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Choi HR, Ho MH, Lin CC. Futile life-sustaining treatment in the intensive care unit - nurse and physician experiences: meta-synthesis. BMJ Support Palliat Care 2024; 14:36-46. [PMID: 38050047 DOI: 10.1136/spcare-2023-004640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/19/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Continuing futile life-sustaining treatment prolongs patients' suffering and family members' and medical staff's psychological distress. Additionally, continuing futile treatment is inefficient in healthcare resource distribution. Although the withdrawal of futile life-sustaining treatment is ideal, the prevalence is variable. OBJECTIVE To synthesise nurses' and physicians' experiences with continuing futile life-sustaining treatment in the intensive care unit. DESIGN This meta-synthesis was conducted following the thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing transparency in reporting the synthesis of qualitative research statement were used in reporting the synthesis of qualitative research statements. METHODS AND DATA SOURCES A systematic search was conducted following the inclusion and exclusion criteria in APA PsycINFO, CINAHL Plus, EMBASE, MEDLINE, PubMed and Web of Science in May 2023. Two reviewers independently screened and extracted the data. The extracted data were analysed using thematic analysis of qualitative research. FINDINGS A total of 16 studies were finally included, and 141 quotes were extracted and analysed. The main findings were categorised into four themes: (1) contextual and cultural diversity, (2) perceptions of futile treatment, (3) professional roles and responsibilities, and (4) emotional distress. CONCLUSION The study highlights the influence of culture, religion and family members, as well as perceptions of futile treatment among clinicians, on continuing futile life-sustaining treatment. Also, nurses' awareness of their roles and responsibilities in ensuring patients' comfort at end of life was revealed. This study informs future research to explore the experiences of futile life-sustaining treatment across various contexts.
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Affiliation(s)
- Hye Ri Choi
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
| | - Mu-Hsing Ho
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
| | - Chia-Chin Lin
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
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Garg A, Soto AL, Knies AK, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data. Neurocrit Care 2021; 35:468-479. [PMID: 33619667 PMCID: PMC8380750 DOI: 10.1007/s12028-021-01200-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with a severe acute brain injury admitted to the intensive care unit often have a poor neurological prognosis. In these situations, a clinician is responsible for conducting a goals-of-care conversation with the patient's surrogate decision makers. The diversity in thought and background of surrogate decision makers can present challenges during these conversations. For this reason, our study aimed to identify predictive characteristics of US surrogate decision makers' favoring life-sustaining treatment (LST) over comfort measures only for patients with severe acute brain injury. METHODS We analyzed data from a cross-sectional survey study that had recruited 1588 subjects from an online probability-based US population sample. Seven hundred and ninety-two subjects had randomly received a hypothetical scenario regarding a relative intubated with severe acute brain injury with a prognosis of severe disability but with the potential to regain some consciousness. Seven hundred and ninety-six subjects had been randomized to a similar scenario in which the relative was projected to remain vegetative. For each scenario, we conducted univariate analyses and binary logistic regressions to determine predictors of LST selection among available respondent characteristics. RESULTS 15.0% of subjects selected LST for the severe disability scenario compared to 11.4% for the vegetative state scenario (p = 0.07), with those selecting LST in both groups expressing less decisional certainty. For the severe disability scenario, independent predictors of LST included having less than a high school education (adjusted OR = 2.87, 95% CI = 1.23-6.76), concern regarding prognostic accuracy (7.64, 3.61-16.15), and concern regarding the cost of care (4.07, 1.80-9.18). For the vegetative scenario, predictors included the youngest age group (30-44 years, 3.33, 1.02-10.86), male gender (3.26, 1.75-6.06), English as a second language (2.94, 1.09-7.89), Evangelical Protestant (3.72, 1.28-10.84) and Catholic (4.01, 1.72-9.36) affiliations, and low income (< $25 K). CONCLUSION Several demographic and decisional characteristics of US surrogate decision makers predict LST selection for patients with severe brain injury with varying degrees of poor prognosis. Surrogates concerned about the cost of medical care may nevertheless be inclined to select LST, albeit with high levels of decisional uncertainty, for patients projected to have severe disabilities.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
| | - Andrea K Knies
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
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Lin CY, Lee YC. Choosing and Doing wisely: triage level I resuscitation a possible new field for starting palliative care and avoiding low-value care - a nationwide matched-pair retrospective cohort study in Taiwan. BMC Palliat Care 2020; 19:87. [PMID: 32563245 PMCID: PMC7305586 DOI: 10.1186/s12904-020-00590-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/09/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The association between palliative care and life-sustaining treatment following emergency department (ED) resuscitation is unclear. This study aims to analyze the usage of palliative care and life-sustaining treatments among ED triage level I resuscitation patients based on a nationally representative sample of patients in Taiwan. METHODS A matched-pair retrospective cohort study was conducted to examine the association between palliative care and outcome variables using multivariate logistic regression and Kaplan-Meier survival analyses. Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services (palliative care group) under a universal health insurance scheme. Retrospective cohort matching was performed with those who received standard care at a ratio of 1:4 (usual care group). Outcome variables included the number of visits to emergency and outpatient departments, hospitalization duration, total medical expenses, utilization of life-sustaining treatments, and duration of survival following ED triage level I resuscitation. RESULTS The mean survival duration following level I resuscitation was less than 1 year. Palliative care was administered to 15% of the resuscitation cohort. The palliative care group received significantly less life-sustaining treatment than did the usual care group. CONCLUSION Among patients who underwent level I resuscitation, palliative care was inversely correlated with the scope of life-sustaining treatments. Furthermore, triage level I resuscitation status may present a possible new field for starting palliative care intervention and reducing low-value care.
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Affiliation(s)
- Chih-Yuan Lin
- Department of Neurology, Taipei City Hospital, Taipei, Taiwan
- Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health, Taipei, Taiwan
| | - Yue-Chune Lee
- Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Master Program on Trans-disciplinary Long-Term Care and Management, National Yang-Ming University, Taipei, Taiwan
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Chen YC, Loh EW, Huang TW. Humanity behind the intention of primary caregiver to choose withdrawing life-sustaining treatment for terminating patients. PATIENT EDUCATION AND COUNSELING 2020; 103:S0738-3991(20)30329-3. [PMID: 32561315 DOI: 10.1016/j.pec.2020.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Mechanical ventilation, a measure of life-sustaining treatment (LST), may not be helpful and can be devastating for patients with terminal illness. We explored the effects of demographic characteristics, attitude, subjective norms, and perceived behavioral control on the behavioral intentions of primary caregivers to withdraw LST of long-term ventilator-dependent patients. METHODS Primary caregivers of ventilator-dependent patients in the respiratory care units of six hospitals participated in the study. A cross-sectional design including the domains of attitude, subjective norms, perceived behavioral control, and behavioral intention was adopted. RESULTS Valid data for 99 participants were analyzed using logistic regression. Religious belief, a spousal relationship with the patient, item 5 in subjective norms, and item 5 in perceived behavioral control positively influenced the intention to withdraw patient LST. CONCLUSIONS Religious beliefs, a spousal relationship, perceived behavioral control (confidence in relieving patient suffering), and the opportunity of current favorable subjective norms are major determinants of the intention to withdraw patients' LST. PRACTICE IMPLICATIONS Shared decision-making with the kin and primary caregivers of long-term ventilator-dependent patients at the end of life is crucial.
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Affiliation(s)
- Ya-Chin Chen
- Department of Nursing, Yuanlin Christian Hospital, Changhua, Taiwan.
| | - El-Wui Loh
- Center for Evidence-Based Health Care, Department of Medical Research, Taipei Medical University Shuang Ho Hospital, Zhonghe District, New Taipei City, Taiwan; Shared Decision Making Resource Center, Department of Medical Research, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
| | - Tsai-Wei Huang
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.
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Hwang DY, Knies AK, Mampre D, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L. Concerns of surrogate decision makers for patients with acute brain injury: A US population survey. Neurology 2020; 94:e2054-e2068. [PMID: 32341190 PMCID: PMC7282883 DOI: 10.1212/wnl.0000000000009406] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether groups of surrogates for patients with severe acute brain injury (SABI) with poor prognosis can be identified based on their prioritization of goals-of-care (GOC) decisional concerns, an online survey of 1,588 adults recruited via a probability-based panel representative of the US population was conducted. METHODS Participants acted as a surrogate for a GOC decision for a hypothetical patient with SABI and were randomized to 1 of 2 prognostic scenarios: the patient likely being left with a range of severe functional disability (SD) or remaining in a vegetative state (VS). Participants prioritized a list of 12 decisional concerns via best-worst scaling. Latent class analysis (LCA) was used to discover decisional groups. RESULTS The completion rate was 44.6%; data weighting was conducted to mitigate nonresponse bias. For 792 SD respondents, LCA revealed 4 groups. All groups shared concerns regarding respecting patient wishes and minimizing suffering. The 4 groups were otherwise distinguished by unique concerns that their members highlighted: an older adult remaining severely disabled (34.4%), family consensus (26.4%), doubt regarding prognostic accuracy (20.7%), and cost of long-term care (18.6%). For the 796 VS respondents, LCA revealed 5 groups. Four of the 5 groups had similar concern profiles to the 4 SD groups. The largest (29.0%) expressed the most prognostic doubt. An additional group (15.8%) prioritized religious concerns. CONCLUSIONS Although surrogate decision makers for patients with SABI are concerned with respecting patient wishes and minimizing suffering, certain groups highly prioritize other specific decisional factors. These data can help inform future interventions for supporting decision makers.
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Affiliation(s)
- David Y Hwang
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT.
| | - Andrea K Knies
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - David Mampre
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Stanislav Kolenikov
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Marci Schalk
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Heather Hammer
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Douglas B White
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Robert G Holloway
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Kevin N Sheth
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Liana Fraenkel
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
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Maura Y, Yamamoto M, Tamaki T, Odachi R, Ito M, Kitamura Y, Sobue T. Experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life. Int J Qual Stud Health Well-being 2019; 14:1632110. [PMID: 31213147 PMCID: PMC6586137 DOI: 10.1080/17482631.2019.1632110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2019] [Indexed: 11/14/2022] Open
Abstract
Purpose: This study aimed to clarify the experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life. Methods: A semi-structured interview was performed for four family caregivers who wanted to refuse life-prolonging treatment suggested by the physicians. Results: In this study, four caregivers who refused life-prolonging treatment suggested by the physicians for their elderly parents completed semi-structured interviews. The obtained data were analyzed in relation to the theme "Experiences of caregivers who desire to refuse life-prolonging treatment for their elderly parents at the end of life." As a result, 38 subcategories and 12 categories were extracted. Conclusions: Participants in this study initially had a negative view of life-prolonging treatment. However, they agonized over the decision when they received conflicting advice from the physicians. The participants indicated that physicians' advice and attitudes complicated their decisions to reject life-prolonging treatment for their elderly parents.
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Affiliation(s)
- Yuki Maura
- Department of Nursing, Faculty of Nursing and Rehabilitation, Konan Women’s University, Kobe, Hyogo, Japan
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Mariko Yamamoto
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Tomoko Tamaki
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Nursing, School of Nursing, Mukogawa Women’s University, Nishinomiya, Hyogo, Japan
| | - Ryo Odachi
- Division of Health Sciences, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Nursing and Laboratory Science, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Mikiko Ito
- Department of Nursing, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yuri Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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SCIP-ping Over Opportunities to Discuss Comfort Care With ICU Families. Crit Care Med 2019; 47:865-867. [PMID: 31095015 DOI: 10.1097/ccm.0000000000003756] [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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Paulsen B, Johnsen R, Hadders H. Nurses' experience with relatives of patients receiving end-of-life care in nursing homes and at home: A questionnaire-based cross-sectional study. Nurs Open 2018; 5:431-441. [PMID: 30062037 PMCID: PMC6056440 DOI: 10.1002/nop2.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/21/2018] [Indexed: 11/09/2022] Open
Abstract
AIM The aim of this study was to explore any differences between nurses working in nursing home and home-based care in their experiences regarding relatives' ability to accept the imminence of death and relatives' ability to reach agreement when deciding on behalf of patients unable to consent. DESIGN An electronic questionnaire-based cross-sectional study. METHOD An electronically distributed survey to 884 nurses in long-term care in Norway in May 2014. A total of 399 nurses responded (45%), of which 197 worked in nursing homes and 202 in home-based care. RESULTS Nurses in home-based care, more often than their colleagues in nursing homes, experienced that relatives had difficulties in accepting that patients were dying. Nurses who often felt insecure about whether life extension was in consistency with patients' wishes and nurses who talked most about life-prolonging medical treatment in communication with relatives more often experienced that relatives being reluctant to accept a poor prognosis and disagreements between relatives in their role as proxy decision makers for the patient.
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Affiliation(s)
- Bård Paulsen
- Health service researchSINTEF Technology and SocietyTrondheimNorway
| | - Roar Johnsen
- Department of Public Health and NursingNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Hans Hadders
- Department of Public Health and NursingNorwegian University of Science and Technology (NTNU)TrondheimNorway
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Kageyama Y, Asano M. Thinking about the patient's wishes: practical wisdom of discharge planning nurses in assisting surrogate decision-making. Scand J Caring Sci 2017; 31:796-804. [PMID: 28144974 DOI: 10.1111/scs.12399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 09/13/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The accelerating trend towards shorter hospital stays in Japan has made modes of decision-making essential for effective patient transition from the hospital to recuperation in the regional community, and the ageing of the population has brought a rise in surrogate decision-making by the families of patients lacking decision-making ('self-decision') capacity. AIM To verbalise and elucidate the practical wisdom of discharge planning nurses by focusing on the perceptions and judgements, they apply in practice and describing their methodology in concrete terms. RESEARCH METHOD Participants were six discharge planning nurses and one person with previous experience as a discharge planning nurse, all working at discharge planning departments of acute care hospitals. Separate, semi-structured, interactive interviews were conducted with each participant. The study design was qualitative descriptive in form with qualitative content analysis. All participants provided written informed consent to participate in the study, which was approved by the study institution. RESULTS Three concepts were extracted as the basis for discharge planning nurses' perception and judgement at acute care hospitals: working for mutual envisionment of the available postdischarge options; helping the family act as spokesperson(s) for the patient's wishes; and understanding the family inclusive of the patient as a relationship of strongly interaffecting interests. CONCLUSION The practical wisdom of the nurse, working in mutual envisionment with the family, and collaborative decision-making through discussion with those who know the patient, leads to rational discharge assistance.
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Affiliation(s)
- Yoko Kageyama
- School of Nursing, University of Shizuoka, Shizuoka, Japan.,Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Midori Asano
- Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya, Japan
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10
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Noh H, Kwak J. End-of-life decision making for persons with dementia: Proxies' perception of support. DEMENTIA 2016; 17:478-493. [DOI: 10.1177/1471301216648473] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Healthcare proxies need support in making end-of-life decisions for persons with dementia (PWD). This study explored perceptions of support in decision making among proxies of PWD through semi-structured interviews with 20 proxies. Thematic analysis identified three sources of support: family, doctors, and religiosity/spirituality. Family's engagement in care discussions and support for proxies' decisions were viewed helpful while disagreement or criticism, combined with lack of knowledge about PWD's condition and needs, were not. Doctors were viewed supportive when proxies felt doctors respected their opinions and PWD's wishes. Doctor-PWD rapport influenced proxies' views of medical advice from doctors. Although religiosity/spirituality provided guidance and hope, it also presented conflicts when PWD's wishes differed from proxies' beliefs. Therefore, families of PWD should be provided with assistance in reconciling or mediating family conflicts and further education about the illness trajectory as well as risks/benefits of life-sustaining treatments. Assistance should also be provided to address religious/spiritual conflicts.
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Affiliation(s)
- Hyunjin Noh
- The University of Alabama School of Social Work, Tuscaloosa, AL, USA
| | - Jung Kwak
- University of Wisconsin–Milwaukee, Helen Bader School of Social Welfare, Milwaukee, WI, USA
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L’utilisation des échelles de niveaux d’interventions médicales en centre hospitalier. Can J Aging 2016; 35:70-8. [DOI: 10.1017/s0714980815000574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
ABSTRACTDifferent care settings in Quebec use levels of medical intervention forms, also called levels of care (LOC), to determine the code status of patients and to improve end-of-life care planning. It is not currently possible to know whether the levels of care in hospitals benefit patients and staff in facilitating the decision making process of treatment options and resuscitation measures. No study, to the best of the authors’ knowledge, has been published about LOC, particularly in Quebec and Canada. This literature review was undertaken on levels of care in order to clarify this topic. Relevant articles are discussed under different themes that are pertinent to LOC. The themes addressed in this article include care at the end of life, do-not-resuscitate orders, treatment withdrawal, and decision making at end of life.
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Coombs M, Tang J, Long-Sutehall T. Vigilant attentiveness in families observing deterioration in the dying intensive care patient: A secondary analysis study. Intensive Crit Care Nurs 2016; 33:65-71. [PMID: 26875444 DOI: 10.1016/j.iccn.2015.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Family support in intensive care is often focussed on what information is communicated to families. This is particularly important during treatment withdrawal and end of life care. However, this positions families as passive receivers of information. Less is known about what bereaved family members actually observe at end of life and how this is interpreted. AIM Secondary analysis study was conducted in order to explore the concept of vigilant attentiveness in family members of adult patients dying in intensive care. METHOD Secondary analysis of eight interviews sorted from two primary data sets containing 19 interviews with 25 bereaved family members from two intensive care units in England was undertaken. Directed content analysis techniques were adopted. FINDINGS Families are observant for physiological deterioration by watching for changes in cardiac monitors as well as paying attention to how their relative looks and sounds. Changes in treatment/interventions were also perceived to indicate deterioration. CONCLUSION Families are vigilant and attentive to deterioration, implying that families are active participants in information gathering. By clarifying what families notice, or do not notice during the dying trajectory in ICU, health care professionals can tailor information, helping to prepare families for the death of their relative.
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Affiliation(s)
- Maureen Coombs
- Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand; Capital and Coast District Health Board, Wellington, New Zealand.
| | - Juliana Tang
- Intensive Care Unit, Wellington Regional Hospital, Capital and Coast District Health Board, Wellington, New Zealand
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Coombs M. A scoping review of family experience and need during end of life care in intensive care. Nurs Open 2015; 2:24-35. [PMID: 27708798 PMCID: PMC5047309 DOI: 10.1002/nop2.14] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/02/2015] [Indexed: 11/07/2022] Open
Abstract
AIM To scope systematically and collate qualitative studies on family experience and need during end of life care in intensive care, from the perspective of family members. DESIGN Scoping review of qualitative research. METHODS Standardized processes of study identification, data extraction and data synthesis were used. Multiple bibliographic databases were accessed during 2011 and updated in 2013. RESULTS From an initial 876 references, 16 studies were identified for inclusion. These were predominantly single site, North American studies that explored issues relating to the temporal stages in the end of life trajectory and the requirement for information and emotional support at end of life. With a strong focus on family need and experience during the transition from active treatment to end of life care, more work is required to understand how doctors and nurses can support families from treatment withdrawal through to death.
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Affiliation(s)
- Maureen Coombs
- Graduate School of Nursing Midwifery and Health Victoria University Wellington Wellington 6242 New Zealand; Capital and Coast District Health Board Wellington Regional Hospital Wellington 6242 New Zealand
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Dionne-Odom JN, Willis DG, Bakitas M, Crandall B, Grace PJ. Conceptualizing surrogate decision making at end of life in the intensive care unit using cognitive task analysis. Nurs Outlook 2014; 63:331-40. [PMID: 25982772 DOI: 10.1016/j.outlook.2014.10.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/29/2014] [Accepted: 10/05/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. PURPOSE To identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU. METHODS Qualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center's ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews. DISCUSSION The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDM's judgment about the acceptability of either the patient's medical treatments or his or her condition. CONCLUSION The framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs.
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Affiliation(s)
| | - Danny G Willis
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA
| | - Marie Bakitas
- University of Alabama at Birmingham, School of Nursing, Birmingham, AL
| | - Beth Crandall
- Applied Research Associates, Inc, Cognitive Solutions Division, Fairborn, OH
| | - Pamela J Grace
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA
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Peter E, Mohammed S, Simmonds A. Narratives of aggressive care: Knowledge, time, and responsibility. Nurs Ethics 2013; 21:461-72. [PMID: 24106260 DOI: 10.1177/0969733013502804] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While witnessing and providing aggressive care have been identified as predominant sources of moral distress, little is known about what nurses "know" to be the "right thing to do" in these situations. RESEARCH OBJECTIVES The purpose of this study was to explore what nurses' moral knowledge is in situations of perceived overly aggressive medical care. RESEARCH DESIGN A critical narrative approach was used. PARTICIPANTS A total of 15 graduate nursing students from various practice areas participated. FINDINGS Four narrative types were identified, including "Wait and see: medical uncertainty," "Deflected responsibilities to respond to dying, death, or futility," "Divergent understandings, responsibilities, and temporalities," and "Privileged medical understandings and responsibilities." DISCUSSION The knowledge of differentially situated persons is acknowledged in dissimilar ways, the time required to determine that enough has been done is perceived differently, and how moral responsibilities are understood also varies. CONCLUSIONS A better understanding of how social roles influence how time, knowledge, and responsibility are related to the provision of aggressive care is needed.
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Duke G. Attitudes regarding life-sustaining measures in people born in Japan, China, and Vietnam and living in Texas. Int J Palliat Nurs 2013; 19:76-83. [PMID: 23435536 DOI: 10.12968/ijpn.2013.19.2.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cultural beliefs about and preferences for care at the end of life are diverse and unique in many respects. This descriptive qualitative study presents findings about the attitudes and preferences of people born in Japan, China, and Vietnam and living in the southern part of the USA regarding life-sustaining measures. In-depth personal and focus group interviews were conducted with 46 participants and thematic analysis completed. The findings reflected some similarities and differences among the three groups concerning initiation and discontinuance of artificial nutrition and mechanical ventilation. They also demonstrated the requirement for sensitivity to individual needs when honouring the wishes of patients and surrogate decision makers. Interventional studies should follow that test educational strategies to improve practice outcomes for health-care providers who care for these populations at this vulnerable time of life.
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Nikki L, Lepistö S, Paavilainen E. Experiences of family members of elderly patients in the emergency department: A qualitative study. Int Emerg Nurs 2012; 20:193-200. [DOI: 10.1016/j.ienj.2012.08.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 07/29/2012] [Accepted: 08/09/2012] [Indexed: 12/30/2022]
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Hansen L, Press N, Rosenkranz SJ, Baggs JG, Kendall J, Kerber A, Williamson A, Chesnutt MS. Life-sustaining treatment decisions in the ICU for patients with ESLD: a prospective investigation. Res Nurs Health 2012; 35:518-32. [PMID: 22581585 DOI: 10.1002/nur.21488] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2012] [Indexed: 12/13/2022]
Abstract
We conducted a prospective study in the ICU of life-sustaining treatment and comfort care decisions over time in patients with end-stage liver disease (ESLD) from the perspectives of patients, family members, and healthcare professionals. Six patients with ESLD, 19 family members, and 122 professionals participated. The overarching theme describing the decision-making process was "on the train." Four sub-themes positioned patients and family members as passengers with limited control, unable to fully understand the decision-making process. Findings suggest that including patients and family members in non-immediate life-saving decisions and verifying early on their understanding may help to improve the decision-making process.
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Affiliation(s)
- Lissi Hansen
- Oregon Health & Science University, Portland, OR 97239-2941, USA
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Beck CT. A metaethnography of traumatic childbirth and its aftermath: amplifying causal looping. QUALITATIVE HEALTH RESEARCH 2011; 21:301-311. [PMID: 21131566 DOI: 10.1177/1049732310390698] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Integrating results from multiple analytic approaches used in a research program by the same researcher is a type of metasynthesis that has not often been reported in the literature. In this article the findings of one type of qualitative synthesis approach, a metaethnography, of six qualitative studies on birth trauma and its resulting posttraumatic stress disorder from my program of research are presented. This metaethnography provides a wide-angle lens to view and interpret the far-reaching, stinging tentacles of this often invisible phenomenon that new mothers experience. I used Noblit and Hare's seven-step approach for synthesizing the findings of qualitative studies. The original trigger of traumatic childbirth resulted in six amplifying feedback loops, four of which were reinforcing (positive direction), and two which were balancing (negative direction). Leverage points that identify where pressure in the amplifying causal loop can break the feedback loop where necessary are discussed.
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Affiliation(s)
- Cheryl Tatano Beck
- University of Connecticut School of Nursing, Storrs, Connecticut 06269-2026, USA.
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