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Oakley CI, Chou CZ, Wiste R, Lugassy M. Communicating About Death by Neurologic Criteria #479. J Palliat Med 2024; 27:702-703. [PMID: 38728084 DOI: 10.1089/jpm.2024.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
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2
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Kirschen MP, Lewis A, Greer DM. The 2023 American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination Consensus Guidelines: What the Critical Care Team Needs to Know. Crit Care Med 2024; 52:376-386. [PMID: 37921516 DOI: 10.1097/ccm.0000000000006099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Guidelines for brain death/death by neurologic criteria (BD/DNC) determination were revised to provide a consistent and updated approach to BD/DNC evaluation across all ages by the American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine. This article is intended to complement the guidelines and highlight aspects relevant to the critical care community; the actual guidelines should be used to update hospital protocols and dictate clinical practice. Because BD/DNC evaluations are conducted in the ICU, it is essential for members of the critical care community to familiarize themselves with these guidelines. The fundamental concept of BD/DNC has not changed; BD/DNC is permanent loss of function of the brain as a whole, including the brain stem, resulting in coma, brainstem areflexia, and apnea in the setting of an adequate stimulus. The BD/DNC evaluation requires a sufficient observation period to ensure there is no chance of recovery, followed by exclusion of potentially confounding conditions like hypothermia, hypotension, severe metabolic disturbances, or medication effects. Specific guidance is provided for patients who were treated with therapeutic hypothermia or medical or surgical interventions to manage intracranial hypertension. The guidelines outline a structured and meticulous neurologic examination and detail the responses consistent with BD/DNC. A protocol is provided for how to safely perform apnea testing, including modifications needed for patients on extracorporeal membrane oxygenation. Controversial issues such as consent, BD/DNC evaluation in pregnancy, preservation of neuroendocrine function, and primary posterior fossa injuries are addressed. The ultimate goal is to ensure a consistent and accurate approach to BD/DNC evaluation in patients of all ages, fostering public trust in the medical community's ability to determine death. By adhering to these guidelines, critical care clinicians can confidently navigate the challenging aspects of BD/DNC determination.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Critical Care Medicine, Neurology, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY
| | - David M Greer
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA
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Lazaridis C, Wolf M, Roth WH, Fan T, Mansour A, Goldenberg FD. Apnea Test: The Family in the Room. Neurocrit Care 2023:10.1007/s12028-023-01906-y. [PMID: 38158482 DOI: 10.1007/s12028-023-01906-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Mary Wolf
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - William H Roth
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Tracey Fan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Ali Mansour
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Fernando D Goldenberg
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
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4
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Wang G, Antel R, Goldfarb M. The Impact of Randomized Family-Centered Interventions on Family-Centered Outcomes in the Adult Intensive Care Unit: A Systematic Review. J Intensive Care Med 2023:8850666231173868. [PMID: 37161268 DOI: 10.1177/08850666231173868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Objective: To review the literature for randomized family-centered interventions with family-centered outcomes in the adult intensive care unit (ICU). Data Sources: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library database from inception until February 2023. Study Selection: We included articles involving randomized controlled trials (RCTs) in the adult critical care setting evaluating family-centered interventions and reporting family-centered outcomes. Data Extraction: We extracted data on author, year of publication, setting, number of participants, intervention category, intervention, and family-centered outcomes. Data Synthesis: There were 52 RCTs included in the analysis, mostly involving communication and receiving information (38%) and receiving care and meeting family member needs (38%). Nearly two-thirds of studies (N = 35; 67.3%) found improvements in at least 1 family-centered outcome. Most studies (N = 24/40; 60%) exploring the impact of family-centered interventions on mental health outcomes showed improvement. Improvements in patient-centered outcomes (N = 7/17; 41%) and healthcare worker outcomes (N = 1/5; 20%) were less commonly found. Conclusions: Family-centered interventions improve family-centered outcomes in the adult ICU and may be beneficial to patients and healthcare workers.
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Affiliation(s)
- Gary Wang
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Ryan Antel
- McGill Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
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5
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Sarti AJ, Sutherland S, Meade M, Hornby L, Wilson LC, Landriault A, Vanderspank-Wright B, Valiani S, Keenan S, Weiss MJ, Werestiuk K, Beed S, Kramer AH, Kawchuk J, Cardinal P, Dhanani S, Lotherington K, Pagliarello G, Chassé M, Gatien M, Parsons K, Chandler JA, Nickerson P, Shemie SD. Death determination by neurologic criteria-what do families understand? Can J Anaesth 2023; 70:637-650. [PMID: 37131029 PMCID: PMC10203015 DOI: 10.1007/s12630-023-02416-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 11/15/2022] [Accepted: 11/26/2022] [Indexed: 05/04/2023] Open
Abstract
PURPOSE Currently, there is little empirical data on family understanding about brain death and death determination. The purpose of this study was to describe family members' (FMs') understanding of brain death and the process of determining death in the context of organ donation in Canadian intensive care units (ICUs). METHODS We conducted a qualitative study using semistructured, in-depth interviews with FMs who were asked to make an organ donation decision on behalf of adult or pediatric patients with death determination by neurologic criteria (DNC) in Canadian ICUs. RESULTS From interviews with 179 FMs, six main themes emerged: 1) state of mind, 2) communication, 3) DNC may be counterintuitive, 4) preparation for the DNC clinical assessment, 5) DNC clinical assessment, and 6) time of death. Recommendations on how clinicians can help FMs to understand and accept DNC through communication at key moments were described including preparing FMs for death determination, allowing FMs to be present, and explaining the legal time of death, combined with multimodal strategies. For many FMs, understanding of DNC unfolded over time, facilitated with repeated encounters and explanation, rather than during a single meeting. CONCLUSION Family members' understanding of brain death and death determination represented a journey that they reported in sequential meeting with health care providers, most notably physicians. Modifiable factors to improve communication and bereavement outcomes during DNC include attention to the state of mind of the family, pacing and repeating discussions according to families' expressed understanding, and preparing and inviting families to be present for the clinical determination including apnea testing. We have provided family-generated recommendations that are pragmatic and can be easily implemented.
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Affiliation(s)
- Aimee J Sarti
- Department of Critical Care, The Ottawa Hospital, General Campus, Ottawa, ON, K1H 8L6, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Stephanie Sutherland
- Department of Critical Care, The Ottawa Hospital, General Campus, Ottawa, ON, K1H 8L6, Canada
| | - Maureen Meade
- Department of Critical Care, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | | | - Angele Landriault
- Practice, Performance and Innovation Unit, Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada
| | - Brandi Vanderspank-Wright
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Sabira Valiani
- Department of Adult Critical Care, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Sean Keenan
- BC Transplant, Vancouver, BC, Canada
- Division of Critical Care, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | | | | | - Stephen Beed
- Department of Critical Care, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary and Southern Alberta Organ and Tissue Donation Program, Calgary, AB, Canada
| | - Joann Kawchuk
- Department of Adult Critical Care, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Pierre Cardinal
- Department of Critical Care, The Ottawa Hospital, General Campus, Ottawa, ON, K1H 8L6, Canada
| | - Sonny Dhanani
- Division of Critical Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | | | - Giuseppe Pagliarello
- Department of Critical Care, The Ottawa Hospital, General Campus, Ottawa, ON, K1H 8L6, Canada
| | - Michaël Chassé
- Department of Medicine, Centre hospitalier de L'Université de Montréal, Montreal, QC, Canada
| | - Mary Gatien
- Horizon Health Network, Miramichi, NB, Canada
| | - Kim Parsons
- Organ Procurement and Exchange of Newfoundland and Labrador, St. John's, NL, Canada
| | - Jennifer A Chandler
- Common Law Section, Faculty of Law, University of Ottawa, Ottawa, ON, Canada
| | - Peter Nickerson
- Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sam D Shemie
- Canadian Blood Services, Ottawa, ON, Canada
- Division of Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
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Wall A, Polk H, Bedros N, Casanova M, Trahan C, Clay M, Adams BL, Niles P, Testa G, Fine R. Organ Donation and End-of-Life Discussions: A Scripting Template for Supportive Palliative Care. J Pain Symptom Manage 2022; 64:e300-e304. [PMID: 35961430 DOI: 10.1016/j.jpainsymman.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/27/2022] [Accepted: 08/03/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Anji Wall
- Baylor University Medical Center (A.J., G.T.), Division of Abdominal Transplantation, Dallas, Texas.
| | - Heather Polk
- Baylor University Medical Center (H.P.), Department of Internal Medicine, Dallas, Texas
| | - Nicole Bedros
- Baylor University Medical Center (N.B.), Division of Trauma and Acute Care Surgery, Dallas, Texas
| | - Mark Casanova
- Baylor University Medical Center (M.C., R.F.), Supportive Palliative Care, Dallas, Texas
| | - Chad Trahan
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Michael Clay
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Bradley L Adams
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Patricia Niles
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Giuliano Testa
- Baylor University Medical Center (A.J., G.T.), Division of Abdominal Transplantation, Dallas, Texas
| | - Robert Fine
- Baylor University Medical Center (M.C., R.F.), Supportive Palliative Care, Dallas, Texas
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Bjelland S, Jones K. A Systematic Review on Improving the Family Experience After Consent for Deceased Organ Donation. Prog Transplant 2022; 32:152-166. [DOI: 10.1177/15269248221087429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The demand for transplanted organs outweighs the supply and intensifies the need to improve care for donor families. Studies have shown inadequate care by hospital staff can increase posttraumatic stress disorder and complicated grief in these families but putting solutions into practice remains slow. Objective This systematic review identified factors that relieve or contribute to distress for deceased organ donor families in the time since the decision to donate. Additionally, it provides insights into potential improvements at public health, educational, and health system levels to address these deficiencies. Methods Search terms included organ don*, famil* or relati*, family-centered, grief, and experience*. The search covered original research articles, published in English, from 2014 to July 2021. Results Four key themes emerged among the studies. (a) Understanding factors that affect the emotional aftermath can help staff prevent posttraumatic stress disorder and complicated grief. (b) Improving communication by hospital staff includes: avoiding medical jargon, providing adequate audio and visual explanations, and understanding that the next of kin is struggling to comprehend the tragedy and the information they are being told. (c) End-of-life care such as memory making, bringing in palliative care resources, and parting ceremonies can assist with familial coping as well as staff interactions. (d) Families want more support in the months and years after the donation decision. Discussion Changes at multiple levels can improve the quality of care for families whose relative gave the gift of life, but more research and translation into practice are needed.
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Affiliation(s)
- Sonja Bjelland
- University of Illinois at Chicago College of Nursing, Urbana, IL, USA
| | - Krista Jones
- Department of Population Health Nursing Science, University of Illinois at Chicago College of Nursing, Urbana, IL, USA
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What Is the Effect of Organ Donation Authorization Rates When Utilizing a Standardized Effective Request Process? Crit Care Explor 2022; 4:e0615. [PMID: 35036924 PMCID: PMC8754178 DOI: 10.1097/cce.0000000000000615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To determine if implementation of a standardized effective request process (ERP) can increase organ donation authorization rates. DESIGN A retrospective, observational study was performed using data acquired from the Midwest Transplant Network. chi-square test was used to analyze categorical data, with p value of less than 0.05 deemed significant. SETTING The Midwest Transplant Network located in Westwood, KS from January 1, 2013 to June 30, 2017. PATIENTS A total of 1,391 consecutive patients were identified as potential donors based on medical evaluation of the patient's neurologic status, organ function, and established age criteria. INTERVENTIONS An ERP was used when discussing donation with 733 patients (53%), compared with no ERP usage with 658 patients (47%). MEASUREMENTS AND MAIN RESULTS A significant increase (30%) in donation rates was observed when an ERP was used. A comparative decrease in donation rates was observed whenever a breakdown in any of the four identified steps occurred. LIMITATIONS The data analyzed was gathered retrospectively. Due to the retrospective nature of our study, there is no way to determine delay in authorization times versus no delay. Although most population data information about the authorized donors was known, this information was limited in patients who declined. CONCLUSIONS With proper preparation and planning, the implementation of a standardized ERP may improve organ donation rates and increase the number of life-saving organs for transplant.
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Guáqueta Parada SR, Henao-Castaño ÁM, Motta Robayo CL, Triana Restrepo MC, Burgos Herrera JD, Neira Fernández KD, Peña Almanza BA. Intervenciones de Enfermería ante la Necesidad de Información de la Familia del Paciente Crítico. REVISTA CUIDARTE 2021. [DOI: 10.15649/cuidarte.1775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introducción: Durante el ingreso y permanencia del paciente en la unidad de cuidado intensivo, es imperativo considerar la satisfacción de las necesidades comunicacionales e informativas de la familia del paciente. Objetivo: Integrar los resultados de investigación sobre las intervenciones llevadas a cabo para satisfacer la necesidad de información de las familias de los pacientes en la unidad de cuidado intensivo. Materiales y Métodos: Se realizó una revisión integrativa de estudios en bases de datos Sciencedirect, PubMed, Biblioteca Virtual en Salud y Scielo, con la estrategia de búsqueda [Critical care] and [Needs assessment] and [Family] con criterios de inclusión de estudios publicados entre el año 2009 y el 2019 en idioma inglés, español y portugués disponibles en texto completo Resultados: Después de la lectura analítica de 41 estudios seleccionados se organizaron en 5 temas; uso de folletos de información, sesiones educativas, llamadas telefónicas, uso de tecnologías de la información y comunicación y reuniones familiares. Conclusión: Las intervenciones de enfermería que se han utilizado en la satisfacción de la necesidad de información de la familia son muy variadas e incluyen entre otras los folletos o el uso de TICs, sin embargo la intervención que responde en mayor medida a esta necesidad son las reuniones formales con la familia. Las intervenciones reportadas en los resultados de investigación para responder a la necesidad de información son herramientas clave para que el personal de enfermería las utilice según los recursos con los cuales dispone en su entorno laboral como salas de información para la familia.
Como citar este artículo: Guáqueta Parada Sandra Rocio, Henao Castaño Ángela María, Motta Robayo Claudia Lorena, Triana Restrepo Martha Cecilia, Burgos Herrera Juan David, Neira Fernández Karen Daniela, Peña Almanza Berni Alonso. Intervenciones de Enfermería ante la Necesidad de Información de la Familia del Paciente Crítico. Revista Cuidarte. 2021;12(2):e1775. http://dx.doi.org/10.15649/cuidarte.1775
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Knhis NDS, Martins SR, Magalhães ALP, Ramos SF, Sell CT, Koerich C, Brehmer LCDF. Family interview for organ and tissue donation: good practice assumptions. Rev Bras Enferm 2021; 74:e20190206. [PMID: 34161535 DOI: 10.1590/0034-7167-2019-0206] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 12/30/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to identify information that can support creating good practice assumptions to develop family interview for organ and tissue donation. METHODS this scoping study, conducted in two Brazilian hospitals in the southern, between April and December 2017, included integrative review and consultation with 15 families who experienced interview for organ donation. For data analysis, thematic content analysis was used. RESULTS three categories emerged: communication of death, which shows the need to know the history of hospitalization of patients; emotional support, the team must have mastery of the stages of mourning; information about donation, professionals need to know the stages of the donation process and respect families' time. FINAL CONSIDERATIONS good practice assumptions point to the need for team training, respect for family time and the use of simple language.
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Affiliation(s)
| | | | | | - Saulo Fábio Ramos
- Universidade Federal de Santa Catarina. Florianópolis, Santa Catarina, Brazil
| | | | - Clarice Koerich
- Universidade Federal de Santa Catarina, Hospital Universitário Polyodoro Ernani de São Thiago. Florianópolis, Santa Catarina, Brazil
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11
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Moss SJ, Wollny K, Poulin TG, Cook DJ, Stelfox HT, Ordons ARD, Fiest KM. Bereavement interventions to support informal caregivers in the intensive care unit: a systematic review. BMC Palliat Care 2021; 20:66. [PMID: 33980242 PMCID: PMC8117265 DOI: 10.1186/s12904-021-00763-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/28/2021] [Indexed: 12/29/2022] Open
Abstract
Background Informal caregivers of critically ill patients in intensive care unit (ICUs) experience negative psychological sequelae that worsen after death. We synthesized outcomes reported from ICU bereavement interventions intended to improve informal caregivers’ ability to cope with grief. Data sources MEDLINE, EMBASE, CINAHL and PsycINFO from inception to October 2020. Study selection Randomized controlled trials (RCTs) of bereavement interventions to support informal caregivers of adult patients who died in ICU. Data extraction Two reviewers independently extracted data in duplicate. Narrative synthesis was conducted. Data synthesis Bereavement interventions were categorized according to the UK National Institute for Health and Clinical Excellence three-tiered model of bereavement support according to the level of need: (1) Universal information provided to all those bereaved; (2) Selected or targeted non-specialist support provided to those who are at-risk of developing complex needs; and/or (3) Professional specialist interventions provided to those with a high level of complex needs. Outcome measures were synthesized according to core outcomes established for evaluating bereavement support for adults who have lost other adults to illness. Results Three studies of ICU bereavement interventions from 31 ICUs across 26 hospitals were included. One trial examining the effect of family presence at brain death assessment integrated all three categories of support but did not report significant improvement in emotional or psychological distress. Two other trials assessed a condolence letter intervention, which did not decrease grief symptoms and may have increased symptoms of depression and post-traumatic stress disorder, and a storytelling intervention that found no significant improvements in anxiety, depression, post-traumatic stress, or complicated grief. Four of nine core bereavement outcomes were not assessed anytime in follow-up. Conclusions Currently available trial evidence is sparse and does not support the use of bereavement interventions for informal caregivers of critically ill patients who die in the ICU. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00763-w.
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Affiliation(s)
- Stephana J Moss
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Krista Wollny
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Faculty of Nursing, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Therese G Poulin
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Henry T Stelfox
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Amanda Roze des Ordons
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, Calgary, AB, Canada
| | - Kirsten M Fiest
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada. .,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada. .,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada. .,Alberta Health Services, Calgary, AB, Canada. .,Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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12
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Linzey JR, Foshee R, Srinivasan S, Adapa AR, Wind ML, Brake C, Daou BJ, Sheehan K, Schermerhorn TC, Jacobs TL, Pandey AS. Neurosurgical patients admitted via the emergency department initiating comfort care measures: a prospective cohort analysis. Acta Neurochir (Wien) 2021; 163:309-315. [PMID: 32820377 DOI: 10.1007/s00701-020-04534-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Given the serious nature of many neurosurgical pathologies, it is common for hospitalized patients to elect comfort care (CC) over aggressive treatment. Few studies have evaluated the incidence and risk factors of CC trends in patients admitted for neurosurgical emergencies. OBJECTIVES To analyze all neurosurgical patients admitted to a tertiary care academic referral center via the emergency department (ED) to determine incidence and characteristics of those who initiated CC measures during their initial hospital admission. METHODS We performed a prospective, cohort analysis of all consecutive adult patients admitted to the neurosurgical service via the ED between October 2018 and May 2019. The primary outcome was the initiation of CC measures during the patient's hospital admission. CC was defined as cessation of life-sustaining measures and a shift in focus to maintaining the comfort and dignity of the patient. RESULTS Of the 428 patients admitted during the 7-month period, 29 (6.8%) initiated CC measures within 4.0 ± 4.0 days of admission. Patients who entered CC were significantly more likely to have a medical history of cerebrovascular disease (58.6% vs. 33.3%, p = 0.006), dementia (17.2% vs. 1.5%, p = 0.0004), or cancer with metastatic disease (24.1% vs. 7.0%, p = 0.001). Patients with a presenting pathology associated with cerebrovascular disease were significantly more likely to initiate CC (62.1% vs. 35.3, p = 0.04). Patients who underwent emergent surgery were significantly more likely to enter CC compared with those who had elective surgery (80.0% vs. 42.7%, p = 0.02). Only 10 of the 29 (34.5%) patients who initiated CC underwent a neurosurgical operation (p = 0.002). Twenty of the 29 (69.0%) patients died within 0.8 ± 0.8 days after the initiation of CC measures. CONCLUSION CC measures were initiated in 6.8% of patients admitted to the neurosurgical service via the ED, with the majority of patients entering CC before an operation and presenting with a cerebrovascular pathology.
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Affiliation(s)
- Joseph R Linzey
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Rachel Foshee
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | | | - Arjun R Adapa
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Meghan L Wind
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Carina Brake
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Badih Junior Daou
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Kyle Sheehan
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Thomas C Schermerhorn
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Teresa L Jacobs
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA.
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Garrett JR, Berkowitz I. Response to Open Peer Commentaries "Rethinking the Ethical, Legal, and Clinical Foundations of Informed Consent and Shared Decision-Making for Brain Death Determination". THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:W1-W5. [PMID: 32441593 DOI: 10.1080/15265161.2020.1762796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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14
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Lazaridis C. Accommodating Apnea Testing Not Death Determination Refusal. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:47-49. [PMID: 32618509 DOI: 10.1080/15265161.2020.1754503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
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15
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Stahl D, Tomlinson T. Death by Neurological Criteria: Caring for Families amid Tragedy. LINACRE QUARTERLY 2020; 86:394-403. [PMID: 32431431 DOI: 10.1177/0024363919874957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
When a patient is declared dead using neurological criteria, intense emotional and ethical challenges can follow. In our experience as clinical ethicists, consults surrounding the declaration of "brain death" can be some of the most difficult. In what follows, we describe some best practices related to death by neurological criteria (DNC). We begin with important policies hospitals need to have in place to ensure that death is properly understood by all members of the clinical team and place some limits on the authority of families to demand continued "treatment" for deceased patients. Next, we explain how best to prepare families for the diagnosis. We then discuss how to talk to families when breaking the news concerning DNC. Finally, we describe how to approach a family that is resisting the determination of death. Summary This article advises clinicians on how to talk to families about brain death.
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Affiliation(s)
- Devan Stahl
- Department of Religion, Baylor University, Waco, TX, USA
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16
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Abstract
In 1968, the criteria for brain death were established by the Harvard Ad Hoc Committee. Despite what may appear to be unambiguous definitions, clinicians, ethicists, and the public have grappled with the concept of brain death since its inception. In light of recent public discourse on the topic, Harvard Medical School convened a conference to examine research and ethical inquiry conducted over the past 50 years related to death as defined by neurologic criteria. Drawing on the report produced by this conference, this article provides an overview of the development of brain death criteria, describes recent controversies and updates, and discusses implications of these criteria for nurses.
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Chen C, Michaels J, Meeker MA. Family Outcomes and Perceptions of End-of-Life Care in the Intensive Care Unit: A Mixed-Methods Review. J Palliat Care 2019; 35:143-153. [PMID: 31543062 DOI: 10.1177/0825859719874767] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this review was to evaluate end-of-life care (EOLC) in the intensive care unit (ICU) from the perspective of family members. Sandelowski's segregated approach from Joanna Briggs Institute (JBI) Mixed-Methods Systematic Reviews guided this review. A search was conducted in PubMed, CINAHL, PsycINFO, EMBASE, and ProQuest databases and identified 50 papers (33 quantitative, 15 qualitative, and 2 mixed-methodology studies). Five synthesized themes (distressing emotions, shared decision-making, proactive communication, personalized end-of- life care, and valuing of nursing care) were identified. For quantitative results, study methodologies and interventions were heterogeneous and did not always improve family members' perceived quality of care and family members' psychological distress. Configuration of qualitative and quantitative data revealed ICU end-of-life interventions were ineffective because they were not guided by family members' reported needs and perceptions. To fulfill the family members' needs for the patients' EOLC in the ICU, researchers should develop a theory to explicitly explain how the family members experience ICU EOLC and implement a theory-based intervention to improve family psychological outcomes.
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Affiliation(s)
- Chiahui Chen
- School of Nursing, University at Buffalo-The State University of New York, Buffalo, NY, USA
| | - Jacqueline Michaels
- School of Nursing, University at Buffalo-The State University of New York, Buffalo, NY, USA.,School of Nursing and Allied Health, SUNY Empire State College, Saratoga Springs, NY, USA
| | - Mary Ann Meeker
- School of Nursing, University at Buffalo-The State University of New York, Buffalo, NY, USA
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18
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Comparison the effect of trained and untrained family presence on their anxiety during invasive procedures in an emergency department: A randomized controlled trial. Turk J Emerg Med 2019; 19:100-105. [PMID: 31321342 PMCID: PMC6612628 DOI: 10.1016/j.tjem.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/09/2019] [Accepted: 05/14/2019] [Indexed: 11/22/2022] Open
Abstract
Objective The present study was aimed to compare the effect of the trained and untrained family presence on their anxiety during invasive procedures in an emergency department. Methods In this randomized controlled clinical trial, 90 patients who were candidates for receiving invasive nursing procedures were selected in an emergency department based on the inclusion criteria, and then were equally assigned into 3 groups by the random minimization method: A ("presence of the trained family member group "), B ("presence of the untrained family member group "), and C ("absence and untrained family member group"). The anxiety level was measured before and after implementation of the procedure using the Spielberger State-Trait Anxiety Inventory (STAI). The data were analyzed by SPSS software using the Kolmogorov-Smirnov test, Chi-Square test, Kruskal Wallis Independent-Samples test, Paired Samples T-test, and ANOVA at the significance level of 0.05. Results The three groups were similar in terms of demographic variables. In all three groups, the SATI score significantly decreased after intervention phase (p = 0.001). The mean changes of the SATI score were not statistically different between the groups. However, The STAI score decreased significantly after intervention in the group B compared to the group A (p = 0.011) and C (p = 0.042). However, there was no significant difference between the SATI score in the group A and C (p = 0.867). Conclusion The results of the study revealed that, the “presence of the untrained" family members caused them to experience significantly less anxiety than the other two groups. However, changes in the anxiety score were not significant between the groups.
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19
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Kentish-Barnes N, Siminoff LA, Walker W, Urbanski M, Charpentier J, Thuong M, Sarti A, Shemie SD, Azoulay E. A narrative review of family members’ experience of organ donation request after brain death in the critical care setting. Intensive Care Med 2019; 45:331-342. [DOI: 10.1007/s00134-019-05575-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/19/2019] [Indexed: 11/27/2022]
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20
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Critical synopsis and key questions in brain death determination. Intensive Care Med 2019; 45:306-309. [PMID: 30725142 DOI: 10.1007/s00134-019-05549-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
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21
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Linzey JR, Burke JF, Nadel JL, Williamson CA, Savastano LE, Wilkinson DA, Pandey AS. Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures. J Neurosurg 2018; 131:1725-1733. [PMID: 30554183 DOI: 10.3171/2018.7.jns181226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/31/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery. METHODS This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively. RESULTS Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70-79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00. CONCLUSIONS Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.
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Affiliation(s)
| | | | | | - Craig A Williamson
- Departments of2Neurology and
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Luis E Savastano
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - D Andrew Wilkinson
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Aditya S Pandey
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
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22
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Aredes JDS, Firmo JOA, Giacomin KC. [Deaths that save lives: the complexities of medical care for patients with suspected brain death]. CAD SAUDE PUBLICA 2018; 34:e00061718. [PMID: 30427410 DOI: 10.1590/0102-311x00061718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/12/2018] [Indexed: 11/21/2022] Open
Abstract
The objective of this study was to understand how physicians at the largest emergency department in a large Brazilian city orient care for critical patients with suspected brain death and who are potential organ donors. This ethnographic study was conducted in an emergency care hospital, a reference in traumatology in Latin America, located in downtown Belo Horizonte, Minas Gerais State. The institution took pioneering steps in Brazil with a specific sector where patients with suspected brain death are referred. The fieldwork was performed over the course of nine months, based on targeted observations and interviews with 43 on-duty staff physicians (25 men and 18 women), from 28 and 69 years of age. Data analysis followed the "signs, meanings, and actions" model. The ethnography revealed the process of medical care for patients with suspected brain death, including: intensive care, adherence to protocol, and communicating the patient's status to the family. In the latter case, the dialogue reveals the controversies in the concept of brain death, the sociocultural context, and the emergency care context. It became clear that this process of medical care extrapolates merely normative issues, entering into a complex web of elements, especially the professional's role as mediator of a myriad of interwoven elements and tensions. Between confirmation of the brain death and communicating the situation to the family, ambivalent perceptions emerge, both for the physicians and the family members. The study evidenced how the tenuous definition of what constitutes life and death touches on all of the medical act, with direct implications on care for patients/potential donors and their families.
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Affiliation(s)
| | | | - Karla Cristina Giacomin
- Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brasil.,Secretaria Municipal de Saúde, Belo Horizonte, Brasil
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Kentish-Barnes N, Chevret S, Cheisson G, Joseph L, Martin-Lefèvre L, Si Larbi AG, Viquesnel G, Marqué S, Donati S, Charpentier J, Pichon N, Zuber B, Lesieur O, Ouendo M, Renault A, Le Maguet P, Kandelman S, Thuong M, Floccard B, Mezher C, Galon M, Duranteau J, Azoulay E. Grief Symptoms in Relatives Who Experienced Organ Donation Requests in the ICU. Am J Respir Crit Care Med 2018; 198:751-758. [DOI: 10.1164/rccm.201709-1899oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Sylvie Chevret
- Service de Biostatistique et Information Médicale, Saint-Louis University Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
- Biostatistics and Clinical Epidemiology Research (ECSTRA) Team, U1153, INSERM, Paris Diderot University, Sorbonne University, Paris, France
| | | | - Liliane Joseph
- Transplant Coordination Team, Bicêtre University Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | | | | | - Gérald Viquesnel
- Surgical Intensive Care Unit, Côte de Nacre Hospital, Caen, France
| | - Sophie Marqué
- Medical and Surgical Intensive Care Unit, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France
| | - Stéphane Donati
- Medical and Surgical Intensive Care Unit, Sainte Musse Hospital, Toulon, France
| | - Julien Charpentier
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Nicolas Pichon
- Medical and Surgical Intensive Care Unit, Dupuytren University Hospital, Limoges, France
| | - Benjamin Zuber
- Medical and Surgical Intensive Care Unit, André Mignot Hospital, Versailles, France
| | - Olivier Lesieur
- Medical and Surgical Intensive Care Unit, La Rochelle Hospital, La Rochelle, France
| | - Martial Ouendo
- Medical and Surgical Intensive Care Unit, Amiens-Picardy University Hospital, Amiens, France
| | | | - Pascale Le Maguet
- Surgical Intensive Care, Cavale Blanche University Hospital, Brest, France
| | - Stanislas Kandelman
- Anesthesia and Intensive Care Department, Beaujon University Hospital, Assistance Publique – Hôpitaux de Paris, Clichy, France
| | - Marie Thuong
- Intensive Care Unit, Hospital René-Dubos, Pontoise, France
| | - Bernard Floccard
- Anesthesia and Intensive Care, Hospices Civils de Lyon – Edouard Herriot Hospital, Lyon, France; and
| | - Chaouki Mezher
- Medical and Surgical Intensive Care, Belfort-Montbelliard Hospital, Montbelliard, France
| | | | | | - Elie Azoulay
- Famiréa Research Group and
- Biostatistics and Clinical Epidemiology Research (ECSTRA) Team, U1153, INSERM, Paris Diderot University, Sorbonne University, Paris, France
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24
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Fernandes MEN, Bittencourt ZZLDC, Boin IDFSF. Experiencing organ donation: feelings of relatives after consent. Rev Lat Am Enfermagem 2017; 23:895-901. [PMID: 26487140 PMCID: PMC4660412 DOI: 10.1590/0104-1169.0486.2629] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 04/11/2015] [Indexed: 11/22/2022] Open
Abstract
Objective: to identify experiences and feelings on the organ donation process, from the
perspective of a relative of an organ donor in a transplant unit. Method: this was exploratory research using a qualitative approach, performed with seven
family members of different organ donors, selected by a lottery. Sociodemographic
data and the experiences regarding the donation process were collected through
semi-structured interviews. The language material was transcribed and submitted to
content analysis. Results: poor sensitivity of the medical staff communicating the relative's brain death -
the potential donor - and the lack of socio-emotional support prior to the
situation experienced by the family was highlighted by participants. Conclusions: the study identified the need to provide social-emotional support for families
facing the experience of the organ donation process. From these findings, other
care and management practices in health must be discussed to impact the
strengthening of the family ties, post-donation, as well as the organ procurement
indexes.
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Abstract
The Neuro-ICU is a multidisciplinary location that presents peculiar challenges and opportunities for patients with life-threatening neurological disease. Communication skills are essential in supporting caregivers and other embedded providers (e.g., neurosurgeons, advanced practice providers, nurses, pharmacists), through leadership. Limitations to prognostication complicate how decisions are made on behalf of non-communicative patients. Cognitive dysfunction and durable reductions in health-related quality of life are difficult to predict, and the diagnosis of brain death may be challenging and confounded by medications and comorbidities. The Neuro-ICU team, as well as utilization of additional consultants, can be structured to optimize care. Future research should explore how to further improve the composition, communication and interactions of the Neuro-ICU team to maximize outcomes, minimize caregiver burden, and promote collegiality.
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Doran M, Black P. Seeing for themselves - healthcare professionals' views about the presence of family members during brainstem death testing. J Clin Nurs 2017; 26:1597-1607. [PMID: 27486846 DOI: 10.1111/jocn.13488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To provide an insight into the views of healthcare professionals on the presence of family members during brainstem death testing. BACKGROUND Brainstem death presents families with a paradoxical death that can be difficult to define. International research suggests families should be given the choice to be present at brainstem death testing, yet it appears few units offer families the choice to be present and little attention has been paid to developing practice to enable effective facilitation of choice. DESIGN A qualitative, exploratory design was adopted to understand the perceptions of healthcare professionals. Individual semi-structured interviews were audio-taped and carried out over two months. METHODS A purposive sample of 10 nurses and 10 doctors from two tertiary intensive care units in the United Kingdom was interviewed, and transcripts were analysed using content analysis to identify emergent categories and themes. RESULTS Healthcare professionals indicated different perceptions of death in the context of catastrophic brainstem injury. The majority of participants favoured offering families the choice to be present while acknowledging the influence of organisational culture. Identified benefits included acceptance, closure and better understanding. Suggested challenges involved the assumption of trauma or disruption and sense of obligation for families to accept if choice was offered. Key issues involved improving knowledge and communication skills to individually tailor support for families involved. CONCLUSIONS If families are to be offered the choice of witnessing brainstem death testing, considering that needs and conventions will differ according to global cultural backgrounds, then key needs must be met to ensure that effective care and support is provided to families and clinicians. RELEVANCE TO CLINICAL PRACTICE A proactive approach to facilitating family choice to be present at testing requires the development of guidelines that accommodate cultural and professional variations to provide excellence in end-of-life care.
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Affiliation(s)
- Majella Doran
- Clinical Education Centre, Altnagelvin Hospital, Londonderry, Northern Ireland
| | - Pauline Black
- School of Nursing, Ulster University, Londonderry, Northern Ireland
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27
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Patient, family-centred care interventions within the adult ICU setting: An integrative review. Aust Crit Care 2016; 29:179-193. [DOI: 10.1016/j.aucc.2016.08.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/28/2016] [Accepted: 08/04/2016] [Indexed: 11/18/2022] Open
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Muramoto O. Informed consent for the diagnosis of brain death: a conceptual argument. Philos Ethics Humanit Med 2016; 11:8. [PMID: 27737717 PMCID: PMC5062821 DOI: 10.1186/s13010-016-0042-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 09/22/2016] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND This essay provides an ethical and conceptual argument for the use of informed consent prior to the diagnosis of brain death. It is meant to enable the family to make critical end-of-life decisions, particularly withdrawal of life support system and organ donation, before brain death is diagnosed, as opposed to the current practice of making such decisions after the diagnosis of death. The recent tragic case of a 13-year-old brain-dead patient in California who was maintained on a ventilator for over 2 years illustrates how such a consent would have made a crucial difference. METHODS Conceptual, philosophical, and ethical analysis. RESULTS I first consider a conceptual justification for the use of consent for certain non-beneficial and unwanted medical diagnoses. I suggest that the diagnosis of brain death falls into this category for some patients. Because the diagnostic process of brain death lacks the transparency of traditional death determination, has a unique epistemic structure and a complex risk-benefit profile which differs markedly from case to case, and presents conflicts of interest for physicians and society, I argue that pre-diagnostic counseling and informed consent should be part of the diagnostic process. This approach can be termed as "allow cardiac death", whose parallel logic with "allow natural death" is discussed. I also discuss potential negative impacts on organ donation and health care cost from this proposal and offer possible mitigation. I show that the pre-diagnostic counseling can improve the possibility for well-thought-out decisions regarding organ donation and terminating life-support system in cases of hopeless prognosis. This approach differs conceptually from the pluralism of the definition of death, such as those in New Jersey and Japan, and it upholds the Uniform Determination of Death Act. CONCLUSIONS My intention is not to provide an instant panacea for the ongoing impasse of the brain death debate, but to point to a novel conceptual ground for a more pragmatic, and more patient- and family-centered approach. By enabling the family to consent to or decline the diagnostic process of brain death, but not to choose the definition of death, it upholds the current legal definition of death.
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Affiliation(s)
- Osamu Muramoto
- Center for Ethics in Health Care, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd. UHN-86, Portland, 97239-3098, OR, USA.
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Garrouste-Orgeas M, Vinatier I, Tabah A, Misset B, Timsit JF. Reappraisal of visiting policies and procedures of patient's family information in 188 French ICUs: a report of the Outcomerea Research Group. Ann Intensive Care 2016; 6:82. [PMID: 27566711 PMCID: PMC4999564 DOI: 10.1186/s13613-016-0185-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 08/15/2016] [Indexed: 12/02/2022] Open
Abstract
Background The relatives of intensive care unit (ICU) patients must cope with both the severity of illness of their loved one and the unfamiliar and stressful ICU environment. This hardship may lead to post-intensive care syndrome. French guidelines provide recommendations on welcoming and informing families of ICU patients. We questioned whether and how they are applied 5 years after their publication. Methods We conducted a large survey among French ICUs to evaluate their visiting policies and how information was provided to patient’s family. A questionnaire was built up by intensivists and nurses. French ICUs were solicited, and the questionnaire was sent to all participating ICUs, for being filled in by the unit medical and/or nursing head. Data regarding the hospital and ICU characteristics, the visiting policy and procedures, and the management of family information were collected. Results Among the 289 French ICUs, 188 (65 %) participated. Most ICUs have a waiting room 118/188 (62.8 %) and a dedicated room for meeting the family 152/188 (80.8 %). Of the 188 ICUs, 45 (23.9 %) were opened on a 24-h-a-day basis. In the remaining ICUs, the time period allowed for visits was 4.75 ± 1.83 h (median 5 h). In ICUs where visiting restrictions were reported, open visiting was allowed for end-of-life situations in 107/143 (74.8 %). Children are allowed to visit a patient in 164/188 (87.2 %) regardless of their age in 97/164 (59.1 %) of ICUs. Families received an information leaflet in 168/188 (89.3 %). Information was provided to families through structured meetings in 149/188 (79.2 %) of ICUs at patient admission with participation of nurses and nursing assistants in 133/188 (70.4 %) and 55/188 (29.2 %), respectively. Information delivered to the family was reported in the patient chart by only 111/188 ICUs (59 %). Participation in care was infrequent. Conclusions Although French ICUs do not follow the consensus recommendations, slow progress exists compared to previous reports. Implementation of these recommendations is largely needed to offer better welcome and information improvement. Further studies on that topic would enable evaluating remaining obstacles and increasing caregivers’ awareness, both critical for further progresses on that topic. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0185-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maité Garrouste-Orgeas
- IAME, UMR 1137, Sorbonne Paris Cité, Paris Diderot University, 75018, Paris, France. .,Outcomerea Research Group, 75020, Paris, France. .,Service de médecine intensive et de réanimation, Groupe Hospitalier Paris Saint Joseph, 185 rue Raymond Losserand, 75014, Paris, France.
| | - Isabelle Vinatier
- Medical-Surgical ICU, Les Oudaries Hospital, La Roche-Sur-Yon, France
| | - Alexis Tabah
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Burns, Trauma and Critical Care Research Centre, University of Queesland, Brisbane, Australia
| | - Benoit Misset
- Medical ICU, Charles Nicolle University Hospital, Rouen, France
| | - Jean-François Timsit
- IAME, UMR 1137, Sorbonne Paris Cité, Paris Diderot University, 75018, Paris, France.,Outcomerea Research Group, 75020, Paris, France.,Medical ICU, Bichat University Hospital, Paris, France
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Cai X, Robinson J, Muehlschlegel S, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units. Neurocrit Care 2015; 23:131-41. [PMID: 25990137 PMCID: PMC4816524 DOI: 10.1007/s12028-015-0149-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.
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Affiliation(s)
- Xuemei Cai
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
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Rippin AS, Zimring C, Samuels O, Denham ME. Finding a Middle Ground: Exploring the Impact of Patient- and Family-Centered Design on Nurse-Family Interactions in the Neuro ICU. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2015; 9:80-98. [PMID: 26187793 DOI: 10.1177/1937586715593551] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This comparative study of two adult neuro critical care units examined the impact of patient- and family-centered design on nurse-family interactions in a unit designed to increase family involvement. BACKGROUND A growing evidence base suggests that the built environment can facilitate the delivery of patient- and family-centered care (PFCC). However, few studies examine how the PFCC model impacts the delivery of care, specifically the role of design in nurse-family interactions in the adult intensive care unit (ICU) from the perspective of the bedside nurse. METHODS Two neuro ICUs with the same patient population and staff, but with different layouts, were compared. Structured observations were conducted to assess changes in the frequency, location, and content of interactions between the two units. Discussions with staff provided additional insights into nurse attitudes, perceptions, and experiences caring for families. RESULTS Nurses reported challenges balancing the needs of many stakeholders in a complex clinical environment, regardless of unit layout. However, differences in communication patterns between the clinician- and family-centered units were observed. More interactions were observed in nurse workstations in the PFCC unit, with most initiated by family. While the new unit was seen as more conducive to the delivery of PFCC, some nurses reported a loss of workspace control. CONCLUSIONS Patient- and family-centered design created new spatial and temporal opportunities for nurse-family interactions in the adult ICU, thus supporting PFCC goals. However, greater exposure to unplanned family encounters may increase nurse stress without adequate spatial and organizational support.
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Affiliation(s)
| | | | - Owen Samuels
- Neuroscience Critical Care, Emory Healthcare, Atlanta, GA, USA
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Youn TS, Greer DM. Brain death and management of a potential organ donor in the intensive care unit. Crit Care Clin 2015; 30:813-31. [PMID: 25257743 DOI: 10.1016/j.ccc.2014.06.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The concept of brain death developed with the advent of mechanical ventilation, and guidelines for determining brain death have been refined over time. Organ donation after brain death is a common source of transplant organs in Western countries. Early identification and notification of organ procurement organizations are essential. Management of potential organ donors must take into consideration specific pathophysiologic changes for medical optimization. Future aims in intensive and neurocritical care medicine must include reducing practice variability in the operational guidelines for brain death determination, as well as improving communication with families about the process of determining brain death.
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Affiliation(s)
- Teddy S Youn
- Department of Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT 06520, USA
| | - David M Greer
- Department of Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT 06520, USA.
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Equating brain death with human death in medical practice: misconstruing scientific evidence as misconceptions. Crit Care Med 2015; 42:e606-7. [PMID: 25029162 DOI: 10.1097/ccm.0000000000000434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The authors reply. Crit Care Med 2014; 42:e607. [DOI: 10.1097/ccm.0000000000000484] [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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