Where do we go from here? A palliative care perspective

Use of a supportive care pathway for end-of-life care in an intensive care unit: a qualitative study

BACKGROUND

Providing palliative care support in intensive care settings is beneficial, however, barriers to delivering high-quality end-of-life care remain. To address this, pathways have been used to improve the quality of palliative care in generalist settings. This study describes the views of health professionals using a supportive care pathway in intensive care.

DESIGN

Qualitative semi-structured interviews were conducted with ten health professionals working in a surgical intensive care unit. The data were analysed thematically.

RESULTS

Participants were positive about the effect of the supportive care pathway on patient care, particularly in enabling consensus in care planning. Some expressed concerns including the difficulty of identifying the 'correct patients' for the pathway, the risk of it becoming a 'self-fulfilling prophecy', and a euphemism for dying.

CONCLUSION

Pathways are one potential mechanism for guiding care planning and communicating the goals of care to colleagues, patients and families, thus contributing to improvements in palliative care.

Improving end-of-life care for patients with chronic obstructive pulmonary disease

The provision and awareness of the need for end-of-life care has expanded greatly in the past decade. The burgeoning older adult population is obviously a factor in the growth of both hospice and palliative care organizations. Additionally, public awareness and healthcare literacy campaigns have called attention to the plight of those dying in pain. Healthcare professionals have stepped up their initiatives to educate both the patient and family members about the options available to them at the end of life, however many patients with chronic obstructive lung disease (COPD) still do not receive adequate palliation of symptoms. This article will highlight some of the issues related to end-of-life care for individuals diagnosed with COPD and offer suggestions on how better care can be implemented.

The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research

Spirituality and spiritual care are gaining increasing attention but their potential contribution to palliative care remains unclear. The aim of this study was to synthesize qualitative literature on spirituality and spiritual care at the end of life using a systematic ('meta-study') review. Eleven patient articles and eight with healthcare providers were included, incorporating data from 178 patients and 116 healthcare providers, mainly from elderly White and Judaeo-Christian origin patients with cancer. Spirituality principally focused on relationships, rather than just meaning making, and was given as a relationship. Spirituality was a broader term that may or may not encompass religion. A 'spirit to spirit' framework for spiritual care-giving respects individual personhood. This was achieved in the way physical care was given, by focusing on presence, journeying together, listening, connecting, creating openings, and engaging in reciprocal sharing. Affirmative relationships supported patients, enabling them to respond to their spiritual needs. The engagement of family caregivers in spiritual care appears underutilized. Relationships formed an integral part of spirituality as they were a spiritual need, caused spiritual distress when broken and were the way spiritual care was given. Barriers to spiritual care include lack of time, personal, cultural or institutional factors, and professional educational needs. By addressing these, we may make an important contribution to the improvement of patient care towards the end of life.

The end-of-life care experiences of relatives of brain dead intensive care patients

Brain death is a traumatic and sudden event following a severe injury to the brain. Most patients with brain death spend the last days of life in an intensive care unit (ICU), where some families will be approached to ask for organ donation. This qualitative study was carried out with relatives of patients who had died of brain death in an ICU; all relatives were interviewed six months after the death. Twenty ICUs were recruited for this study. The next of kin of 130 patients who died during the study period were approached, and 30 (22%) agreed to be interviewed; one later withdrew. This paper focuses on the perceived palliative care needs of the 29 families. Participants valued the physical care their relatives had received, but communication and breaking bad news was a cause for concern. The facilities on many ICUs, for example, cramped relatives' rooms and little privacy to be with the patients or to say the final goodbye, was a common theme to emerge. Bereavement follow-up did not routinely occur, and this was an identified factor noted by relatives. Families living through the period of brain death in a loved one may have particular needs in terms of end-of-life care and should be offered the support of a palliative care team through the last days of a patient's life and into the period of bereavement. Staff training on how to communicate bad news also should be implemented as a matter of urgency.

Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

OBJECTIVE

The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU).

DESIGN

A prospective pre/post nonequivalent control group design was used for this performance improvement study.

SETTING

Seventeen-bed adult MICU.

PATIENTS

Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation.

INTERVENTIONS

Palliative care consultations.

MEASUREMENTS AND MAIN RESULTS

Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge.

CONCLUSIONS

Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.