2016; 30:960-970. [PMID: 26847523 PMCID: PMC5117124 DOI: 10.1177/0269216316628422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions. AIM Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents. DESIGN We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis. SETTING/PARTICIPANTS We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender. RESULTS The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit-burden considerations. Physicians' individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus. CONCLUSION The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians' feelings to improve the transparency of the decision-making process and reduce bias.
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Affiliation(s)
- Julia Desiree Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Christine Meurer
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative Care Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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A family nursing educational intervention supports nurses and families in an adult intensive care unit. Aust Crit Care 2016; 29:217-223. [PMID: 27688123 DOI: 10.1016/j.aucc.2016.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 11/23/2022] Open
Abstract
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.
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Johnstone MJ, Hutchinson AM, Rawson H, Redley B. Nursing Strategies for Engaging Families of Older Immigrants Hospitalized for End-of-Life Care: An Australian Study. J Patient Exp 2016; 3:57-63. [PMID: 28725839 PMCID: PMC5513648 DOI: 10.1177/2374373516667004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Engaging with families of older non-English-speaking background (NESB) immigrants hospitalized for end-of-life (EOL) care can be challenging, especially when their cultures, lifeways, and family decision-making processes are unfamiliar to the nurses caring for them. Despite the recognized importance of family engagement when providing EOL care, the issue of ethnic minority family engagement has received little attention in the field. AIM To explore and describe the strategies nurses use to facilitate engagement with families of older immigrant NESB patients hospitalized for EOL care. METHODS A qualitative descriptive approach was used. Data were collected via in-depth interviews conducted with 22 registered nurses recruited from 4 Australian health services. FINDINGS Using thematic analysis processes, 5 key strategies were identified: listening and understanding families, encouraging family members to speak first, dealing with angst, redressing naive views about the dying process, and managing intergenerational differences. Underpinning these strategies was a profound "will to engage" with the families and their cultural worldviews. CONCLUSION Further cross-cultural comparative research is required to inform evidence-based policies, practice, and education on this issue.
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Affiliation(s)
- Megan-Jane Johnstone
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Helen Rawson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Bernice Redley
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
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Schram AW, Hougham GW, Meltzer DO, Ruhnke GW. Palliative Care in Critical Care Settings: A Systematic Review of Communication-Based Competencies Essential for Patient and Family Satisfaction. Am J Hosp Palliat Care 2016; 34:887-895. [PMID: 27582376 DOI: 10.1177/1049909116667071] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is an emerging literature on the physician competencies most meaningful to patients and their families. However, there has been no systematic review on physician competency domains outside direct clinical care most important for patient- and family-centered outcomes in critical care settings at the end of life (EOL). Physician competencies are an essential component of palliative care (PC) provided at the EOL, but the literature on those competencies relevant for patient and family satisfaction is limited. A systematic review of this important topic can inform future research and assist in curricular development. METHODS Review of qualitative and quantitative empirical studies of the impact of physician competencies on patient- and family-reported outcomes conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews. The data sources used were PubMed, MEDLINE, Web of Science, and Google Scholar. RESULTS Fifteen studies (5 qualitative and 10 quantitative) meeting inclusion and exclusion criteria were identified. The competencies identified as critical for the delivery of high-quality PC in critical care settings are prognostication, conflict mediation, empathic communication, and family-centered aspects of care, the latter being the competency most frequently acknowledged in the literature identified. CONCLUSION Prognostication, conflict mediation, empathic communication, and family-centered aspects of care are the most important identified competencies for patient- and family-centered PC in critical care settings. Incorporation of education on these competencies is likely to improve patient and family satisfaction with EOL care.
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Affiliation(s)
- Andrew W Schram
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - David O Meltzer
- 3 Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA.,4 Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Gregory W Ruhnke
- 3 Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
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Johnstone MJ, Hutchinson AM, Rawson H, Redley B. Assuaging death anxiety in older overseas-born Australians of culturally and linguistically diverse backgrounds hospitalised for end-of-life care. Contemp Nurse 2016; 52:269-85. [DOI: 10.1080/10376178.2016.1192953] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Perkins E, Gambles M, Houten R, Harper S, Haycox A, O’Brien T, Richards S, Chen H, Nolan K, Ellershaw JE. The care of dying people in nursing homes and intensive care units: a qualitative mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04200] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn England and Wales the two most likely places of death are hospitals (52%) and nursing homes (22%). The Department of Health published its National End of Life Care Strategy in July 2008 (Department of Health.End of Life Care Strategy: Promoting High Quality Care For All Adults at the End of Life. London: Department of Health; 2008) to improve the provision of care, recommending the use of the Liverpool Care Pathway for the Dying Patient (LCP).AimThe original aim was to assess the impact of the LCP on care in two settings: nursing homes and intensive care units (ICUs).DesignQualitative, matched case study.MethodsData were collected from 12 ICUs and 11 nursing homes in England: (1) documentary analysis of provider end-of-life care policy documents; (2) retrospective analysis of 10 deaths in each location using written case notes; (3) interviews with staff about end-of-life care; (4) observation of the care of dying patients; (5) analysis of the case notes pertaining to the observed patient’s death; (6) interview with a member of staff providing care during the observed period; (7) interview with a bereaved relative present during the observation; (8) economic analysis focused on the observed patients; and (9) strict inclusion and selection criteria for nursing homes and ICUs applied to match sites on LCP use/non-LCP use.ResultsIt was not possible to meet the stated aims of the study. Although 23 sites were recruited, observations were conducted in only 12 sites (eight using the LCP). A robust comparison on the basis of LCP use could not, therefore, take place. Although nurses in both settings reported that the LCP supported good care, the LCP was interpreted and used differently across sites, with the greatest variation in ICUs. Although not able to address the original research question, this study provides an unprecedented insight into care at the end of life in two different settings. The majority of nursing homes had implemented some kind of ‘pathway’ for dying patients and most homes participating in the observational stage were using the LCP. However, training in care of the dying was variable and specific issues were identified relating to general practitioner involvement, the use of anticipatory drugs and the assessment of consciousness and the swallowing reflex. In ICUs, end-of-life care was inextricably linked with the withdrawal of active treatment and controlling the pace of death. The data highlight how the decision to withdraw was made and, importantly, how relatives were involved in this process. The fact that most patients died soon after the withdrawal of interventions was reported to limit the appropriateness of the LCP in this setting.LimitationsAlthough the recruitment of matched sites was achieved, variable site participation resulted in a skewed sample. Issues with the sample size and a blurring of LCP use and non-use limit the extent to which the ambitious aims of the study were achieved.ConclusionsThis study makes a unique contribution to understanding the complexity of care at the end of life in two very different settings. More research is needed into the ways in which an organisational culture can be created within which the principles of good end-of-life care become translated into practice.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Elizabeth Perkins
- Health and Community Care Research Unit, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Maureen Gambles
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rachel Houten
- Management School, University of Liverpool, Liverpool, UK
| | - Sheila Harper
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Alan Haycox
- Management School, University of Liverpool, Liverpool, UK
| | - Terri O’Brien
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sarah Richards
- Management School, University of Liverpool, Liverpool, UK
| | - Hong Chen
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Kate Nolan
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - John E Ellershaw
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Otis-Green S, Jones B, Zebrack B, Kilburn L, Altilio TA, Ferrell B. ExCEL in Social Work: Excellence in Cancer Education & Leadership: An Oncology Social Work Response to the 2008 Institute of Medicine Report. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2015; 30:503-513. [PMID: 25146345 PMCID: PMC4339672 DOI: 10.1007/s13187-014-0717-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
ExCEL in Social Work: Excellence in Cancer Education & Leadership was a multi-year National Cancer Institute (NCI)-funded grant for the development and implementation of an innovative educational program for oncology social workers. The program's curriculum focused upon six core competencies of psychosocial-spiritual support necessary to meet the standard of care recommended by the 2008 Institute of Medicine (IOM) Report: Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. The curriculum was delivered through a collaborative partnership between the City of Hope National Medical Center and the two leading professional organizations devoted exclusively to representing oncology social workers--the Association of Oncology Social Work and the Association of Pediatric Oncology Social Workers. Initial findings support the feasibility and acceptability of this tailored leadership skills-building program for participating oncology social workers.
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Affiliation(s)
- Shirley Otis-Green
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope National Medical Center, 1500 E. Duarte Rd., Duarte, CA, 91010, USA,
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Abstract
OBJECTIVES The aim of this study was to determine if a gynecologic cancer patient's comfort level discussing end-of-life care issues with her caregivers is related to her death anxiety level. MATERIALS/METHODS Gynecologic oncology clinic patients were asked to rate their degree of agreeability with 4 statements regarding comfort level discussing end-of-life care issues. Participants also completed the Hoge's Intrinsic Religiosity Scale and Templer's Death Anxiety Scale. RESULTS Four hundred one surveys were distributed. One hundred twenty-nine patients participated, with a response rate of 32.2%. The median age of the sample was 55 years. Most patients were white (72.9%), married (58.9%), and Christian (85.3%). Most patients had ovarian cancer (40.4%). Of the 74 patients who knew their cancer stage, 59% had been diagnosed with advanced (stage III-IV) disease. Thirty-three percent were currently in remission, and 17% had recurrent disease. Of all patients surveyed, 32.6% were currently receiving treatment. Chemotherapy was the most common treatment (62% of those being treated). Higher level of comfort discussing end-of-life care topics such as do-not-resuscitate orders with family members was significantly associated with decreased death anxiety (P = 0.008 and P = 0.001). There was no significant association between comfort level when patients discussed do-not-resuscitate orders with physicians and patients' death anxiety (P = 0.14). After controlling for age, race, marital status, education level, current treatment status, and religiosity, linear regression analysis demonstrated that the relationship between a patient's increased comfort level when discussing end-of-life care topics with family members and decreased death anxiety remained statistically significant (P = 0.005 and P = 0.001). CONCLUSIONS Conversations regarding goals of treatment are an important component of caring for cancer patients. Death anxiety may contribute to decreased communication between patients and their family members regarding the patient's end-of-life care wishes. Obtaining a better understanding of the role death anxiety plays in end-of-life care discussions may help patients receive the end-of-life care they desire.
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Warrillow S, Farley KJ, Jones D. Ten practical strategies for effective communication with relatives of ICU patients. Intensive Care Med 2015; 41:2173-6. [PMID: 25904186 DOI: 10.1007/s00134-015-3815-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 04/07/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Hospital, Austin Health, 145 Studley Road Heidelberg, Melbourne, VIC, 3084, Australia. .,The University of Melbourne, Melbourne, Australia.
| | - K J Farley
- Department of Intensive Care, Western Health, Melbourne, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Austin Health, 145 Studley Road Heidelberg, Melbourne, VIC, 3084, Australia.,The University of Melbourne, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Critical Care Outreach, Austin Hospital, Melbourne, Australia
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Consales G, Zamidei L, Michelagnoli G. Education and training for moral and ethical decision-making at the end of life in critical care. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2014. [DOI: 10.1016/j.tacc.2014.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rhondali W, Dev R, Barbaret C, Chirac A, Font-Truchet C, Vallet F, Bruera E, Filbet M. Family conferences in palliative care: a survey of health care providers in France. J Pain Symptom Manage 2014; 48:1117-24. [PMID: 24780185 DOI: 10.1016/j.jpainsymman.2014.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 02/24/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
Abstract
CONTEXT Family conferences are conducted to assist with end-of-life discussions and discharge planning. OBJECTIVES This study describes the current practices of family conferences in palliative care units (PCUs) in France. METHODS A cross-sectional descriptive survey was sent to each PCU in France (n = 113). Members of the interdisciplinary health care team (palliative care physician, nurse, psychologist, and social worker) who were active in each PCU at the time of the survey were asked to respond. RESULTS Two hundred seventy-six of 452 responses (61%) were obtained from members of the health care team in 91 units (81%). Two hundred seventy-two of 276 health care providers (HCPs) (99%) reported conducting family conferences in their clinical practice. Only 13 participants (5%) reported that they followed a structured protocol. Most respondents completed the questionnaire: palliative care physicians (n = 225; 82%), nurses (n = 219; 79%), and psychologists (n = 181; 66%). The three primary goals of family conferences were to allow family members to express their feelings (n = 240; 87%), identify family caregivers (n = 233; 84%), and discuss the patient's plan of care (n = 219; 79%). The primary reasons for conducting a family conference were: the patient's illness was terminal (n = 216; 78%), family caregivers requested a conference (n = 208; 75%), or terminal sedation was required (n = 189; 69%). One hundred six of 452 HCPs (38%) reported that patients were not invited to participate. The primary indications and goals for a family conference were significantly different among the four health care disciplines. CONCLUSION Most HCPs in our study conducted family conferences. However, most of the family conferences had no structured protocol, half of the participants preferred no patient participation, and a significant variation was noted in the primary indications and goals among disciplines.
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Affiliation(s)
- Wadih Rhondali
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Centre Hospitalier de Lyon-Sud, Pierre Bénite, France; Laboratoire EA, Santé-Individu-Société, Université Lyon, Lyon, France.
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Cécile Barbaret
- Department of Palliative Care, Centre Hospitalier de Lyon-Sud, Pierre Bénite, France
| | - Anne Chirac
- Psychology Institute, Université Lyon 2, Bron, France
| | - Celine Font-Truchet
- Department of Medicine, Centre Hospitalier de Bourg-Saint-Maurice, Bourg-Saint-Maurice, France
| | - Fabienne Vallet
- Department of Palliative Care, Centre Hospitalier William-Morey, Chalon-sur-Saône, France
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Marilene Filbet
- Department of Palliative Care, Centre Hospitalier de Lyon-Sud, Pierre Bénite, France
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Examining family meetings at end of life: The model of practice in a hospice inpatient unit. Palliat Support Care 2014; 13:1283-91. [PMID: 25358963 DOI: 10.1017/s1478951514001138] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Our purpose was to rigorously examine the nature of family meetings as conducted in an inpatient hospice care unit in order to generate an inductive theoretical model. METHOD In this two-phase project, we first interviewed eight members of the interdisciplinary care team who participated in multiple family meetings each week. Interview questions explored why and how they conducted family meetings. Using an observation template created from these interview data, we subsequently conducted ethnographic observations during family meetings. Using the methods of grounded theory, our findings were synthesized into a theoretical model depicting the structure and process of formal family meetings within this setting. RESULTS The core of the family meeting was characterized by cognitive and affective elements aimed at supporting the family and facilitating quality care by clarifying the past, easing the present, and protecting the future. This inductive model was subsequently found to be highly aligned with a sense of coherence, an important influence on coping, and adaptation to the stress of a life-limiting illness. SIGNIFICANCE OF RESULTS Provider communication with family members is particularly critical during advanced illness and end-of-life care. The National Consensus Project clinical practice guidelines for quality palliative care list regular family meetings among the recommended practices for excellent communication during end-of-life care, but do not provide specific guidance on how and when to provide such meetings. Our findings provide a theoretical model that can inform the design of a family meeting to address family members' needs for meaningful and contextualized information, validation of their important contributions to care, and preparation for the patient's death.
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Powazki R, Walsh D, Hauser K, Davis MP. Communication in Palliative Medicine: A Clinical Review of Family Conferences. J Palliat Med 2014; 17:1167-77. [DOI: 10.1089/jpm.2013.0538] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ruth Powazki
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Declan Walsh
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
- Cleveland Clinic Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Katherine Hauser
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mellar P. Davis
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
- Cleveland Clinic Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Abstract
PURPOSE OF REVIEW Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. RECENT FINDINGS DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. SUMMARY There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes.
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Michelson KN, Clayman ML, Haber-Barker N, Ryan C, Rychlik K, Emanuel L, Frader J. The use of family conferences in the pediatric intensive care unit. J Palliat Med 2013; 16:1595-601. [PMID: 24175636 DOI: 10.1089/jpm.2013.0284] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Data about pediatric intensive care unit (PICU) family conferences (FCs) are needed to enhance our understanding of the role of FCs in patient care and build a foundation for future research on PICU communication and decision making. OBJECTIVE The study's objective was to describe the use and content of PICU FCs. DESIGN The study design was a prospective chart review comparing patients who had conferences with those who did not, and a sub-analysis of patients with chronic care conditions (CCCs). SETTING/SUBJECTS The study setting was an academic PICU from January 2011 through June 2011. MEASUREMENTS Medical events under consideration were placement of tracheostomy or gastrostomy tube; initiation of chronic ventilation; palliative care involvement; use of extracorporeal membrane oxygenation, continuous renal replacement, or cardiopulmonary resuscitation; care limitation orders; death; length of stay; and discharge to a new environment. RESULTS From 661 admissions, we identified 74 conferences involving 49 patients. Sixty-four conferences (86%) were held about 40 patients with CCCs. Having a conference was associated with (p<0.05): length of PICU admission; palliative care involvement; initiation of chronic ventilation; extracorporeal membrane oxygenation; cardiopulmonary resuscitation; death; discharge to a new environment; and care limitation orders. Twenty-nine percent of patients who had a new tracheostomy or gastrostomy tube placed had a conference. We identified two categories of discussion topics: information exchange and future management. CONCLUSIONS Most identified FCs involved complex patients or patients who faced decisions affecting the child's quality of life or dying. For many patients who faced life changing decisions we did not identify a FC. Further research is needed to understand how to best utilize FCs and less formal conversations.
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Affiliation(s)
- Kelly Nicole Michelson
- 1 Division of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago, Illinois
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Bylund Grenklo T, Kreicbergs UC, Valdimarsdóttir UA, Nyberg T, Steineck G, Fürst CJ. Communication and Trust in the Care Provided to a Dying Parent: A Nationwide Study of Cancer-Bereaved Youths. J Clin Oncol 2013; 31:2886-94. [DOI: 10.1200/jco.2012.46.6102] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To assess children's trust in the care provided to a dying parent during the final week of life in relation to end-of-life medical information about disease, treatment, and death. Methods This nationwide population-based survey included 622 (73%) of 851 youths who, 6 to 9 years earlier, at age 13 to 16 years, lost a parent to cancer. We asked about the children's reception of end-of-life professional information and trust in the care provided. We also asked about depression and several potential risk factors of distrust in the care provided. Results A majority (82%) reported moderate/very much trust in the care provided. Compared with children who received end-of-life medical information before their loss, the risk of distrust in the care provided was higher in those who received no information (risk ratio [RR], 2.5; 95% CI, 1.5 to 4.1), in those who only received information afterward (RR, 3.2; 95% CI, 1.7 to 5.9), and in those who did not know or remember if end-of-life medical information was provided (RR, 1.7; 95% CI, 1.1 to 2.5). Those reporting distrust in the care provided had an RR of 2.3 (95% CI, 1.5 to 3.5) for depression. Furthermore, the risk of distrust in the care provided was higher among children reporting poor efforts to cure (RR, 5.1; 95% CI, 3.6 to 7.3), and/or a poor relationship with the surviving parent (RR, 2.9; 95% CI, 2.0 to 4.1). Conclusion Our study suggests that children's trust in the care provided to a dying parent was highest when they received end-of-life medical information before their loss.
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Affiliation(s)
- Tove Bylund Grenklo
- Tove Bylund Grenklo, Ulrika C. Kreicbergs, Unnur A. Valdimarsdóttir, Tommy Nyberg, Gunnar Steineck, and Carl Johan Fürst, Karolinska Institutet; Tove Bylund Grenklo and Carl Johan Fürst, Stockholm Sjukhem Foundation; Ulrika C. Kreicbergs, Sophiahemmet University College, Stockholm; Gunnar Steineck, Sahlgrenska Academy, Gothenburg; Carl Johan Fürst, Lund University, Lund, Sweden; and Unnur A. Valdimarsdóttir, University of Iceland, Reykjavík, Iceland, and Harvard School of Public Health, Boston, MA
| | - Ulrika C. Kreicbergs
- Tove Bylund Grenklo, Ulrika C. Kreicbergs, Unnur A. Valdimarsdóttir, Tommy Nyberg, Gunnar Steineck, and Carl Johan Fürst, Karolinska Institutet; Tove Bylund Grenklo and Carl Johan Fürst, Stockholm Sjukhem Foundation; Ulrika C. Kreicbergs, Sophiahemmet University College, Stockholm; Gunnar Steineck, Sahlgrenska Academy, Gothenburg; Carl Johan Fürst, Lund University, Lund, Sweden; and Unnur A. Valdimarsdóttir, University of Iceland, Reykjavík, Iceland, and Harvard School of Public Health, Boston, MA
| | - Unnur A. Valdimarsdóttir
- Tove Bylund Grenklo, Ulrika C. Kreicbergs, Unnur A. Valdimarsdóttir, Tommy Nyberg, Gunnar Steineck, and Carl Johan Fürst, Karolinska Institutet; Tove Bylund Grenklo and Carl Johan Fürst, Stockholm Sjukhem Foundation; Ulrika C. Kreicbergs, Sophiahemmet University College, Stockholm; Gunnar Steineck, Sahlgrenska Academy, Gothenburg; Carl Johan Fürst, Lund University, Lund, Sweden; and Unnur A. Valdimarsdóttir, University of Iceland, Reykjavík, Iceland, and Harvard School of Public Health, Boston, MA
| | - Tommy Nyberg
- Tove Bylund Grenklo, Ulrika C. Kreicbergs, Unnur A. Valdimarsdóttir, Tommy Nyberg, Gunnar Steineck, and Carl Johan Fürst, Karolinska Institutet; Tove Bylund Grenklo and Carl Johan Fürst, Stockholm Sjukhem Foundation; Ulrika C. Kreicbergs, Sophiahemmet University College, Stockholm; Gunnar Steineck, Sahlgrenska Academy, Gothenburg; Carl Johan Fürst, Lund University, Lund, Sweden; and Unnur A. Valdimarsdóttir, University of Iceland, Reykjavík, Iceland, and Harvard School of Public Health, Boston, MA
| | - Gunnar Steineck
- Tove Bylund Grenklo, Ulrika C. Kreicbergs, Unnur A. Valdimarsdóttir, Tommy Nyberg, Gunnar Steineck, and Carl Johan Fürst, Karolinska Institutet; Tove Bylund Grenklo and Carl Johan Fürst, Stockholm Sjukhem Foundation; Ulrika C. Kreicbergs, Sophiahemmet University College, Stockholm; Gunnar Steineck, Sahlgrenska Academy, Gothenburg; Carl Johan Fürst, Lund University, Lund, Sweden; and Unnur A. Valdimarsdóttir, University of Iceland, Reykjavík, Iceland, and Harvard School of Public Health, Boston, MA
| | - Carl Johan Fürst
- Tove Bylund Grenklo, Ulrika C. Kreicbergs, Unnur A. Valdimarsdóttir, Tommy Nyberg, Gunnar Steineck, and Carl Johan Fürst, Karolinska Institutet; Tove Bylund Grenklo and Carl Johan Fürst, Stockholm Sjukhem Foundation; Ulrika C. Kreicbergs, Sophiahemmet University College, Stockholm; Gunnar Steineck, Sahlgrenska Academy, Gothenburg; Carl Johan Fürst, Lund University, Lund, Sweden; and Unnur A. Valdimarsdóttir, University of Iceland, Reykjavík, Iceland, and Harvard School of Public Health, Boston, MA
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Manthous CA. Toward identifying quality critical care communication. J Crit Care 2013; 28:870-1. [PMID: 23764069 DOI: 10.1016/j.jcrc.2013.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/03/2013] [Indexed: 11/15/2022]
Affiliation(s)
- Constantine A Manthous
- Department of Internal Medicine, The Hospital of Central Connecticut & Yale University School of Medicine, New Britain, CT 06050.
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Abstract
PURPOSE OF REVIEW End-of-life care and communication deficits are important sources of conflicts within ICU teams and with patients or families. This narrative review describes recent studies on how to improve palliative care and surrogate decision-making in ICUs and compares the results with previously published literature on this topic. RECENT FINDINGS Awareness and use of end-of-life recommendations is still low. Education about end-of-life is beneficial for end-of-life decisions. Residency and nurses training programmes start to integrate palliative care education in critical care. Integration of palliative care consults is recommended and probably cost-effective. Projects that promote direct contact of care team members with patients/families may be more likely to improve care than educational interventions for caregivers only. The family's response to critical illness includes adverse psychological outcome ('postintensive care syndrome-family'). Information brochures and structured communication protocols are likely to improve engagement of family members in surrogate decision-making; however, validation of outcome effects of their use is needed. SUMMARY Optimizing palliative care and communication skills is the current challenge in ICU end-of-life care. Intervention strategies should be interdisciplinary, multiprofessional and family-centred in order to quickly reach these goals.
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Strand JJ, Billings JA. Integrating palliative care in the intensive care unit. ACTA ACUST UNITED AC 2012; 10:180-7. [PMID: 22819446 DOI: 10.1016/j.suponc.2012.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/30/2012] [Accepted: 06/06/2012] [Indexed: 12/25/2022]
Abstract
The admission of cancer patients into intensive care units (ICUs) is on the rise. These patients are at high risk for physical and psychosocial suffering. Patients and their families often face difficult end-of-life decisions that highlight the importance of effective and empathetic communication. Palliative care teams are uniquely equipped to help care for cancer patients who are admitted to ICUs. When utilized in the ICU, palliative care has the potential to improve a patient's symptoms, enhance the communication between care teams and families, and improve family-centered decision making. Within the context of this article, we will discuss how palliative care can be integrated into the care of ICU patients and how to enhance family-centered communication; we will also highlight the care of ICU patients at the end of life.
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Affiliation(s)
- Jacob J Strand
- Palliative Care Service, Department of Medicine, Massachusetts General Hospital, Boston, USA.
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Measuring intensive care unit palliative care. Crit Care Med 2012; 40:1343-5. [DOI: 10.1097/ccm.0b013e3182431707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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