Transitioning to End-of-Life Care in the Intensive Care Unit: A Case of Unifying Divergent Desires

Differences in Timely Goals of Care Discussions in Nursing Homes Among Black Residents

BACKGROUND

In the United States, disparities persist in end-of-life care outcomes between Black and White nursing home (NH) residents, particularly concerning infection-related management. Timely goals of care (TGOC) discussions are crucial for improving end-of-life outcomes but exhibit racial variations within NHs that are not well understood.

OBJECTIVES

Examine the association between the proportion of Black residents within NHs and TGOC discussion related to infection management.

DESIGN

A national analysis of palliative care survey data from NHs with the Minimum Dataset 3.0 and administrative data.

SETTING/SUBJECTS

892 NHs representing a weighted sample of 14,981 facilities.

MEASURMENTS

TGOC discussions related to infection management were quantified using an index score from the palliative care survey (range: 0-18). Multivariable analyses assessed the association between the proportion of Black residents (≤2%, 2.1%-15%, >15%) and TGOC index scores.

RESULTS

The majority of NHs were for-profit, chain-affiliated, urban facilities with fewer than 100 beds, serving both Medicare and Medicaid beneficiaries. In stratified analyses, NHs with 2.1%-15% (-0.97 score; 95%CI -1.86, -0.07; P < .05) and 15% or more Black residents (-3.86 score; 95%CI -6.62, -1.10; P < .01) showed lower TGOC index scores compared to NHs with 2% or fewer Black residents in the West. NHs with 2.1%-15% Black residents had 1.29 lower TGOC index scores compared to NHs with 2% or fewer Black residents (95%CI -2.51, -0.07; P < .05) in the Northeast.

CONCLUSIONS

TGOC discussions in US NHs are influenced by the proportion of Black residents, highlighting the need for targeted interventions to address regional disparities and improve end-of-life care equity.

The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences

OBJECTIVES

To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members.

DESIGN

A constructivist qualitative study.

SETTING

One hospitals intensive care unit in Southeast China.

METHODS

Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis.

FINDINGS

A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members.

CONCLUSION

The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.¹.

ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study

BACKGROUND

End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending.

OBJECTIVE

To examine whether practices that became ACOs altered spending and utilization at the EOL.

DESIGN

Retrospective analysis of Medicare claims.

PATIENTS

We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients.

MAIN MEASURES

Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation.

KEY RESULTS

The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death.

CONCLUSIONS

With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.

Transferring home to die from critical care units: A scoping review of international practices

PURPOSE

To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

MATERIALS AND METHODS

A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019.

RESULTS

Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes.

CONCLUSIONS

Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.

The use of the concept of transition in different disciplines within health and social welfare: An integrative literature review

AIMS

To continuing the quest of the concept of transition in nursing research and to explore how the concept of transition is used in occupational therapy, oral health and social work as well as in interdisciplinary studies in health and welfare, between 2003-2013.

DESIGN

An integrative literature review.

METHODS

PubMed, CINAHL, PsycINFO, DOSS, SocIndex, Social Science Citation Index and AMED databases from 2003-2013 were used. Identification of 350 articles including the concept of transition in relation to disciplines included. Assessment of articles are in accordance to Meleis' typologies of transition by experts in each discipline. Chosen key factors were entered into Statistical Package for the Social Sciences (SPSS).

RESULTS

Meleis' four typologies were found in all studied disciplines, except development in oral health. The health-illness type was the most commonly explored, whereas in social work and in occupation therapy, situational transitions dominated.

Metasynthesis: Dying adults' transition process from cure-focused to comfort-focused care

AIM

To describe and explain the process of transition from cure-focused to comfort-focused health care as perceived and reported by patients, family members, and healthcare providers.

BACKGROUND

Moving into the last phase of life due to advanced illness constitutes a developmental transition with increased vulnerability for patients and family.

DESIGN

Qualitative metasynthesis.

DATA SOURCES

Medline, CINAHL, and PsycInfo databases searched from inception through March 2016. Primary research reports published from 1990 to 2015, using qualitative designs to report transition experiences of patients, family members, and/or healthcare providers were included.

REVIEW METHODS

Key elements were extracted and organized into matrices. Findings from each report were analysed using qualitative coding.

RESULTS

The sample was 56 unique reports from 50 primary studies. Patients and families emphasized the importance of receiving understandable information, emotional support, respect for personhood and control. The critical juncture of 'realizing terminality' preceded a transition to comfort-focused care. Subsequently, a shift in goals of care emphasizing comfort and quality of life could occur. Continued provision of information, effective support, respect and control promoted 'reframing perceptions' and capacity to embrace a changed identity. Reframing allowed patient and family to find meaning and value in this last phase of life and to embrace the opportunity to prepare for death, nurture relationships, and focus on quality of living.

CONCLUSION

Understanding the developmental process that can be engaged by patients and families at the end of life provides a theoretical basis that can inform choice and timing of interventions to reduce suffering and enhance positive outcomes.

Best intentions or best practice? A case study of the nutritional needs and outcomes of a person with dementia living in a residential aged care home

AIMS

To evaluate the nutritional status and needs of a person with dementia living in an aged care home, including identification of barriers to, and effective strategies for, the provision of person-centred care.

BACKGROUND

Nutrition and hydration care are integral to quality of life for adults with dementia, but there is little research on whether staff knowledge around effective care strategies for residents is translated into optimal care.

DESIGN

Focused ethnographic single-case design.

METHODS

The perspectives of the resident, her prime family member, and six care staff were triangulated through interviews, observation, document audit, and medical file review to investigate the resident's nutrition and hydration status and needs (October 2014-April 2015).

RESULTS

During 3 years in care, this resident had lost weight steadily. Staff appeared attentive but did not maintain a systematic record of body mass index. At meals, staff encouraged eating but used ineffective strategies. Food was not served in ways that facilitated active participation. Eating and drinking were structured as tasks to be completed rather than activities to be enjoyed.

CONCLUSION

This instrumental case study identified a task-oriented, rather than person-centred, approach to nutrition and hydration care, adversely affecting the resident's nutritional health and capability to participate actively.

Advancing palliative and end-of-life science in cardiorespiratory populations: The contributions of nursing science

Nursing science has a critical role to inform practice, promote health, and improve the lives of individuals across the lifespan who face the challenges of advanced cardiorespiratory disease. Since 1997, the National Institute of Nursing Research (NINR) has focused attention on the importance of palliative and end-of-life care for advanced heart failure and advanced pulmonary disease through the publication of multiple funding opportunity announcements and by supporting a cadre of nurse scientists that will continue to address new priorities and future directions for advancing palliative and end-of-life science in cardiorespiratory populations.

Finding your way through EOL challenges in the ICU using Adaptive Leadership behaviours: A qualitative descriptive case study

OBJECTIVE

Using the Adaptive Leadership framework, we describe behaviours that providers used while interacting with family members facing the challenges of recognising that their loved one was dying in the ICU.

RESEARCH METHODOLOGY

In this prospective pilot case study, we selected one ICU patient with end-stage illness who lacked decision-making capacity. Participants included four family members, one nurse and two physicians. The principle investigator observed and recorded three family conferences and conducted one in-depth interview with the family. Three members of the research team independently coded the transcripts using a priori codes to describe the Adaptive Leadership behaviours that providers used to facilitate the family's adaptive work, met to compare and discuss the codes and resolved all discrepancies.

FINDINGS

We identified behaviours used by nurses and physicians that facilitated the family's ability to adapt to the impending death of a loved one. Examples of these behaviours include defining the adaptive challenges for families and foreshadowing a poor prognosis.

CONCLUSIONS

Nurse and physician Adaptive Leadership behaviours can facilitate the transition from curative to palliative care by helping family members do the adaptive work of letting go. Further research is warranted to create knowledge for providers to help family members adapt.

Palliative and supportive care needs of patients with high-grade glioma and their carers: a systematic review of qualitative literature

OBJECTIVE

Patients diagnosed with primary malignant glioma (PMG) face substantial challenges with poor prognosis, high symptom burden and care needs. This study aims to collate current literature detailing the supportive and palliative care needs of patients with PMG and their carers, and to subject it to a novel approach of formal evaluation.

METHODS

Medline, EMBASE, CINAHL, PsychInfo were searched with core concepts: (1) glioma, (2) high-grade disease, and (3) palliative and supportive care needs. A narrative synthesis approach was undertaken including a quality appraisal of the 21 included studies.

RESULTS

Key themes related to the need for consistent well-delivered information around disease sequelae, treatment, and resources available; health service needs including a key professional identified to coordinate care; the need for psychological and social supports, and clear avenues of communication with treating professionals.

CONCLUSION

The literature remains limited in the number and quality of evidence with two level I, eight level II, and eleven level III studies. The findings call for improved information, communication and support practices to address the complexity and breadth of needs.

PRACTICE IMPLICATIONS

Specialised and individually tailored information, attention to clear, consistent communication and support practices should be incorporated into a future needs-based model of care.

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.

End of life management of adult patients in an Australian metropolitan intensive care unit: A retrospective observational study

BACKGROUND

Death in the intensive care unit is often predictable. End of life management is often discussed and initiated when futility of care appears evident. Respect for patients wishes, dignity in death, and family involvement in the decision-making process is optimal. This goal may often be elusive.

PURPOSE

Our purpose was to review the end of life processes and family involvement within our Unit.

METHODS

We conducted a chart audit of all deaths in our 10 bed Unit over a 12-month period, reviewing patient demographics, diagnosis on admission, patient acuity, expectation of death and not-for-resuscitation status. Discussions with the family, treatments withheld and withdrawn and extubation practices were documented. The presence of family or next-of-kin at the time of death, the time to death after withdrawal of therapy and family concerns were recorded.

RESULTS

There were 70 patients with a mean age of 69 years. Death was expected in 60 patients (86%) and not-for-resuscitation was documented in 58 cases (85%). Family discussions were held in 63 cases (90%) and treatment was withdrawn in 34 deaths (49%). After withdrawal of therapies, 31 patients (44%) died within 6h. Ventilatory support was withdrawn in 24 cases (36%). Family members were present at the time of death in 46 cases (66%). Family concerns were documented about the end of life care in only 1 case (1.4%).

CONCLUSION

Our data suggests that death in our Unit was often predictable and that end of life management was a consultative process.