Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study

Intensive Care Unit Nurses' Attitudes Toward Truth-Telling, Life-Sustaining Treatment, and Decision-Making Intention for End-of-Life Patients: A Cross-sectional Survey

Truth-telling and life-sustaining treatment decisions are important elements of the quality of patients' care at the end of life. As the primary caregivers of patients at the end of life in intensive care units (ICUs), ICU nurses play an important role in patient decision making and hospice care. This study aimed to investigate and analyze ICU nurses' attitudes toward truth-telling, attitudes toward end-of-life life-sustaining treatment, and end-of-life decision-making behavioral intentions. One hundred twenty-two ICU nurses participated in this cross-sectional survey. Data were collected using a validated questionnaire. The results showed that ICU nurses' attitudes toward telling patients the truth and end-of-life life-sustaining treatment were both positive, but further improvement is needed. Nurses have a higher willingness to make palliative care decisions for patients at the end of life and to help patients achieve a good death. The truth-telling attitude, the life-sustaining treatment attitude, and whether they knew that cardiopulmonary resuscitation could be legally forgone at the end of life were factors influencing ICU nurses' behavioral intention toward decision making for patients at the end of life (all P s < .05). We conclude that nurses' participation in truth-telling and end-of-life decision making should be promoted, and timely hospice care should be provided to patients to help them achieve a good death.

Development of quality indicators for palliative care in intensive care units and pilot testing them via electronic medical record review

BACKGROUND

Patients in intensive care units (ICUs) often require quality palliative care for relief from various types of suffering. To achieve quality palliative care, specific goals need to be identified, measured, and reported. The present study aimed to develop quality indicators (QIs) for palliative care in ICUs, based on a systematic review and modified Delphi method, and test their feasibility by reviewing electronic medical record (EMR) data.

METHODS

The current study was performed in two phases: the development of QIs using the modified Delphi method, and pilot-testing the quality of palliative care in ICUs based on EMR review. The pilot test included 262 patients admitted to the general or emergency ICU at a university hospital from January 1, 2019, to June 30, 2019.

RESULTS

A 28-item QI set for palliative care in ICUs was developed based on the consensus of 16 experts. The Delphi process resulted in low measurability ratings for two items: "Assessment of the patient's psychological distress" and "Assessment of the patient's spiritual and cultural practices." However, these items were determined to be important for quality care from the perspective of holistic assessment of distress and were adopted in the final version of the QI set. While the pilot test results indicated the feasibility of the developed QIs, they suggested that the frequency of care performance varied, and certain aspects of palliative care in ICUs needed to be improved, namely (1) regular pain assessment, (2) identification of the patient's advance directive and advance care planning for treatment, (3) conducting an interdisciplinary family conference on palliative care, and (4) assessment of psychological distress of family members.

CONCLUSIONS

The QI set, developed using the modified Delphi method and tested using EMR data, provided a tool for assessing the quality of palliative care in ICUs. In the two ICUs considered in this study, aspects of the palliative care process with a low performance frequency were identified, and further national surveys were recommended. It is necessary to conduct ongoing surveys at more facilities to improve the quality of palliative care in ICUs.

Ethisch begründet entscheiden in der Intensivmedizin

The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis.

Decision Aids in the ICU: a scoping review

OBJECTIVE

The purpose of this scoping review was to synthesise the effectiveness and acceptability of decision aids for critically ill patients and family members in the intensive care unit (ICU).

METHODS

A systematic search of four electronic databases and grey literature was undertaken to identify relevant studies on the application of decision aids in the ICU, without publication date restriction, through March 2023. The methodological framework proposed by Arksey and O'Malley was used to guide the scoping review.

RESULTS

Fourteen papers were ultimately included in this review. However, only nine decision aids were available, and it is noteworthy that many of these studies focused on the iterative development and testing of individual decision aids. Among the included studies, 92% (n=13) were developed in North America, with a primary focus on goals of care and life-sustaining treatments. The summary of the effect of decision aid application revealed that the most common indicators were the level of knowledge and code status, and some promising signals disappeared in randomised trials.

CONCLUSIONS

The complexity of treatment decisions in the ICU exceeds the current capabilities of existing decision aids. There is a clear gap in decision aids that are tailored to different cultural contexts, highlighting the need to expand the scope of their application. In addition, rigorous quality control is very important for randomised controlled trial, and indicators for assessing the effectiveness of decision aids need to be further clarified.

Quality indicators in intensive care medicine for Germany - fourth edition 2022

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

How to communicate with family members of the critically ill in the intensive care unit: A scoping review

OBJECTIVE

To map the existing approaches to communication with family members of the critically ill in the intensive care unit and the corresponding implementation requirements and benefits.

METHODS

We conducted a scoping review in February 2022 by searching PubMed, CINAHL, APA PsycINFO, and Cochrane Library for articles published between 2000 and 2022. We included records of all designs that met our inclusion criteria and applied frequency counts and qualitative coding.

RESULTS

The search yielded 3749 records, 63 met inclusion criteria. The included records were of an interventional (43 %) or observational (14 %) study design or review articles (43 %), and provided information in three categories: communication platforms, strategies, and tools. For implementation in the intensive care unit, the approaches required investing time and resources. Their reported benefits were an increased quality of communication and satisfaction among all parties involved, improved psychological outcome among family members, and reduced intensive care unit length of stay and costs.

CONCLUSION

The current approaches to communication with patients' family members offer insights for the development and implementation of communication pathways in the intensive care unit of which the benefits seem to outweigh the efforts. Structured interprofessional frameworks with standardised tools based on empathic communication strategies are encouraged.

Delphi-endorsed Communication Skills Clinicians Need to Care for Hospitalized Incapacitated Patients

Background

Objective

Methods

Results

Conclusion

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.

Physicians' perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

OBJECTIVE

The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians' admission decisions in situations of potentially non-beneficial intensive care.

DESIGN

This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis.

SETTING

Data were collected in a Swiss tertiary care centre between March and June 2013.

PARTICIPANTS

12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions.

RESULTS

Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients' long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician's expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need.

CONCLUSIONS

In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.

eStablish And Formalize Expert Criteria for Avoidable Resuscitation Review (SAFECARR) Electronic Delphi: Development of a Consensus Framework for Classifying and Reviewing Cardiac Arrests Within the PICU

OBJECTIVES

To develop a consensus framework that can guide the process of classifying and reviewing pediatric in-hospital cardiac arrest in the PICU.

DESIGN

A three-round electronic Delphi consensus study with an additional in-person session with pediatric resuscitation experts. The modified electronic Delphi consisted of survey questions sent to the expert panel with the goals of (1) achieving consensus on definitions of avoidable, potentially avoidable, and unavoidable PICU in-hospital cardiac arrest and (2) achieving consensus and ranking of a list of factors that contribute to potentially avoidable PICU in-hospital cardiac arrest.

SETTING

Electronic surveys of resuscitation experts including pediatric critical care, cardiac critical care, emergency medicine, and hospital medicine physicians, nurses, advance practice nurses, and resuscitation researchers.

PATIENTS

Not applicable.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Over three rounds of an electronic Delphi, 24 resuscitation experts participated. In Round 1, consensus was reached for the definitions of potentially avoidable and unavoidable cardiac arrest. Consensus was not reached for avoidable cardiac arrest. In Round 2, the expert panel agreed with seven factors from the literature and achieved consensus on an additional seven factors. Consensus was achieved on the modified definition of avoidable cardiac arrest. In Round 3, participants were asked to rank the contributing factors in order of their importance. For the in-person session, the consensus definitions and contributing factors from the modified electronic Delphi were presented to a multidisciplinary group of pediatric resuscitation experts and reached consensus for all three definitions.

CONCLUSIONS

A multidisciplinary group of pediatric resuscitation experts generated a consensus-based framework to classify and review pediatric in-hospital cardiac arrest in the PICU. Future work will focus on the application of this framework and further validation of these definitions and contributing factors for in-hospital cardiac arrest both within and outside the PICU.