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

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.

Psychological Issues of Patient Transition from Intensive Care to Palliative Care

End-of-life care in the intensive care unit is fraught with complicated psychological responses by patients, families, and staff. Empathic and mindful communication, inclusion of all integral staff in decision-making meetings, and multidimensional support of patients and families can ease the transition away from aggressive life-prolonging to comfort-oriented end of life care. Primary palliative care communication strategies can help clarify goals of care and facilitate transitions. Early integration of specialist palliative care is recommended.

Improving End-of-Life Care Prognostic Discussions

Research has validated the desire of patients and families for ongoing prognostic information; however, few conversations occur before patients reach the advanced stages of their disease trajectory. Physician hesitance and delay in discussing unfavorable prognoses deny patients and families optimal time to prepare for critical decision making. Advanced practice registered nurses can play a crucial, complementary role with the critical care interdisciplinary team to implement strategies to improve communication about prognosis and end of life with patients and families. Clinicians should discuss deterioration in disease-specific characteristics and changes (decline) in functional status. Functional status can serve as an accurate guide for forecasting prognosis, particularly in patients with heart failure, stroke, chronic lung disease, and end-stage renal disease. This article provides an overview of effective intensive care unit prognostic systems and discusses barriers and opportunities for nurses to use evidence-based knowledge related to disease trajectory and prognosis to improve communication and the quality of palliative and end-of-life care for patients.

Dying in the hospital: what happens and what matters, according to bereaved relatives

CONTEXT

Most deaths in Western countries occur in hospital, but little is known about factors determining the quality of dying (QOD).

OBJECTIVES

The aim was to assess the QOD in hospital as experienced by relatives and identify factors related to QOD.

METHODS

A cross-sectional study on 18 wards of a university hospital in The Netherlands was conducted, including relatives of patients who died after an admission of more than six hours, from June 2009 to March 2011. Relatives' perceptions of QOD and quality of care and the relation between dimensions of QOD and overall QOD scores were assessed.

RESULTS

Two hundred forty-nine relatives participated (51%) and rated overall QOD at 6.3 (SD 2.7; range 0-10). According to relatives, patients suffered from 7.0 (SD 5.8) of 22 symptoms and were at peace with imminent death in 37%. Patients had been aware of imminent death in 26%, and relatives were aware in 49%. Furthermore, 39% of patients and 50% of relatives had said good-bye, and 77% of patients died in the presence of a relative. Symptom alleviation was sufficient in 53%, and in 75%, sufficient efforts had been made to relieve symptoms. Characteristics of QOD and quality of care could be summarized in nine domains, explaining 34% of the variation of QOD scores. Medical, personalized, and supportive care were most strongly related to QOD.

CONCLUSION

Relatives rated QOD as sufficient. A majority of patients and relatives were not sufficiently prepared for imminent death, and relatives experienced many problems. QOD appears to be a multidimensional construct, strongly affected by medical care and staff attentiveness.

Prognostic categories and timing of negative prognostic communication from critical care physicians to family members at end-of-life in an intensive care unit

Negative prognostic communication is often delayed in intensive care units, which limits time for families to prepare for end-of-life. This descriptive study, informed by ethnographic methods, was focused on exploring critical care physician communication of negative prognoses to families and identifying timing influences. Prognostic communication of critical care physicians to nurses and family members was observed and physicians and family members were interviewed. Physician perception of prognostic certainty, based on an accumulation of empirical data, and the perceived need for decision-making, drove the timing of prognostic communication, rather than family needs. Although prognoses were initially identified using intuitive knowledge for patients in one of the six identified prognostic categories, utilizing decision-making to drive prognostic communication resulted in delayed prognostic communication to families until end-of-life (EOL) decisions could be justified with empirical data. Providers will better meet the needs of families who desire earlier prognostic information by separating prognostic communication from decision-making and communicating the possibility of a poor prognosis based on intuitive knowledge, while acknowledging the uncertainty inherent in prognostication. This sets the stage for later prognostic discussions focused on EOL decisions, including limiting or withdrawing treatment, which can be timed when empirical data substantiate intuitive prognoses. This allows additional time for families to anticipate and prepare for end-of-life decision-making.