The "big picture": communicating with families about end-of-life care in intensive care unit

Knowledge mobilization in critical care and the evolving communication role of nurses

BACKGROUND

The importance of appropriate communication skills within a health care setting rests upon the need for effective information sharing. When successful, this provides a supportive working environment for staff and has a positive impact on patient care and outcomes.

AIMS

The purpose of this study was to explore how knowledge/evidence is acquired, shared, and applied in the Critical Care (CC) environment for staff and patients/family members.

STUDY DESIGN

A qualitative approach was used, consisting of semi-structured interviews and focus groups. Data analysis was conducted using an iterative thematic approach.

RESULTS

Data collected prior to the COVID-19 pandemic from United Kingdom (UK) critical care workers (N = 46), patients, and family members (N = 21) identified four communication roles performed by the nursing staff: team member; diplomat; translator and friend.

CONCLUSIONS

It was evident that without suitable training and support, the stresses and demands placed upon the nurses could lead to disenfranchisement and burnout.

RELEVANCE TO CLINICAL PRACTICE

These findings are relevant and timely given the impact of the pandemic, highlighting the need for accessible and alternate communication strategies to support nurses by reducing stress, moral distress and increasing psychological safety. Improved communication can provide tailored information for staff and patients/family improving the CC experience for all.

Breaking bad news in medical services: a comprehensive systematic review

Objective

This study was performed with the aims of screening the previous studies on breaking bad news in all medical wards.

Methods

Eligible observational studies were selected. The quality of the studies was assessed using the STROBE checklist. The findings were reported using Garrard's table. All the stages of the present study were performed in terms of the PRISMA statement.

Results

Totally, 40 articles were included in the study and 96 items were extracted. The results show that breaking bad news is a recipient-centered process. Respect, empathy, and support were reported. The news presenters are better to use guidelines based on evidence-based findings. It is suggested that the presenter should use simple and understandable content. Moreover, suitable time and space are important to present the news. The results show the importance of paying enough attention to the emotions of the recipient and the need to provide support after breaking bad news.

Conclusion

The recipient must be the center of the programs. It is necessary to pay attention to the characteristics of the news presenter, the news content, and finally the support.Practice Implication: Understand the recipient, trained presenter, and use of the evidence-based results, improve the breaking bad news outcome.

End-of-Life Communication in the Emergency Department: The Emergency Physicians' Perspectives

Introduction:

End-of-life (EOL) conditions are commonly encountered by emergency physicians (EP). We aim to explore EPs’ experience and perspectives toward EOL discussions in acute settings.

Methods:

A qualitative survey was conducted among EPs in three tertiary institutions. Data on demographics, EOL knowledge, conflict management strategies, comfort level, and perceived barriers to EOL discussions were collected. Data analysis was performed using SPSS and SAS.

Results:

Of 63 respondents, 40 (63.5%) were male. Respondents comprised 22 senior residents/registrars, 9 associate consultants, 22 consultants, and 10 senior consultants. The median duration of emergency department practice was 8 (interquartile range: 6–10) years. A majority (79.3%) reported conducting EOL discussions daily to weekly, with most (90.5%) able to obtain general agreement with families and patients regarding goals of care. Top barriers were communications with family/clinicians, lack of understanding of palliative care, and lack of rapport with patients. 38 (60.3%) deferred discussions to other colleagues (e.g., intensivists), 10 (15.9%) involved more family members, and 13 (20.6%) employed a combination of approaches. Physician's comfort level in discussing EOL issues also differed with physician seniority and patient type. There was a positive correlation between the mean general comfort level when discussing EOL and the seniority of the EPs up till consultancy. However, the comfort level dropped among senior consultants as compared to consultants. EPs were most comfortable discussing EOL of patients with a known terminal illness and least comfortable in cases of sudden death.

Conclusions:

Formal training and standardized framework would be useful to enhance the competency of EPs in conducting EOL discussions.

Clinicians' accounts of communication with patients in end-of-life care contexts: A systematic review

OBJECTIVE

Communication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians' understandings of communication in end-of-life care.

METHODS

A systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms "palliative care," "terminal care" or "end-of-life care," and "communication". Articles were assessed for quality using a modified JQI-QARI tool.

RESULTS

The findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication.

CONCLUSION

Training needs for effective communication in end-of-life contexts are not currently being met.

PRACTICE IMPLICATIONS

Clinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.

Nurses' Communication With the Families of Patients at the End-of-Life

BACKGROUND

Effective communication is important in providing quality care to families at the end-of-life. In the end-of-life situations, the nurses' views on how to communicate with the family are not well understood.

AIM

This study was conducted to explore the nurses' experiences of their communication with families of patients at the end-of-life situations.

METHODS

The authors used standards for reporting qualitative research. The data were analyzed by conventional content analysis. Semi-structured interviews were conducted with 24 Iranian nurses who had the experiences of dealing with patients' families at the end-of-life.

RESULTS

Nurses' perceptions of communication with families emerged base on the main theme: "Disrupted communication" consisting of two categories: "restricted communication" and "abortive communication."

CONCLUSION

The results of this study highlight the need to increase the professional and ethical sensitivity of nurses in dealing with patients' families at the end-of-life.

Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

Background

While a palliative approach is generally perceived to be an integral part of the intensive care unit (ICU), the provision of palliative care in this setting is challenging. This review aims to identify factors (barriers and facilitators) influencing a palliative approach in intensive care settings, as perceived by health care professionals.

Method

A systematic mixed-methods review was conducted. Multiple electronic databases were used, and the following search terms were utilized: implementation, palliative care, and intensive care unit. In total, 1843 articles were screened, of which 24 met the research inclusion/exclusion criteria. A thematic synthesis method was used for both qualitative and quantitative studies.

Results

Four key prerequisite factors were identified: (a) organizational structure in facilitating policies, unappropriated resources, multi-disciplinary team involvement, and knowledge and skills; (b) work environment, including physical and psychosocial factors; (c) interpersonal factors/barriers, including family and patients’ involvement in communication and participation; and (d) decision-making, e.g., decision and transition, goal conflict, multidisciplinary team communication, and prognostication.

Conclusion

Factors hindering the integration of a palliative approach in an intensive care context constitute a complex interplay among organizational structure, the care environment and clinicians’ perceptions and attitudes. While patient and family involvement was identified as an important facilitator of palliative care, it was also recognized as a barrier for clinicians due to challenges in shared goal setting and communication.

Thinking about strengths in end-of-life nursing practice: the case of intensive care unit nurses

BACKGROUND

The intensive care unit (ICU) is a care context that is sometimes described as being unconducive to the values and ideals of a good death in end-of-life care. Such assumptions render the ICU emblematic of a troubling discourse about end-of-life care in this clinical context.

AIM

To stimulate a reflective examination of intensive care nursing practice with respect to end-of-life care.

METHODS

The work of contemporary nursing scholar Laurie Gottlieb is used to perform a strengths-based relational ethical examination of previously published literature that describes critical care nurses' experiences of providing end-of-life care in the ICU.

FINDINGS

This literature suggests that the relational ethical value of authentic engagement, which is fundamental to the disciplinary ethos of expert palliative care nursing, is reflected in the everyday practice of intensive care nurses whose patients die while under their care.

CONCLUSION

A strengths-based approach can make visible the relational ethical practice of critical care nurses who care for dying patients and their families in the ICU.

Impact of death education courses on emergency nurses' perception of effective behavioral responses in dealing with sudden death in China: A quasi-experimental study

BACKGROUND

Nurses in emergency departments have to provide rescue care and life support for moribund patients, but also emotional support to patients' relatives. On the other hand, emergency nurses are also the most vulnerable to the sudden death of patients. Nurses working in the emergency department were invited to participate in a death education course.

OBJECTIVE

To explore the impact of a death education course on the emergency nurses' perception of effective behavioral responses in dealing with sudden death.

DESIGN

A quasi-experimental study.

SETTINGS

A level A tertiary general hospital in China.

PARTICIPANTS

A total number of 34 emergency nurses who met the inclusion criteria were randomly selected from the emergency department.

METHODS

Participants received a death education course of 20 credit hours based on dealing with a sudden-death model. The general data questionnaire and the Chinese version of the list proposed by Fraser & Atkins were completed before the intervention and six weeks post-intervention. The scores of each item in the effective behavioral response to the sudden death questionnaire of the emergency nurses before and after the intervention were compared.

RESULTS

After the intervention, the nurses considered that 10 items were relatively helpful (above 4 points) and 2 items relatively less helpful (<3 points). The post-intervention average scores of all items were higher than the pre-intervention ones, and there were significant differences in the scores of the 13 items pre- and post-intervention.

CONCLUSION

The death education course enhanced emergency nurses' perceptions of effective behavioral responses in dealing with sudden death, which contributes to the improvement of the quality of their work.

Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence

BACKGROUND

Effective communication between healthcare professionals and relatives of patients approaching the end-of-life is vital to ensure patients have a 'good death'. To improve communication, it is important to first identify how this is currently being accomplished.

AIM

To review qualitative evidence concerning characteristics of communication about prognosis and end-of-life care between healthcare professionals and relatives of patients approaching the end-of-life.

DESIGN

Qualitative systematic review (PROSPERO registration CRD42017065560) using thematic synthesis. Peer-reviewed, English language articles exploring the content of conversations and how participants communicated were included. No date restrictions were applied. Quality of included studies was appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research.

DATA SOURCES

An electronic database search of CINAHL, MEDLINE, PsycINFO and EMBASE was performed.

RESULTS

Thirty-one papers were included. Seven themes were identified: highlighting deterioration; involvement in decision-making, post-decision interactional work, tailoring, honesty and clarity, specific techniques for information delivery and roles of different healthcare professionals. Varied levels of family involvement in decision-making were reported. Healthcare professionals used strategies to aid understanding and collaborative decision-making, such as highlighting the patient's deterioration, referring to patient wishes and tailoring information delivery. Doctors were regarded as responsible for discussing prognosis and decision-making, and nurses for providing individualized care.

CONCLUSION

Findings suggest training could provide healthcare professionals with these strategies to improve communication. Interventions such as question prompt lists could help relatives overcome barriers to involvement in decision-making. Further research is needed to understand communication with relatives in different settings and with different healthcare professionals.

Lasting Legacy: Maternal Perspectives of Perinatal Palliative Care

BACKGROUND

Many of the leading causes of infant mortality are diagnosed prenatally, presenting providers with the ability to present perinatal palliative care planning as an option.

OBJECTIVE

Our study adds to the literature both by describing infant interaction with the health care system and by gaining deeper understanding of the maternal experience after being offered perinatal palliative care.

METHODS

The study was conducted at a public university-based medical center in the Midwest. Phase 1 consisted of a retrospective review of electronic medical records of 27 mother-infant pairs offered perinatal palliative care, 18 of whom elected to develop a perinatal palliative care. Phase 2 consisted of a focus group and interviews of seven of the mothers.

RESULTS

In the initial phase of this study, results revealed differences regarding the infant's end-of-life trajectory, including location of death, number of invasive procedures, and death in the setting of withholding versus withdrawing life-sustaining treatment. Highlighting that without a perinatal palliative care plan in place, the default treatment for infants with prenatally diagnosed life-limiting conditions is likely to be invasive and painful with often times minimal likelihood of long-term survival. Analysis of interview and focus group data revealed three themes: care, choice, and legacy.

CONCLUSION

The authors used their experience with the health care system to draw implications for practice from the focus group and interview data, which care can serve to promote women feeling cared for and cared about, as well as promote opportunities for hope during a fragile pregnancy.

What is palliative care? Perceptions of healthcare professionals

Background

Despite increased attention and knowledge in palliative care, there is still confusion concerning how to interpret the concept of palliative care and implement it in practice. This can result in difficulties for healthcare professionals in identifying patients whom would benefit from palliative care, which, in turn, could lead to a delay in meeting patients’ needs.

Aim

To explore healthcare professionals’ perceptions of palliative care.

Method

Data were collected through twelve interprofessional focus group interviews in community care and hospital wards in south Sweden (n = 74). All interviews were analysed with latent content analysis.

Results

Three domains were revealed: first, a blurred conceptual understanding as participants described palliative care using synonyms, diagnoses, phases, natural care and holism; second, a challenge to communicate transitions concerned the importance of how and when the transition to palliative care was communicated and documented; finally, a need for interprofessional collaboration was described as well as the consequences for severely ill persons, relatives and healthcare professionals when it was not established.

Conclusion

The perceptions about how to interpret palliative care differed as well as when palliative care should be offered and decided, which might have practical consequences. How long a person has left to live is of great significance for decision‐making, caregiving and preparation in palliative care. The challenge is to use interprofessional communication to promote understanding and collaborate across varied care levels. Integrating palliative care across diverse care levels could be one way to reduce the ambiguity of palliative care.

The role of the nurse at the end of the life of a critically ill patient

OBJECTIVE

Analyze the role of the nurse at the end of the life of a critically ill patient.

METHOD

Bibliographic review from a search of the health science databases such as PubMed, CINAHL, Cuiden, Scopus, Cochrane, as well as specialized platforms, general and thematic browsers. The limits were language (English or Spanish) and publication date (2005-2015).

RESULTS

180 articles met the inclusion criteria, and 16 of them were selected for analysis. The main results were grouped into three categories of analysis: direct patient care, family-focussed care and the nurse's role within the team.

CONCLUSIONS

the described roles place the nurse as a key element in humanising death in the ICU and so nurses can and must lead change, playing an active role in creating strategies that really promote the integration of a palliative care approach in ICU.

Implementation of a Nurse-Led Family Meeting in a Neuroscience Intensive Care Unit

PURPOSE/OBJECTIVES

The aims of this study were to develop, implement, and evaluate the impact of early intensive care unit (ICU) nurse-led family meetings on nurse-family communication, family decision making, and satisfaction of family members.

BACKGROUND

Intensive care unit nurses are in an ideal position to meet family needs, and family members may cope better with the crisis of an ICU admission if consistent honest information is provided by nurses; however, there are no early ICU family meetings led by bedside nurses.

METHODS

This quality improvement project was implemented in a 10-bed neuroscience ICU over a 3-month period. A convenience sample of 23 nurses participated in the project. Following development of a communication protocol to facilitate nurse-led meetings, the nurses received education and then implemented the protocol. Thirty-one family members participated in the project. Family members were surveyed before and after the meetings.

RESULTS

Mean meeting time was 26 (SD, 14) minutes. Following implementation of the meetings, findings demonstrated that families felt that communication improved (P = .02 and P = .008), they had appropriate information for decision making allowing them to feel in control (P = .002), and there was an increase in family satisfaction (P = .001).

CONCLUSION

Early ICU nurse-led family meetings were feasible, improved communication between ICU nurses and family members, facilitated decision making in ICU families, and increased satisfaction of family members.

Oncology nurses' perceptions of obstacles and role at the end-of-life care: cross sectional survey

Background

Major obstacles exist in the care of patients at the end of life: lack of time, poor or inadequate communication, and lack of knowledge in providing care. Three possible nursing roles in care decision-making were investigated: Information Broker, Supporter, and Advocate. The purpose of this study was to examine obstacles faced by oncology nurses in providing end-of-life (EOL) care and to examine roles of nurses in providing care.

Methods

A descriptive, cross-sectional, correlational design was applied. The study was conducted at two major University Hospitals of Oncology in Lithuania that have a combined total of 2365 beds. The study sample consisted of 239 oncology registered nurses. Data collection tool included a questionnaire about assessment of obstacles and supportive behaviors, nursing roles, and socio-demographic characteristics.

Results

The two items perceived by respondents as the most intense obstacles to providing EOL care were The nurse’s opinion on immediate patient care is not welcome, valued or discussed and.

Family has no access to psychological help after being informed about the patient’s diagnosis. The majority of respondents self-assigned the role of Supporter.

Conclusions

Major obstacles in providing care included the nurse’s opinion that immediate patient care was not valued, lack of nursing knowledge on how to treat the patient’s grieving family, and physicians who avoided conversations with the patient and family members about diagnoses and prospects. In EOL care nurses most frequently acted as Supporters and less frequently as Advocates.

Nurses’ moral experiences of assisted death: A meta-synthesis of qualitative research

Background:

Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses’ experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses’ experiences of caring for people who request this option.

Aim:

To synthesize what has been learned about nurses’ experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.

Design:

Qualitative meta-synthesis.

Methods:

Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.

Results:

The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.

Discussion:

The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses’ moral agency that operate in everyday end-of-life care.

Ethical considerations:

Research ethics board approval was not required for this synthesis of previously published literature.

Conclusion:

In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.

A preliminary evaluation of trust and shared decision making among intensive care patients' family members

PURPOSE

The purpose of this study was to preliminarily evaluate ICU family members' trust and shared decision making using modified versions of the Wake Forest Trust Survey and the Shared Decision Making-9 Survey.

METHODS

Using a descriptive approach, the perceptions of family members of ICU patients (n=69) of trust and shared decision making were measured using the Wake Forest Trust Survey and the 9-item Shared Decision Making (SDM-9) Questionnaire. Both surveys were modified slightly to apply to family members of ICU patients and to include perceptions of nurses as well as physicians.

RESULTS

Overall, family members reported high levels of trust and inclusion in decision making. Family members who lived with the patient had higher levels of trust than those who did not. Family members who reported strong agreement among other family about treatment decisions had higher levels of trust and higher SDM-9 scores than those who reported less family agreement.

CONCLUSION

The modified surveys may be useful in evaluating family members' trust and shared decision making in ICU settings. Future studies should include development of a comprehensive patient-centered care framework that focuses on its central goal of maintaining provider-patient/family partnerships as an avenue toward effective shared decision making.

Dying Care Interventions in the Intensive Care Unit

PURPOSE

Providing high-quality end-of-life care is a challenging area in intensive care practice. The aim of the current study was to assess the practice of registered nurses (RNs) with respect to dying care and spiritual support interventions in intensive care units (ICUs) in the Czech Republic (CR) and find correlations between particular factors or conditions and the frequency of NIC interventions usage.

DESIGN AND METHODS

A cross-sectional, descriptive study was designed. A questionnaire with Likert scales included the particular activities of dying care and spiritual support interventions and an evaluation of the factors influencing the implementation of the interventions in the ICU. The group of respondents consisted of 277 RNs working in 29 ICUs in four CR regions. The Mann-Whitney U test and Pearson correlation coefficient were used for statistical evaluation.

FINDINGS

The most and least frequently reported RN activities were "treat individuals with dignity and respect" and "facilitate discussion of funeral arrangements," respectively. The frequencies of the activities in the biological, social, psychological, and spiritual dimensions were negatively correlated with the frequency of providing care to dying patients. A larger number of activities were related to longer lengths of stay in the ICU, higher staffing, more positive opinions of the RNs regarding the importance of education in a palliative care setting, and attending a palliative care education course.

CONCLUSIONS

The psychosocial and spiritual activities in the care of dying patients are used infrequently by RNs in CR ICUs. The factors limiting the implementation of palliative care interventions and strategies improving implementation warrant further study.

CLINICAL RELEVANCE

Assessment of nursing activities implemented in the care of dying patients in the ICU may help identify issues specific to nursing practice.

Palliative and end-of-life care in pediatric solid organ transplantation

End-of-life care is a component of palliative care and takes a holistic, individualized approach to patients, focusing on the assessment of quality of life and its maintenance until the end of life, and beyond, for the patient's family. Transplant teams do not always make timely referrals to palliative care teams due to various clinician and perceived family barriers, an important one being the simultaneous, active care plan each patient would have alongside an end-of-life plan. Application of findings and further research specific to the pediatric solid organ population would be of significant benefit to guide transplant teams as to the most effective time to introduce end-of-life care, who to involve in ongoing discussions, and important ethical and cultural considerations to include in care planning. Attention must also be paid to clinician training and support in this challenging area of health care.

Innovative solutions: the C.O.R.E. to sociocultural care in nursing

Terminal weaning of patients follows a standardized medical care protocol. However, the evidence found for optimal terminal weaning protocols may lack individualization for the patient and family. As nursing students in the critical care unit, we have designed a conceptual model that bridges the gap between cultural diversity and terminal weaning. This conceptual model integrates comfort, organization, rituals, and environment into the process of terminal weaning. The model assists nurses in all specialties, particularly critical care, to provide culturally appropriate end-of-life care for the patient and their family.

Communication by nurses in the intensive care unit: qualitative analysis of domains of patient-centered care

BACKGROUND

High-quality communication is a key determinant and facilitator of patient-centered care. Nurses engage in most of the communication with patients and patients' families in the intensive care unit.

OBJECTIVE

To perform a qualitative analysis of nurses' communications.

METHODS

Ethnographic observations of 315 hours of interactions and 53 semistructured interviews with 33 nurses were conducted in a 26-bed cardiac-medical intensive care unit in an academic hospital and a 26-bed general intensive care unit in a Veterans Affairs hospital in Portland, Oregon. Communication interactions were categorized into 5 domains of patient-centered care. Interviews were analyzed to identify major themes in nurses' roles and preferences for communicating with patients and patients' families within the domains.

RESULTS

Most communication occurred in the domains of biopsychosocial information exchange, patient as person, and clinician as person. Nurses endorsed the importance of the domains of shared power and responsibility and therapeutic alliance but had relatively few communication interactions in these areas. Communication behaviors were strongly influenced by the nurses' roles as translators of information between physicians and patients and the patients' families and what the nurses were and were not willing to communicate to patients and patients' families.

CONCLUSIONS

Critical care, including communication, is a collaborative effort. Understanding how nurses engage in patient-centered communication in the intensive care unit can guide future interventions to improve patient-centered care.

A model for emergency department end-of-life communications after acute devastating events--part II: moving from resuscitative to end-of-life or palliative treatment

The model for emergency department (ED) end-of-life communications after acute devastating events addresses decision-making capacity, surrogates, and advance directives, including legal definitions and application of these steps. Part II concerns communications moving from resuscitative to palliative and end-of-life treatments. After completing the steps involved in determining decision-making, emergency physicians (EPs) should consider starting palliative measures versus continuing resuscitative treatment. As communications related to these end-of-life decisions increasingly fall within the scope of emergency medicine (EM) practice, we need to become educated about and comfortable with them.

Intensive care nurses’ involvement in the end-of-life process – perspectives of relatives

In this article, we report findings from a qualitative study that explored how the relatives of intensive care unit patients experienced the nurses’ role and relationship with them in the end-of-life decision-making processes. In all, 27 relatives of 21 deceased patients were interviewed about their experiences in this challenging ethical issue. The findings reveal that despite bedside experiences of care, compassion and comfort, the nurses were perceived as vague and evasive in their communication, and the relatives missed a long-term perspective in the dialogue. Few experienced that nurses participated in meetings with doctors and relatives. The ethical consequences imply increased loneliness and uncertainty, and the experience that the relatives themselves have the responsibility of obtaining information and understanding their role in the decision-making process. The relatives therefore felt that the nurses could have been more involved in the process.

Prognostic communication of critical care nurses and physicians at end of life

Many critical care nurses express reluctance to communicate prognostic information to patients and family members, especially prior to physician communication of this information. Yet, the findings from this study indicate that critical care nurses play a crucial, complementary role to physicians in prognostic communication. Nurses' contributions result in a broader picture of prognosis to patients and family members and facilitate end-of-life discussions.

Training nurses for interdisciplinary communication with families in the intensive care unit: an intervention

BACKGROUND

Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses.

METHODS

We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. A "learner centered" approach to skills training that has several integral components was employed. AMONG THESE ARE: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered. Before and after the program we conducted a detailed assessment of participants' self-rated communication skills and of the techniques and materials we used.

RESULTS AND CONCLUSIONS

Post-program responses documented significant improvement in self-evaluated skills for each of the core tasks we assessed. Evidence suggests that communication with patients and families in the ICU can be most effectively approached in an interdisciplinary way. For nurses to fully realize their potential for optimal communication as members of the multidisciplinary team, they must be equipped with the necessary skills. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.

Nursing Roles and Strategies in End-of-Life Decision Making in Acute Care: A Systematic Review of the Literature

The objective of this paper is to analyze the literature concerning nurses' roles and strategies in EOL decision making in acute care environments, synthesize the findings, and identify implications for future research. We conducted searches in CINAHL and PubMed, using a broad range of terms. The 44 articles retained for review had quantitative and qualitative designs and represented ten countries. These articles were entered into a matrix to facilitate examining patterns, themes, and relationships across studies. Three nursing roles emerged from the synthesis of the literature: information broker, supporter, and advocate, each with a set of strategies nurses use to enact the roles. Empirical evidence linking these nursing roles and strategies to patients and family members outcomes is lacking. Understanding how these strategies and activities are effective in helping patients and families make EOL decisions is an area for future research.

Conversations in end-of-life care: communication tools for critical care practitioners

BACKGROUND

Communication skills are the key for quality end-of-life care including in the critical care setting. While learning general, transferable communication skills, such as therapeutic listening, has been common in nursing education, learning specific communication tools, such as breaking bad news, has been the norm for medical education. Critical care nurses may also benefit from learning communication tools that are more specific to end-of-life care.

STRATEGY

We conducted a 90-min interactive workshop at a national conference for a group of 78 experienced critical care nurses where we presented three communication tools using short didactics. We utilized theatre style and paired role play simulation. The Ask-Tell-Ask, Tell Me More and Situation-Background-Assessment-Recommendation (SBAR) tools were demonstrated or practiced using a case of a family member who feels that treatment is being withdrawn prematurely for the patient. The audience actively participated in debriefing the role play to maximize learning. The final communication tool, SBAR, was practiced using an approach of pairing with another member of the audience. At the end of the session, a brief evaluation was completed by 59 nurses (80%) of the audience.

SUMMARY

These communication tools offer nurses new strategies for approaching potentially difficult and emotionally charged conversations. A case example illustrated strategies for applying these skills to clinical situations. The three tools assist critical care nurses to move beyond compassionate listening to knowing what to say. Ask-Tell-Ask reminds nurses to carefully assess concerns before imparting information. Tell Me More provides a tool for encouraging dialogue in challenging situations. Finally, SBAR can assist nurses to distill complex and often long conversations into concise and informative reports for colleagues.

Assessing Challenges in End-of-Life Conversations With Elderly Patients With Multiple Morbidities

Introduction: This study reports on physicians' experiences in conducting end-of-life conversations with elderly patients who suffered from multiple co-morbidities (MCM). Our hypothesis was that both the lack of prognostic certainty and the lack of good communication tools contributed to physicians' discomfort with conducting EOL conversations with patients and families of patients with these conditions especially when compared with patients and families of patients who had a single, clear terminal diagnosis (e.g. pancreatic cancer). Methods: Focus group questions were semi-structured and explored three general themes: (1) differences between having an end-of-life conversation with patients/families with MCM versus those with a single, terminal diagnosis; (2) timing of the end-of-life conversation; and (3) approaches to the end-of-life conversation. Results: Three themes emerged: (1) It is more difficult for them to have EOL conversations with patients with MCM and their families, as opposed to conversations with families and patients who have a clear, terminal diagnosis. (2) In deciding when to raise the subject of EOL care, participants reported that they rely on a number of physical and/or social signs to prompt these discussions. Yet a major reason for the difficulty that providers face in initiating these discussions with MCM patients and families is that there is a lack of a clear threshold or prompting event. (3) Participants mentioned three types of approaches to initiating EOL conversations: (a) direct approach, (b) indirect approach, (c) collaborative approach. Conclusion: Prognostic indicies and communication scripts may better prepare physicians to facilitate end-of-life conversations with MCM patients/families.

[The end of life in the intensive care unit from the nursing perspective: a phenomenological study]

INTRODUCTION

Intensive Care Units do not adapt to the social and health reality regarding the phenomenon of death and this results in a high degree of dissatisfaction among professional, relatives and patients. The special characteristics of these units give the nursing staff a main roll as carers of critical dying patients. The principal aim of this study is to know the nursing staffs' experiences and attitudes towards the phenomenon of death in the intensive care units.

PARTICIPANTS AND METHOD

A descriptive qualitative study of phenomenological character was performed. Constant comparison and progressive incorporation of participants was made, using intentional sampling up to data saturation (n=16). The data collection technique used was a semi-structured in-depth interview, which were recorded and literally transcribed. The data collected was verified by the informants and analyzed according to the steps proposed by Taylor-Bogdan.

RESULTS

The analysis shows 5 thematic categories: death and beliefs, emotional work, environmental factors, decision-making management of death in intensive care units and relationships with relatives.

CONCLUSIONS

The management model of death in intensive care units focuses on medical intervention and overlooks the opinions of the nurses, relatives and patients. This study shows the contributions that can be provided by the nursing staff in decision making and in the care of the dying patients in these wards.

Institutional geographies in dying: nurses' actions and observations on dying spaces inside and outside intensive care units

This paper articulates the geographies associated with intensive care nursing work with dying patients and their families. Six focus groups were conducted with 27 registered critical care nurses who practice in hospitals in a mid-western city in the United States. The analysis is structured by three emerging themes (i) the importance of a 'good' and 'sacred' place, (ii) the body as mapped by medical specialties, and (iii) problems with procedurally driven suspension of 'do not resuscitate' orders beyond intensive care units (ICUs). Recommendations describe the need for institutional recognition of the moral importance of strong relationships between nurses, clients, and their families, and nurses' wide-ranging roles in bridging the various spatial domains of intensive care.