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Heradstveit SH, Larsen MH, Solberg MT, Steindal SA. Critical care nurses' role in the decision-making process of withdrawal of life-sustaining treatment: A qualitative systematic review. J Clin Nurs 2023; 32:6012-6027. [PMID: 37082871 DOI: 10.1111/jocn.16728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/22/2023]
Abstract
AIM To synthesise the qualitative evidence regarding the role of critical care nurses in the decision-making process of withdrawing life-sustaining treatment in critically ill adults. DESIGN Qualitative systematic review. REVIEW METHODS This qualitative systematic review employed the guidelines of Bettany-Saltikov and McSherry. The review was reported according to the ENTREQ checklist. Pairs of authors independently assessed eligibility, appraised methodological quality and extracted data. Data were synthesised using thematic synthesis. DATA SOURCES CINAHL, MEDLINE and EMBASE were searched for studies published between January 2001 and November 2021. RESULTS Twenty-three studies were included. Three analytical themes were synthesised: performing ethical decision-making to safeguard patients' needs rights, and wishes; tailoring a supporting role to guide the family's decision-making process; and taking on the role of the middleman by performing coordination. CONCLUSION The role of the critical care nurses in the decision-making process in withdrawal of life-sustaining treatment requires experience and the development of the clinical perspective of critical care nurses. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Enhanced knowledge of the decision-making process of withdrawing life-sustaining treatment can prepare critical care nurses to be more equipped to master this role and enhance their ability to handle the emotional and moral stress associated with this part of the critical care unit. IMPACT The literature reveals the complex and challenging role of critical care nurses during the decision-making process of withdrawing life-sustaining treatment. Critical care nurses perform ethical decision-making to safeguard patients' concerns, guide the family's decision-making process and take on the role of the middleman. The findings have implications for critical nurses working in critical care units in hospitals and for educators and students in training in critical care nursing. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution was included.
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Affiliation(s)
- Siri Hammersland Heradstveit
- Department for Postgraduate Studies, Lovisenberg Diaconal University College, Oslo, Norway
- Division of Emergencies and Critical Care, Pediatric Intensive Care, Oslo University Hospital, Oslo, Norway
| | - Marie Hamilton Larsen
- Department for Postgraduate Studies, Lovisenberg Diaconal University College, Oslo, Norway
| | - Marianne Trygg Solberg
- Department for Postgraduate Studies, Lovisenberg Diaconal University College, Oslo, Norway
| | - Simen A Steindal
- Department for Postgraduate Studies, Lovisenberg Diaconal University College, Oslo, Norway
- Faculty of Health Studies, VID Specialized University, Oslo, Norway
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Othman EH, Zeilani R, AlOsta MR, Khalaf IA. Do nurses participate in end-of-life decision making? Int J Palliat Nurs 2023; 29:217-223. [PMID: 37224098 DOI: 10.12968/ijpn.2023.29.5.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND To explore how Jordanian nurses participate in the end-of-life (EoL) decision-making process. METHODS Interviews with 10 patients and family caregivers, and focus group discussions with seven healthcare professionals (HCPs), were conducted. Interviews were audio-recorded, transcribed and analysed following inductive thematic analysis. FINDINGS The participants agreed that nurses are not fully engaged and did not have a direct role in the EoL decision-making process. However, the participants highlighted that 'nurses bridge the gaps in the decision-making process', where nurses act as mediators to facilitate the decision-making process. Lastly, nurses were viewed as 'nurturers and supporters during the journey of the patient's illness'; they were always available to answer their questions, offer help and advise when necessary during palliative referral and throughout the illness. CONCLUSIONS Although nurses did not directly participate in EoL decisions, they have several vital contributions that need to be rearranged into structured decisional coaching.
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Affiliation(s)
- Elham H Othman
- Assistant professor, Applied Science Private University, Jordan
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How nurses’ and physicians’ emotions, psychosocial factors, and professional roles influence the end-of-life decision making process: An interpretive description study. Intensive Crit Care Nurs 2022; 71:103249. [DOI: 10.1016/j.iccn.2022.103249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 03/07/2022] [Accepted: 03/18/2022] [Indexed: 11/19/2022]
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Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study. BMC Med Ethics 2022; 23:12. [PMID: 35172834 PMCID: PMC8851755 DOI: 10.1186/s12910-022-00752-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups. RESULTS Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe.
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Ma JE, Haverfield M, Lorenz KA, Bekelman DB, Brown-Johnson C, Lo N, Foglia MB, Lowery JS, Walling AM, Giannitrapani KF. Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach. Palliat Med 2021; 35:1542-1552. [PMID: 34080488 DOI: 10.1177/02692163211020473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. AIM Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. DESIGN A qualitative thematic analysis of semi-structured interviews. SETTING/PARTICIPANTS Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. RESULTS Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers. CONCLUSIONS Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
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Affiliation(s)
- Jessica E Ma
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC, USA
| | - Marie Haverfield
- Department of Communication Studies, San José State University, San José, CA, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO, USA.,Center of Innovation for Veteran-Centered and Value Driven Care and Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Natalie Lo
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Jensen HI, Halvorsen K, Jerpseth H, Fridh I, Lind R. Practice Recommendations for End-of-Life Care in the Intensive Care Unit. Crit Care Nurse 2021; 40:14-22. [PMID: 32476029 DOI: 10.4037/ccn2020834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices. CLINICAL RELEVANCE Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members. PURPOSE OF PAPER To provide recommendations for high-quality end-of-life care for patients and family members. CONTENT COVERED This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.
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Affiliation(s)
- Hanne Irene Jensen
- Hanne Irene Jensen is an associate professor at the Department of Anaesthesiology and Intensive Care, Vejle and Middelfart Hospitals, Vejle, Denmark, and the University of Southern Denmark, Odense, Denmark
| | - Kristin Halvorsen
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Heidi Jerpseth
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Isabell Fridh
- Isabell Fridh is an associate professor at the Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden
| | - Ranveig Lind
- Ranveig Lind is an associate professor at UiT, the Arctic University of Norway, and a research nurse in the intensive care unit at University Hospital of North Norway, Tromsø, Norway
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Abstract
The phenomenon of end-of-life (EOL) decision-making is a lived experience by which individuals or families make decisions about care they will receive prior to death. A postmodern philosophical approach suggests EOL decision-making is a varied contextual phenomenon that is highly influenced by subjectivity. Thus, there is no specific definition for the phenomenon of EOL decision-making. Watson's theory of human caring complements a postmodern approach in guiding the nursing process of caring for individuals as they experience EOL decision-making.
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Affiliation(s)
- Komal Patel Murali
- PhD Student, New York University, Rory Meyers College of Nursing, New York, NY, USA
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Wholihan D. Psychological Issues of Patient Transition from Intensive Care to Palliative Care. Crit Care Nurs Clin North Am 2019; 31:547-556. [PMID: 31685121 DOI: 10.1016/j.cnc.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Dorothy Wholihan
- NYU Meyers College of Nursing, 433 First Avenue, New York, NY 10010, USA.
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Anderson RJ, Bloch S, Armstrong M, Stone PC, Low JT. Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence. Palliat Med 2019; 33:926-941. [PMID: 31184529 PMCID: PMC6691601 DOI: 10.1177/0269216319852007] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Rebecca J Anderson
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Steven Bloch
- 2 Department of Language and Cognition, Division of Psychology and Language Sciences, University College London, London, UK
| | - Megan Armstrong
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Patrick C Stone
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Joseph Ts Low
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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10
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Stokes H, Vanderspank-Wright B, Fothergill Bourbonnais F, Wright DK. Meaningful experiences and end-of-life care in the intensive care unit: A qualitative study. Intensive Crit Care Nurs 2019; 53:1-7. [DOI: 10.1016/j.iccn.2019.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/14/2019] [Accepted: 03/23/2019] [Indexed: 10/27/2022]
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11
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Meeker MA, McGinley JM, Jezewski MA. Metasynthesis: Dying adults' transition process from cure-focused to comfort-focused care. J Adv Nurs 2019; 75:2059-2071. [PMID: 30734354 DOI: 10.1111/jan.13970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 11/30/2022]
Abstract
AIM To describe and explain the process of transition from cure-focused to comfort-focused health care as perceived and reported by patients, family members, and healthcare providers. BACKGROUND Moving into the last phase of life due to advanced illness constitutes a developmental transition with increased vulnerability for patients and family. DESIGN Qualitative metasynthesis. DATA SOURCES Medline, CINAHL, and PsycInfo databases searched from inception through March 2016. Primary research reports published from 1990 to 2015, using qualitative designs to report transition experiences of patients, family members, and/or healthcare providers were included. REVIEW METHODS Key elements were extracted and organized into matrices. Findings from each report were analysed using qualitative coding. RESULTS The sample was 56 unique reports from 50 primary studies. Patients and families emphasized the importance of receiving understandable information, emotional support, respect for personhood and control. The critical juncture of 'realizing terminality' preceded a transition to comfort-focused care. Subsequently, a shift in goals of care emphasizing comfort and quality of life could occur. Continued provision of information, effective support, respect and control promoted 'reframing perceptions' and capacity to embrace a changed identity. Reframing allowed patient and family to find meaning and value in this last phase of life and to embrace the opportunity to prepare for death, nurture relationships, and focus on quality of living. CONCLUSION Understanding the developmental process that can be engaged by patients and families at the end of life provides a theoretical basis that can inform choice and timing of interventions to reduce suffering and enhance positive outcomes.
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12
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McCaughan D, Roman E, Smith AG, Garry AC, Johnson MJ, Patmore RD, Howard MR, Howell DA. Haematology nurses' perspectives of their patients' places of care and death: A UK qualitative interview study. Eur J Oncol Nurs 2019; 39:70-80. [PMID: 30850141 PMCID: PMC6417764 DOI: 10.1016/j.ejon.2019.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/04/2018] [Accepted: 02/06/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Patients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well understood. The purpose of our study was to explore haematology nurses' perspectives of their patients' places of care and death. METHOD Qualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach. RESULTS Five inter-related factors were identified as contributing to the likelihood of patients' receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home. CONCLUSIONS Hospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred.
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Affiliation(s)
- Dorothy McCaughan
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
| | - Alexandra G Smith
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
| | - Anne C Garry
- Department of Palliative Care, York Hospital, York, YO31 8HE, UK.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK.
| | - Russell D Patmore
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull, HU16 5JQ, UK.
| | - Martin R Howard
- Department of Haematology, York Hospital, York, YO31 8HE, UK.
| | - Debra A Howell
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
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Al Mutair A, Al Shaer A, Al Ghamdi F, Al Ghamdi A. The Experiences of Muslim Family Members of Critically Ill Patients During End-of-Life Care in Saudi Arabia: A Qualitative Phenomenological Study. Clin Nurs Res 2018; 29:375-381. [DOI: 10.1177/1054773818788969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to identify the needs, beliefs, and practices of Muslim family members during the end-of-life care for a family member in the intensive care unit (ICU) in Saudi Arabia. This was a phenomenological study using in-depth individual interviews to gather data. Ten family members of adult ICU patients receiving end-of-life care were interviewed. The experiences of family members during end-of-life care were reflected in four major themes: (a) the spirituality of death, (b) family’s need for information, (c) being there, and (d) the ICU environment. Participants placed high value on religious practices such as prayer, and appreciated when these practices could be accommodated in the ICU. Family participants also detailed their need for frequent communication and opportunities to ask questions about the care of their critically ill loved one. Being able to spend as much time as desired in close proximity to the critically ill patient particularly as the end of life approaches was also important, with participants suggesting that visitation times should be waived. Finally, family participant suggested that changes were needed to the ICU environment to make accommodating large families easier and more comfortable particularly when they wish to spend significant time at the bedside of their loved one. Family should be prioritized as an extension of the care provided to critically ill ICU patients, particularly those approaching end of life. A model of care should be introduced to deliver supportive and holistic care during the end-of-life care journey, supported by appropriate education regarding family care at the end of life.
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Affiliation(s)
- Abbas Al Mutair
- Inaya Medical College, Riyadh, Saudi Arabia
- Wollongong University, Australia
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14
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González-Rincón M, Díaz de Herrera-Marchal P, Martínez-Martín ML. The role of the nurse at the end of the life of a critically ill patient. ENFERMERIA INTENSIVA 2018; 30:78-91. [PMID: 29903540 DOI: 10.1016/j.enfi.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 12/21/2017] [Accepted: 02/05/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
| | | | - M L Martínez-Martín
- Sección Departamental Enfermería, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
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15
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Listening to How Experienced Nurses Care for the Dying Husband and His Spouse. Dimens Crit Care Nurs 2018; 36:193-201. [PMID: 28375996 DOI: 10.1097/dcc.0000000000000246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Although most nurses in critical care settings provide nursing care for marital couples when 1 of the partners is dying, this is a relatively new area of research. OBJECTIVE The aim of this study is to describe the nature of nursing care provided for marital couples in the critical care unit when the husbands were dying. METHOD A qualitative interpretive description was used to construct this study. Data were collected by conducting semistructured individual interviews with 15 experienced critical care nurses in quiet conference rooms. The initial sample was recruited by invitation, and then followed by the snowball method. Institutional review board approval was obtained at the supporting institution. Interviews were recorded and transcribed to facilitate analysis. Data were analyzed line by line with constant comparison to formulate key ideas and then organized into themes. RESULTS Three themes were identified: (a) experienced nurses support the wife and husband, (b) experienced nurses connect spiritually with the wife and husband, and (c) experienced nurses provide skillful care for the wife and her husband who is dying. These themes form a description of the nature of nursing care needed by novice nurses. Emphasis for novice nurses includes focusing on the uniqueness of the marital couple as the patient, being less task oriented, and being more emotionally sensitive to the needs of the marital dyad. In this study, experienced nurses relay the importance of engaging self with these couples and being present at the end of life. DISCUSSION Future research directions are to explore innovative ways nurses may provide spiritual and emotional support to these marital couples and to measure what care activities the wife deems most beneficial for her and her husband at his end of life.
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Oncology nurses' perceptions of obstacles and role at the end-of-life care: cross sectional survey. BMC Palliat Care 2017; 16:74. [PMID: 29258492 PMCID: PMC5735910 DOI: 10.1186/s12904-017-0257-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 11/30/2017] [Indexed: 01/09/2023] Open
Abstract
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.
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Kozlowski D, Hutchinson M, Hurley J, Rowley J, Sutherland J. The role of emotion in clinical decision making: an integrative literature review. BMC MEDICAL EDUCATION 2017; 17:255. [PMID: 29246213 PMCID: PMC5732402 DOI: 10.1186/s12909-017-1089-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/29/2017] [Indexed: 05/18/2023]
Abstract
BACKGROUND Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. METHODS A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning. RESULTS Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement. CONCLUSIONS Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a clear theoretical framework and educational preparation may not reflect the importance of emotional competence to effective CDM.
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Affiliation(s)
- Desirée Kozlowski
- Discipline of Psychology, School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - Marie Hutchinson
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - John Hurley
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - Joanne Rowley
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
| | - Joanna Sutherland
- School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW Australia
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Ong KK, Ting KC, Chow YL. The trajectory of experience of critical care nurses in providing end-of-life care: A qualitative descriptive study. J Clin Nurs 2017; 27:257-268. [DOI: 10.1111/jocn.13882] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Keh Kiong Ong
- Alice Lee Centre for Nursing Studies; Yong Loo Lin School of Medicine; National University of Singapore; Singapore Singapore
| | | | - Yeow Leng Chow
- Alice Lee Centre for Nursing Studies; Yong Loo Lin School of Medicine; National University of Singapore; Singapore Singapore
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Frenette M, Saint-Arnaud J, Serri K. Levels of Intervention: How Are They Used in Quebec Hospitals? JOURNAL OF BIOETHICAL INQUIRY 2017; 14:229-239. [PMID: 28324205 DOI: 10.1007/s11673-017-9778-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 10/21/2016] [Indexed: 06/06/2023]
Abstract
In order to promote better practices and communication around end-of-life decision-making, several Canadian hospitals in the province of Quebec have developed a tool called "Levels of Intervention" (LOI). No work to date has been published demonstrating improvement since these forms were implemented. The purpose of the present study was to obtain information about the use of LOI forms across Quebec hospitals and to identify gaps in practice as well as areas for improvement. A retrospective study was undertaken of 299 charts of patients who had died in three Quebec hospitals with a LOI ordered. Results were analysed through a principlism ethical framework. High compliance with the level of intervention ordered at the time of death was recorded, as well as high involvement of patient and/or family, demonstrating the efficiency of LOI in promoting respect for autonomy. Other results show delays in end-of-life care discussions in the course of the hospitalization. Only a small proportion of patients who died had a palliative care consultation, which may reflect equity issues in access to care. This study highlights the importance of the LOI in Quebec and the role it is playing in respect for end-of-life preferences as well as in the involvement of patients and families in the decision-making process. Training specific to end-of-life decision-making conversations would help support the LOI form's use, as would developing provincial or national guidelines on the use of LOI to standardize organizational policies and practice around end-of-life care.
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Affiliation(s)
- Marjolaine Frenette
- Public Health School (local 3035), University of Montreal, C. P. 6128, succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada.
| | - Jocelyne Saint-Arnaud
- Department of Social and Preventive Medicine, Public Health School, University of Montreal and Center for Research in Ethics (CRÉ), President Clinical Ethics Committee, Sacré-Coeur Hospital, Montreal, QC, Canada
| | - Karim Serri
- Sacré-Coeur Hospital and University of Montreal, Montreal, QC, Canada
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Olding M, McMillan SE, Reeves S, Schmitt MH, Puntillo K, Kitto S. Patient and family involvement in adult critical and intensive care settings: a scoping review. Health Expect 2016; 19:1183-1202. [PMID: 27878937 PMCID: PMC5139045 DOI: 10.1111/hex.12402] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite international bodies calling for increased patient and family involvement, these concepts remain poorly defined within literature on critical and intensive care settings. OBJECTIVE This scoping review investigates the extent and range of literature on patient and family involvement in critical and intensive care settings. Methodological and empirical gaps are identified, and a future agenda for research into optimizing patient and family involvement is outlined. METHODS Searches of MEDLINE, CINAHL, Social Work Abstracts and PsycINFO were conducted. English-language articles published between 2003 and 2014 were retrieved. Articles were included if the studies were undertaken in an intensive care or critical care setting, addressed the topic of patient and family involvement, included a sample of adult critical care patients, their families and/or critical care providers. Two reviewers extracted and charted data and analysed findings using qualitative content analysis. FINDINGS A total of 892 articles were screened, 124 were eligible for analysis, including 61 quantitative, 61 qualitative and 2 mixed-methods studies. There was a significant gap in research on patient involvement in the intensive care unit. The analysis identified five different components of family and patient involvement: (i) presence, (ii) having needs met/being supported, (iii) communication, (iv) decision making and (v) contributing to care. CONCLUSION Three research gaps were identified that require addressing: (i) the scope, extent and nature of patient involvement in intensive care settings; (ii) the broader socio-cultural processes that shape patient and family involvement; and (iii) the bidirectional implications between patient/family involvement and interprofessional teamwork.
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Affiliation(s)
- Michelle Olding
- British Columbia Centre for Excellence in HIV/AIDSVancouverBCCanada
| | - Sarah E. McMillan
- Collaborative Academic PracticeUniversity Health NetworkTorontoONCanada
| | - Scott Reeves
- Centre for Health and Social Care ResearchKingston University and St. George's University of LondonLondonUK
| | | | | | - Simon Kitto
- Department of Innovation in Medical EducationFaculty of MedicineUniversity of OttawaOttawaONCanada
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Watson AC, October TW. Clinical Nurse Participation at Family Conferences in the Pediatric Intensive Care Unit. Am J Crit Care 2016; 25:489-497. [PMID: 27802949 PMCID: PMC5751701 DOI: 10.4037/ajcc2016817] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Clinical nurses attend family conferences in the intensive care unit, but their role during these meetings is not yet fully understood. OBJECTIVES To assess perceived and observed contributions of the clinical nurse during family conferences. METHODS Prospective cross-sectional survey and review of 40 audio-recorded family conferences conducted in the 44-bed pediatric intensive care unit of an urban pediatric hospital. RESULTS Survey responses from 47 nurses were examined. Most nurses thought it important to attend family conferences, but identified workload as a barrier to attendance. They perceived their roles as gaining firsthand knowledge of the discussion and providing a unique perspective regarding patient care, emotional support, and advocacy. Audio recordings revealed that bedside nurses attended 20 (50%) of 40 family conferences and spoke in 5 (25%) of the 20. Nurses verbally contributed 4.6% to the overall speech at the family conference, mostly providing information on patient care. CONCLUSIONS The clinical nurse is often absent or silent during family conferences in the intensive care unit, despite the important roles they want to play in these settings. Strategies to improve both the physical and verbal participation of clinical nurses during the family conference are suggested, especially in the context of previous research demonstrating the need for more attention in family conferences to social-emotional support and patient advocacy.
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Affiliation(s)
- Anne C Watson
- Anne C. Watson is the research nurse coordinator for critical care medicine, Children's National Health Systems, Washington, DC. Tessie W. October is an attending physician in the pediatric intensive care unit at Children's National Health Systems, Washington, DC, and an assistant professor in the Department of Pediatrics, George Washington University, Washington, DC.
| | - Tessie W October
- Anne C. Watson is the research nurse coordinator for critical care medicine, Children's National Health Systems, Washington, DC. Tessie W. October is an attending physician in the pediatric intensive care unit at Children's National Health Systems, Washington, DC, and an assistant professor in the Department of Pediatrics, George Washington University, Washington, DC
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Kisorio LC, Langley GC. End-of-life care in intensive care unit: Family experiences. Intensive Crit Care Nurs 2016; 35:57-65. [DOI: 10.1016/j.iccn.2016.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 02/29/2016] [Accepted: 03/16/2016] [Indexed: 11/27/2022]
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Noome M, Beneken genaamd Kolmer DM, van Leeuwen E, Dijkstra BM, Vloet LCM. The nursing role during end-of-life care in the intensive care unit related to the interaction between patient, family and professional: an integrative review. Scand J Caring Sci 2016; 30:645-661. [DOI: 10.1111/scs.12315] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/13/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Marijke Noome
- Bachelor of Nursing; The Hague University of Applied Sciences; The Hague The Netherlands
- Research Department of Emergency and Critical Care; HAN University of Applied Sciences; Nijmegen The Netherlands
- Research Department Informal Care; The Hague University of Applied Sciences; The Hague The Netherlands
| | - Deirdre M. Beneken genaamd Kolmer
- Research Department Informal Care; The Hague University of Applied Sciences; The Hague The Netherlands
- Tranzo; School of Social and Behavioral Sciences; Tilburg University; Tilburg The Netherlands
| | - Evert van Leeuwen
- Section Ethics, Philosophy and the History of Medicine; Scientific Institute for Quality of Healthcare; Radboud University Medical Centre Nijmegen; Nijmegen The Netherlands
| | - Boukje M. Dijkstra
- Research Department of Emergency and Critical Care; HAN University of Applied Sciences; Nijmegen The Netherlands
- Intensive Care Unit; Radboud University Medical Centre Nijmegen; Nijmegen The Netherlands
| | - Lilian C. M. Vloet
- Research Department of Emergency and Critical Care; HAN University of Applied Sciences; Nijmegen The Netherlands
- Scientific Institute for Quality of Healthcare; Radboud University Medical Centre Nijmegen; Nijmegen The Netherlands
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Jerpseth H, Dahl V, Nortvedt P, Halvorsen K. Nurses' role and care practices in decision-making regarding artificial ventilation in late stage pulmonary disease. Nurs Ethics 2016; 24:821-832. [PMID: 26822302 DOI: 10.1177/0969733015626600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Decisions regarding whether or not to institute mechanical ventilation during the later stages of chronic obstructive pulmonary disease is challenging both ethically, emotionally and medically. Caring for these patients is a multifaceted process where nurses play a crucial role. Research question and design: We have investigated how nurses experienced their own role in decision-making processes regarding mechanical ventilation in later stages of chronic obstructive pulmonary disease and how they consider the patients' role in these processes. We applied a qualitative approach, with six focus-group interviews of nurses (n = 26). Ethical considerations: The Regional Committees for Medical and Health Research Ethics approved the study. Voluntary informed consent was obtained. FINDINGS The nurses found themselves operating within a cure-directed treatment culture wherein they were unable to stand up for the caring values. They perceived their roles and responsibilities in decision-making processes regarding mechanical ventilation to patients as unclear and unsatisfactory. They also experienced inadequate interdisciplinary cooperation. DISCUSSION Lack of communication skills, the traditional hierarchical hospital culture together with operating in a medical-orientated treatment culture where caring values is rated as less important might explain the nurses' absence in participation in the decision about mechanical ventilation. CONCLUSION To be able to advocate for the patients' and their own right to be included in decision-making processes, nurses need an awareness of their own responsibilities. This requires personal courage, leadership who are capable of organising common interpersonal meetings and willingness on the part of the physicians to include and value the nurses' participation in decision-making processes.
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Affiliation(s)
- Heidi Jerpseth
- Oslo and Akershus University College of Applied Sciences, Norway
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Abstract
Despite the benefits of advance directives (AD) to patients and care providers, they are often not completed due to lack of patient awareness. The purpose of the current article is to advocate for creation and use of an innovative information visualization (infovisual) as a health communication tool aimed at improving AD dissemination and engagement. The infovisual would promote AD awareness by encouraging patients to learn about their options and inspire contemplation and conversation regarding their end-of-life (EOL) journey. An infovisual may be able to communicate insights that are often communicated in words, but are much more powerfully communicated by example. Furthermore, an infovisual could facilitate vivid understanding of options and inspire the beginning of often difficult conversations among care providers, patients, and loved ones. It may also save clinicians time, as care providers may be able to spend less time explaining details of EOL care options. Use of an infovisual could assist in ensuring a well-planned EOL journey.
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Affiliation(s)
- Janet Woollen
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Suzanne Bakken
- Department of Biomedical Informatics, Columbia University, New York, NY
- School of Nursing, Columbia University, New York, NY
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Siffleet J, Williams AM, Rapley P, Slatyer S. Delivering best care and maintaining emotional wellbeing in the intensive care unit: the perspective of experienced nurses. Appl Nurs Res 2015; 28:305-10. [DOI: 10.1016/j.apnr.2015.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 01/16/2015] [Accepted: 02/21/2015] [Indexed: 11/17/2022]
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Peden-McAlpine C, Liaschenko J, Traudt T, Gilmore-Szott E. Constructing the story: How nurses work with families regarding withdrawal of aggressive treatment in ICU – A narrative study. Int J Nurs Stud 2015; 52:1146-56. [DOI: 10.1016/j.ijnurstu.2015.03.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 03/20/2015] [Accepted: 03/21/2015] [Indexed: 11/30/2022]
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Abstract
OBJECTIVES Nurses are generally present, and often influential, in supporting patient and family acceptance of medical futility and in assisting doctors in negotiating referral to palliative care. Yet the specificities of the nursing role and how nurses may contribute to timely and effective referrals is not well understood. This study aimed to systematically explore hospital-based nurses' accounts of the transition to palliative care, and the potential role of nurses in facilitating more effective palliative care transitions. DESIGN Qualitative study using semistructured interviews. SETTING Two health services with public as well as private clinical environments in a major metropolitan area of Australia. PARTICIPANTS Hospital-based nurses (n=20) who regularly work with patients at the point of referral and in managing transitions to palliative care. RESULTS Four significant themes emerged from thematic analysis. These include: (1) professional dynamics and the roles played by nurses in initiating the transition to palliative care; (2) the value of nurses' informal interactions in timely and effective transitions; (3) the emerging challenge of managing task-oriented nursing versus intense emotional nursing work at the point of medical futility and (4) the emotional burden experienced by nurses within this clinical context. Nurses self-reported occupying critical albeit complex roles in the management of medical futility and the transition to palliative care. They reported experiencing significant emotional burden in balancing interpersonal and interprofessional relationships during this time. CONCLUSIONS The results suggest that nurses may be utilised in a more formalised and systematic fashion in the context of managing medical futility and the need to topicalise the transition, with the focus shifted away from medical referrals towards more team-based and patient-centred timely transitions. Further research focused on the experiences of doctors, allied health professionals, patients and families is required to provide a broader interdisciplinary understanding of futility and contributions to the negotiation of palliative care.
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Affiliation(s)
- Emma Kirby
- School of Social Science, The University of Queensland, Brisbane, Queensland, Australia
| | - Alex Broom
- School of Social Science, The University of Queensland, Brisbane, Queensland, Australia
| | - Phillip Good
- Department of Palliative Care, St Vincent's Hospital, Brisbane, Queensland, Australia
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Abstract
BACKGROUND The intensive care unit environment focuses on interventions and support therapies that prolong life. The exercise by nurses of their autonomy impacts on perception of the role they assume in the multidisciplinary team and on their function in the intensive care unit context. There is much international research relating to nurses' involvement in end-of-life situations; however, there is a paucity of research in this area in Brazil. In the Brazilian medical scenario, life support limitation generated a certain reluctance of a legal nature, which has now become unjustifiable with the publication of a resolution by the Federal Medical Council. In Brazil, the lack of medical commitments to end-of-life care is evident. OBJECTIVE To understand the process by which nurses exercise autonomy in making end-of-life decisions in intensive care units. RESEARCH DESIGN Symbolic Interactionism and Corbin and Strauss theory methodology were used for this study. PARTICIPANTS AND RESEARCH CONTEXT Data were collected through single audio-recorded qualitative interviews with 14 critical care nurses. The comparative analysis of the data has permitted the understanding of the meaning of nurse's experience in exercising autonomy relating to end-of-life decision-making. ETHICAL CONSIDERATIONS Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were anonymized. FINDINGS The results revealed that nurses experience the need to exercise autonomy in intensive care units on a daily basis. Their experience expressed by the process of increase opportunities to exercise autonomy is conditioned by the pressure of the intensive care unit environment, in which nurses can grow, feel empowered, and exercise their autonomy or else can continuously depend on the decisions made by other professionals. CONCLUSION Nurses exercise their autonomy through care. They work to create new spaces at the same time that they acquire new knowledge and make decisions. Because of the complexity of the end-of-life situation, nurses must adopt a proactive attitude that inserts them into the decision-making process.
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McLeod A. Nurses’ views of the causes of ethical dilemmas during treatment cessation in the ICU: a qualitative study. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/bjnn.2014.10.3.131] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anne McLeod
- Senior Lecturer in Critical Care, School of Health Sciences, City University, Northampton Square, London, England
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McAndrew NS, Leske JS. A Balancing Act: Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units. Clin Nurs Res 2014; 24:357-74. [PMID: 24864319 DOI: 10.1177/1054773814533791] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this qualitative, descriptive study was to describe end-of-life decision-making experiences as understood by critical care nurses and physicians in intensive care units (ICUs). A purposive sample of seven nurses and four physicians from a large teaching hospital were interviewed. Grounded theory analysis revealed the core category of "end-of-life decision making as a balancing act." Three interacting subthemes were identified: emotional responsiveness, professional roles and responsibilities, and intentional communication and collaboration. Balancing factors included a team approach, shared goals, understanding the perspectives of those involved, and knowing your own beliefs. In contrast, feeling powerless, difficult family dynamics, and recognition of suffering caused an imbalance. When balance was achieved during end-of-life decision making, nurses and physicians described positive end-of-life experiences. The consequence of an imbalance during an end-of-life decision-making experience was moral distress. Practice recommendations include development of support interventions for nurses and physicians involved in end-of-life decision making and further research to test interventions aimed at improving communication and collaboration.
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Pattison N, Carr SM, Turnock C, Dolan S. 'Viewing in slow motion': patients', families', nurses' and doctors' perspectives on end-of-life care in critical care. J Clin Nurs 2013; 22:1442-54. [PMID: 23506296 DOI: 10.1111/jocn.12095] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2012] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore the meaning of end-of-life care for critically ill cancer patients, families, oncologists, palliative care specialists, critical care consultants and nurses. BACKGROUND End-of-life care for critically ill patients, of whom nearly 20% will die in critical care, remains somewhat problematic (Truog et al. 2008). End-of-life care is an established domain in cancer; however, research has not been conducted previously into dying, critically ill cancer patients' experiences. DESIGN Qualitative, phenomenological in-depth interviews were undertaken. METHODS Phenomenology was used to explore experiences of 27 participants: surviving patients at high risk of dying, bereaved families, oncologists, palliative and critical care consultants, and nurses. Purposive sampling from a UK critical care unit was carried out. In-depth interviews were taped analysed using Van Manen's phenomenological analysis framework. RESULTS A phenomenological interpretation of dying in cancer critical illness, and the impact on opportunities for end-of-life care, is presented. Three main themes included: dual prognostication; the meaning of decision-making; and care practices at end of life: choreographing a good death. End-of-life care was an emotive experience for all participants; core tenets for good end-of-life care included comfort, less visible technology, privacy and dignity. These findings are discussed in relation to end-of-life care, cancer and critical illness. CONCLUSION The speed of progressing towards dying in critical illness is often unknown and subsequently affects potential for end-of-life care. Caring was not unique to nurses and end-of-life care in critical care came with considerable emotional cost. RELEVANCE TO CLINICAL PRACTICE There is an opportunity for nurses to use the care of patients dying in critical care to develop specialist knowledge and lead in care, but it requires mastery and reconciliation of both technology and end-of-life care. Healthcare professionals can help facilitate acceptance for families and patients, particularly regarding involvement in decisions and ensuring patient advocacy.
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Jensen HI, Ammentorp J, Johannessen H, Ørding H. Challenges in end-of-life decisions in the intensive care unit: an ethical perspective. JOURNAL OF BIOETHICAL INQUIRY 2013; 10:93-101. [PMID: 23299401 DOI: 10.1007/s11673-012-9416-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 06/24/2012] [Indexed: 05/23/2023]
Abstract
When making end-of-life decisions in intensive care units (ICUs), different staff groups have different roles in the decision-making process and may not always assess the situation in the same way. The aim of this study was to examine the challenges Danish nurses, intensivists, and primary physicians experience with end-of-life decisions in ICUs and how these challenges affect the decision-making process. Interviews with nurses, intensivists, and primary physicians were conducted, and data is discussed from an ethical perspective. All three groups found that the main challenges were associated with interdisciplinary collaboration and future perspectives for the patient. Most of these challenges were connected with ethical issues. The challenges included different assessments of treatment potential, changes and postponements of withholding and withdrawing therapy orders, how and when to identify patients' wishes, and suffering caused by the treatment. To improve end-of-life decision-making in the ICU, these challenges need to be addressed by interdisciplinary teams.
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Affiliation(s)
- Hanne Irene Jensen
- Department of Anaesthesiology, Vejle Hospital, Kabbeltoft 25, 7100 Vejle, Denmark.
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Aradilla-Herrero A, Tomás-Sábado J, Gómez-Benito J. Death Attitudes and Emotional Intelligence in Nursing Students. OMEGA-JOURNAL OF DEATH AND DYING 2013; 66:39-55. [DOI: 10.2190/om.66.1.c] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aims of this study were to analyze the relationships between death attitudes and perceived emotional intelligence in a sample of nursing students, and to determine whether there are differences between different academic years with regard to both emotional intelligence and death attitudes. The participants were 243 nursing students. They all responded voluntarily and anonymously to a questionnaire that assessed the following constructs: Fear of death, Death anxiety, Death depression, Death obsession, and Emotional intelligence (Attention, Clarity, and Mood Repair). Students' scores on Fear of Death of Others subscale ( p < .05) decreased significantly across the 3 years of the nursing degree program and increased significantly on emotional Clarity ( p < .05), a dimension of emotional intelligence. The multiple linear regression analyses confirmed the predictive value of Attention, Clarity, and Mood Repair regarding levels of Fear of Death of Others. The importance of including emotional skills training and death-education programs as part of professional nursing curricula are discussed.
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Affiliation(s)
- Amor Aradilla-Herrero
- Escola Universitària d'Infermeria Gimbernat, Universitat Autònoma de Barcelona, Spain
| | - Joaquín Tomás-Sábado
- Escola Universitària d'Infermeria Gimbernat, Universitat Autònoma de Barcelona, Spain
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Slatore CG, Hansen L, Ganzini L, Press N, Osborne ML, Chesnutt MS, Mularski RA. Communication by nurses in the intensive care unit: qualitative analysis of domains of patient-centered care. Am J Crit Care 2012; 21:410-8. [PMID: 23117904 DOI: 10.4037/ajcc2012124] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Christopher G Slatore
- Section of Pulmonary and Critical Care Medicine, Portland Veterans Affairs Medical Center, Oregon, USA.
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Lind R, Lorem GF, Nortvedt P, Hevrøy O. Intensive care nurses’ involvement in the end-of-life process – perspectives of relatives. Nurs Ethics 2012; 19:666-76. [DOI: 10.1177/0969733011433925] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | | | - Per Nortvedt
- University of Oslo, Norway; Oslo and Akershus University College of Applied Sciences, Norway
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Fernández-Sola C, Granero-Molina J, Manrique GA, Castro-Sánchez AM, Hernández-Padilla JM, Márquez-Membrive J. New regulation of the right to a dignified dying in Spain: repercussions for nursing. Nurs Ethics 2012; 19:619-28. [PMID: 22323394 DOI: 10.1177/0969733011429016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preserving dignity during the dying process requires reviewing the roles of those involved in the treatment, care methods and decision-making. This article examines the participation and responsibility assigned to nurses regarding decision-making in the final stages of life, as laid out in the Rights to and Guarantee of Dignity for the Individual During the Process of Death Act. This text has been analysed on the levels of socio-cultural practice and discourse practice, using the critical discourse analysis methodology. The results show that, although the law is another result of the social trend of patient empowerment, the responsibility of the nurses is not recognised, and they are left out of the decision-making process in the final stages of life.
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Negotiated dying: A grounded theory of how nurses shape withdrawal of treatment in hospital critical care units. Int J Nurs Stud 2011; 48:1466-74. [DOI: 10.1016/j.ijnurstu.2011.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 06/09/2011] [Accepted: 06/14/2011] [Indexed: 11/20/2022]
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Coombs MA, Addington-Hall J, Long-Sutehall T. Challenges in transition from intervention to end of life care in intensive care: a qualitative study. Int J Nurs Stud 2011; 49:519-27. [PMID: 22078212 DOI: 10.1016/j.ijnurstu.2011.10.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 10/11/2011] [Accepted: 10/19/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Providing quality end of life care is a challenging area in intensive care practice. The most demanding aspect for doctors and nurses in this setting is not the management of care at end of life per se, but facilitating the transition from active intervention to palliation and finally, end of life care. Whilst there is understanding about some aspects of this transition, recognition of the complex and inter-related processes that work to shift the patient's trajectory from cure to end of life care is required. This is important in order to work towards solutions for issues that continue to pose problems for health care professionals. OBJECTIVES To identify the challenges for health care professionals when moving from a recovery trajectory to an end of life trajectory in intensive care. DESIGN Qualitative methods of enquiry. METHODS AND SETTING Single semi-structured interviews with 13 medical staff and 13 nurses associated with 17 decedents who underwent treatment withdrawal in intensive care were carried out. Participants were drawn from two Intensive Care Units in a large university-affiliated hospital in England. FINDINGS Patients who died in intensive care appeared to follow a three-stage end of life trajectory: admission with hope of recovery; transition from intervention to end of life care; a controlled death. The transition from intervention to end of life care was reported as being the most problematic and ambiguous stage in the end of life trajectory, with potential for conflict between medical teams, as well as between doctors and nurses. CONCLUSIONS End of life care policy emphasises the importance of end of life care for all patients regardless of setting. These findings demonstrate that in intensive care, there is need to focus on transition from curative intervention to end of life care, rather than end of life care itself so that effective and timely decision making underpins the care of the 20% of intensive care patients who die in this setting each year.
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Affiliation(s)
- Maureen A Coombs
- Cardiac Intensive Care Unit, Southampton University Hospitals Trust, Tremona Road, Southampton, Hampshire SO16 6YD, United Kingdom.
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Nursing Roles and Strategies in End-of-Life Decision Making in Acute Care: A Systematic Review of the Literature. Nurs Res Pract 2011; 2011:527834. [PMID: 21994831 PMCID: PMC3184494 DOI: 10.1155/2011/527834] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 07/10/2011] [Accepted: 07/14/2011] [Indexed: 11/25/2022] Open
Abstract
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.
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Efstathiou N, Clifford C. The critical care nurse's role in end-of-life care: issues and challenges. Nurs Crit Care 2011; 16:116-23. [PMID: 21481113 DOI: 10.1111/j.1478-5153.2010.00438.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM The purpose of this article is to discuss the challenges critical care nurses face when looking after patients needing End-of-Life (EoL) care in critical care environments. BACKGROUND Critical care nurses frequently provide care to patients who fail to respond to treatments offered to support and prolong life. The dying phase for individuals in critical care settings, commonly after withholding/withdrawing treatment, is very short posing great demands on critical care nurses to provide physical and emotional support to both patients and their families. Despite the existence of recognized care planning frameworks that may help nurses in providing EoL care, these are not used by all units and many nurses rely on experience to inform practice. A number of aspects such as communication, patient/family-centred decision-making, continuity of care, emotional/spiritual support and support for health professionals have been indicated as contributing factors towards the provision of effective EoL care. These are considered from the perspective of critical care nursing. CONCLUSION Skills development in key aspects of care provision may improve the provision of EoL care for critical care patients and their families. RELEVANCE TO CLINICAL PRACTICE Critical care nurses have an essential role in the provision of effective EoL care; however, this dimension of their role needs further exploration. It is noted that educational opportunities need to be provided for critical care nurses to increase the knowledge on planning and delivering EoL care. To inform this evaluation of current EoL care provision in critical care is necessary to address a knowledge deficit of the needs of nurses who seek to support patients and their families at a critical time.
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Affiliation(s)
- Nikolaos Efstathiou
- University of Birmingham, College of Medical and Dental Sciences, School of Health and Population Sciences, Nursing and Physiotherapy, Birmingham, UK.
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Abstract
The aim of this study was to explore metaphors for discovering values and norms held by nurses in home-based nursing care. Ten interviews were analysed and interpreted in accordance with a metaphor analytical method. In the analysis, metaphoric linguistic expressions and two entailments emerged, grounded in the conceptual metaphor ‘home-based nursing care is an endless journey’, which were created in a cross-domain mapping between the two conceptual domains of home-based nursing care and travel. The metaphor exposed home-based nursing care as being in constant motion, thereby requiring nurses to adjust to circumstances that demand ethical maturity. The study focuses on the importance of developing further theories supporting nurses’ expressions of their experiences of everyday ethical issues.
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Affiliation(s)
- Stina Öresland
- Umeå University, Sweden & Buskerud University College, Norway,
| | | | - Astrid Norberg
- Umeå University & Ersta Sköndal University College, Sweden
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Santana Cabrera L, Gil Hernández N, Méndez Santana A, Marrero Sosa I, Alayón Cabrera S, Martín González JC, Sánchez Palacios M. [Perception of ethical attitudes of intensive care nurses on treatment limitation]. ENFERMERIA INTENSIVA 2010; 21:142-9. [PMID: 20674430 DOI: 10.1016/j.enfi.2010.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 05/17/2010] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Analyze the perception of intensive care nurses regarding the limitation of therapeutic efforts (LET). METHOD A 2-month cross-sectional, descriptive study carried out among Intensive Care nursing staff of our Hospital. An anonymous survey was used to assess the attitudes of intensive care nurses on LET. RESULTS Fifty-two nurses (86.6%), 57.7% women, with a working experience of 8.8±4.8 years and 17.7%, had some additional training in ethics. The decision not to hospitalize a patient whose short term quality of life is very poor changes when the patient's opinion is considered (36.5% vs 61.5%, p=0.008), a difference that is greater in male nurses without prior training in ethics. A total of 23.1% were not aware of the existence of agreed on guidelines on LET in the Service. A total of 17.3% consider that limiting treatment, either by not providing it or by withdrawing it, is a form of passive euthanasia, which would be an acceptable practice as opposed to euthanasia and 84.6% consider that administering a treatment is not the same as withdrawing it. Of those surveyed, 36.5% felt that the neither the nursing staff should not participate in the decision to limit treatment nor the patients (34.6%) nor family (23.1%). CONCLUSIONS Nursing is not aware of the importance it can have, along with the family and patient, in decision making in relationship to the limitation of the treatment of the critical patient, providing a humanizing and ethical view of the care.
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Affiliation(s)
- L Santana Cabrera
- Servicio de Medicina Intensiva, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Gran Canaria, España.
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