Shared Decision-Making for Patients with Stroke in Neurocritical Care: A Qualitative Meta-Synthesis

Decision-making for patients with stroke in neurocritical care is uniquely challenging because of the gravity and high preference sensitivity of these decisions. Shared decision-making (SDM) is recommended to align decisions with patient values. However, limited evidence exists on the experiences and perceptions of key stakeholders involved in SDM for neurocritical patients with stroke. This review aims to address this gap by providing a comprehensive analysis of the experiences and perspectives of those involved in SDM for neurocritical stroke care to inform best practices in this context. A qualitative meta-synthesis was conducted following the methodological guidelines of the Joanna Briggs Institute (JBI), using the thematic synthesis approach outlined by Thomas and Harden. Database searches covered PubMed, CIHAHL, EMBASE, PsycINFO, and Web of Science from inception to July 2023, supplemented by manual searches. After screening, quality appraisal was performed using the JBI Appraisal Checklist. Data analysis comprised line-by-line coding, development of descriptive themes, and creation of analytical themes using NVivo 12 software. The initial search yielded 7,492 articles, with 94 undergoing full-text screening. Eighteen articles from five countries, published between 2010 and 2023, were included in the meta-synthesis. These studies focused on the SDM process, covering life-sustaining treatments (LSTs), palliative care, and end-of-life care, with LST decisions being most common. Four analytical themes, encompassing ten descriptive themes, emerged: prognostic uncertainty, multifaceted balancing act, tripartite role dynamics and information exchange, and influences of sociocultural context. These themes form the basis for a conceptual model offering deeper insights into the essential elements, relationships, and behaviors that characterize SDM in neurocritical care. This meta-synthesis of 18 primary studies offers a higher-order interpretation and an emerging conceptual understanding of SDM in neurocritical care, with implications for practice and further research. The complex role dynamics among SDM stakeholders require careful consideration, highlighting the need for stroke-specific communication strategies. Expanding the evidence base across diverse sociocultural settings is critical to enhance the understanding of SDM in neurocritical patients with stroke.Trial registration This study is registered with PROSPERO under the registration number CRD42023461608.

Dignity at stake: Caring for persons with impaired autonomy

Dignity, usually considered an essential ethical value in healthcare, is a relatively complex, multifaceted concept. However, healthcare professionals often have only a vague idea of what it means to respect dignity when providing care, especially for persons with impaired autonomy. This article focuses on two concepts of dignity, human dignity and dignity of identity, and aims to analyse how these concepts can be applied in the care for persons with impaired autonomy and in furthering the practice of respect and protection from harm. Three vignettes were designed to illustrate typical caring situations involving patients with mild to severely impaired autonomy, including patients with cognitive impairments. In situations like these, there is a risk of the patient's dignity being disrespected and violated. The vignettes were then analysed with respect to the two concepts of dignity to find out whether this approach can illuminate what is at stake in these situations and to provide an understanding of which measures could safeguard the dignity of these patients. The analysis showed that there are profound ethical challenges in the daily care of persons with impaired autonomy. We suggest that these two concepts of human dignity could help guide healthcare professionals to develop practical skills in person-centred, ethically grounded care, where the patient's wishes and needs are the starting point.

Asset vulnerability analytical framework and systems thinking as a twin methodology for highlighting factors that undermine efficient food production

Food production in developing countries has been highly susceptible to both climatic and non-climatic stressors. To identify the factors that prevent the rural poor from producing food efficiently, various participatory methodologies have been utilised. However, most methodologies have implicitly illustrated how vulnerable the livelihood activities of the poor are from an asset-based perspective. As assets give people the capability to thrive, we make a case for the asset vulnerability analytical framework (AVAF) and systems thinking (ST) as an integrated methodological framework. Data for this study were obtained from the rural Delta State of Nigeria through the principles and traditions of participatory research, which include Venn (or institutional) diagrams, transect walks, brainstorming, community risk mapping and historical timelines. Findings indicate that the AVAF, on the one hand, will make it relatively easier for development practitioners to effectively identify the factors that undermine the poor’s ability to maximise their livelihood assets during food production. The ST, on the other hand, will enable development practitioners to visualise the long-term consequences of the continued inability of the poor to maximise their livelihood assets. This article argues that the utilisation of both AVAF and ST will simplify the complex challenges of decision-making. This, in turn, will facilitate the implementation of appropriate policy interventions to protect the crucial assets necessary for the rural poor to produce their food efficiently and sustainably.

Keywords: asset vulnerability analytical framework; systems thinking; subsistence farmers; Delta State; Nigeria.

Communication, the Key in Creating Dignified Encounters in Unexpected Sudden Death - With Stroke as Example

Aim:

The aim of this study was to illuminate the communication and its meaning in unexpected sudden death with stroke as example, as experienced by stroke team members and next of kin.

Subject and Methods:

The study has a qualitative design. Secondary analysis of data from four previous interview studies with stroke team members; physicians, registered nurses, and enrolled nurses from the stroke units (SU) and next of kin of patients who had died due to acute stroke during hospital stay were utilized.

Results:

Communication is revealed as the foundation for care and caring with the overarching theme foundation for dignified encounters in care built-up by six themes illuminating the meaning of communication in unexpected sudden death by stroke.

Conclusion:

Communication shown as the foundation for dignified encounters in care as experienced by stroke team members and next of kin enables the patient to come forth as a unique person and uphold absolute dignity in care. Acknowledging the next of kin's familiarity with the severely ill patient will contribute to personalizing the patient and in this way be the ground for a person centeredness in care despite the patients’ inability to defend their own interests. Through knowledge about the patient as a person, the foundation for dignified care is given, expressed through respect for the patient's will and desires and derived through conversations between carers and next of kin.

Ethical issues in the care of patients with stroke: A scoping review

AIMS AND OBJECTIVES

The aim was to identify and analyse the ethical issues in the care of patients with stroke (PwS). The goal was to understand the nature of the existing knowledge on the topic and to identify whether there are ethical issues specific to the care of PwS.

BACKGROUND

Stroke is a disease with possible multiple effects on the patient's overall condition and experienced ethical issues in the care. Additionally, stroke impacts the life of the significant other. For health professionals, the care of PwS is challenging at different stages of the care process. The care of stroke includes several ethically sensitive situations from the perspectives of all participants.

DESIGN

Scoping review.

METHODS

The review was conducted following the five-stage methodological framework of Arksey and O'Malley (2005). The literature search was conducted in several electronic databases and complemented with a manual search, resulting in 15 reviewed articles. The analysis was conducted by charting descriptive numerical data and by content analysis of the narrative representations.

RESULTS

The studies focused on hospital or rehabilitation contexts and a high number of studies had a qualitative approach. Three main themes were identifiable: "decision-making as an ethically challenging act," "care process-specific ethical issues" and "environmental ethical issues."

CONCLUSIONS

Ethical issues occur at different stages of the care process of PwS and from the viewpoints of all those involved. However, not all the recognised ethical issues were stroke specific. As the number of the reviewed articles was limited, more research is needed for a comprehensive understanding of the topic.

RELEVANCE TO CLINICAL PRACTICE

Individual health professionals may use the results in observing their own action from an ethical perspective and to deepen the ethical understanding of the care of PwS. In health care organisations, the results may be used in developing the ethical quality of care.

Hindrances to achieve professional confidence: The nurse’s participation in ethical decision-making

Background:

Research suggests that nurses generally do not participate in ethical decision-making in accordance with ethical guidelines for nurses. In addition to completing their training, nurses need to reflect on and use ethically grounded arguments and defined ethical values such as patient’s dignity in their clinical work.

Objectives:

The purpose of this article is to gain a deeper understanding of how nurses deal with ethical decision-making in daily practice. The chosen research question is “How do nurses participate in ethical decision-making for the patient?”

Design and method:

We use Gadamer’s philosophical hermeneutics as well as Kvale and Brinkmann’s three levels of understanding in interpreting the data material. Nine registered nurses were interviewed.

Ethical considerations:

The Ombudsman of Norwegian Social Science Data and the head of the hospital approved the investigation. The participants received both oral and written information about the study and they gave their consent. We informed the participants that the participation was voluntary and that they were free to withdraw at any point in the course of the study. The requirement of anonymity and proper data storage was in accordance with the World Medical Association Declaration of Helsinki (1964). The participants were assured that privacy, and confidentiality would be duly protected.

Results:

Four key themes emerged: (1) confusion in relation to professional and operational expectations of role, (2) ideal somnolence, (3) inadequate argumentation skills, and (4) compound pressure.

Conclusion:

Ethical ideals appear to be latent in the mindset of the participants; however, the main finding of this investigation is that nurses need to activate the ideals and apply them into practice. Furthermore, management needs to initiate professional reasoning and interdisciplinary discussions leading to common goals for patients.

Dignity realization of patients with stroke in hospital care: A grounded theory

Background:

Dignity is seen as an important but complex concept in the healthcare context. In this context, the discussion of dignity includes concepts of other ethical principles such as autonomy and privacy. Patients consider dignity to cover individuality, patient’s feelings, communication, and the behavior of healthcare personnel. However, there is a lack of knowledge concerning the realization of patients’ dignity in hospital care and the focus of the study is therefore on the realization of dignity of the vulnerable group of patients with stroke.

Aim:

The aim of the study was to create a theoretical construct to describe the dignity realization of patients with stroke in hospital care.

Research design and participants:

Patients with stroke (n = 16) were interviewed in 2015 using a semi-structured interview containing open questions concerning dignity. The data were analyzed using constant comparison of Grounded Theory.

Ethical considerations:

Ethical approval for the research was obtained from the Ethics Committee of the University. The permission for the research was given by the hospital. Informed consent was obtained from participants.

Findings:

The “Theory of Dignity Realization of Patients with Stroke in Hospital Care” consists of a core category including generic elements of the new situation and dignity realization types. The core category was identified as “Dignity in a new situation” and the generic elements as health history, life history, individuality and stroke. Dignity of patients with stroke is realized through specific types of realization: person-related dignity type, control-related dignity type, independence-related dignity type, social-related dignity type, and care-related dignity type.

Discussion:

The theory has similar elements with the previous literature but the whole construct is new. The theory reveals possible special characteristics in dignity realization of patients with stroke.

Conclusion:

For healthcare personnel, the theory provides a frame for a better understanding and recognition of how dignity of patients with stroke is realized.

What are the barriers to initiating end-of-life conversations with patients in the last year of life?

INTRODUCTION

Improving end of life care is a national imperative. Unsatisfactory care persists particularly in acute hospitals, with shortcomings, variability in communication and advance care planning identified as fundamental issues. This review explored the literature to identify what is known about the barriers to initiating end-of-life conversations with patients from the perspective of doctors and nurses in the acute hospital setting.

METHOD

Six electronic databases were searched for potentially relevant records published between 2008 and 2015. Studies were included if the authors reported on barriers to discussing end of life with families or patients as described by doctors or nurses in hospital settings, excluding critical care.

RESULTS

Of 1267 potentially relevant records, 12 were included in the review. Although there is limited high-quality evidence available, several barriers were identified. Recurrent themes within the literature related to a lack of education and training, difficulty in prognostication, cultural differences and perceived reluctance of the patient or family.

CONCLUSIONS

This study illustrated that, in addressing barriers to communication, consideration needs to be extended to include how to embed good communication practice between patients and health professionals into the culture of this setting. Board level commitment is required to raise awareness of, and familiarity with, policies and protocols concerning communication and end-of-life care. Communication training should include practical skills and tools, opportunities to explore the personal beliefs of practitioners and managing their emotions, opportunities to analyse the local organisational (physical and social environment) and team barriers.

End of Life Care for Patients Dying of Stroke: A Comparative Registry Study of Stroke and Cancer

BACKGROUND

Although stroke is a significant public health challenge and the need for palliative care has been emphasized for these patients, there is limited data on end-of-life care for patients dying from stroke.

OBJECTIVE

To study the end-of-life care during the last week of life for patients who had died of stroke in terms of registered symptom, symptom management, and communication, in comparison with patients who had died of cancer.

DESIGN

This study is a retrospective, comparative registry study.

METHODS

A retrospective comparative registry study was performed using data from a Swedish national quality register for end-of-life care based on WHO`s definition of Palliative care. Data from 1626 patients who had died of stroke were compared with data from 1626 patients who had died of cancer. Binary logistic analyses were used to calculate odds ratios, with 95% CI.

RESULTS

Compared to patients who was dying of cancer, the patients who was dying of stroke had a significantly higher prevalence of having death rattles registered, but a significantly lower prevalence of, nausea, confusion, dyspnea, anxiety, and pain. In addition, the stroke group had significantly lower odds ratios for health care staff not to know whether all these six symptoms were present or not. Patients who was dying of stroke had significantly lower odds ratio of having informative communication from a physician about the transition to end-of-life care and of their family members being offered bereavement follow-up.

CONCLUSIONS

The results indicate on differences in end-of-life care between patients dying of stroke and those dying from cancer. To improve the end-of-life care in clinical practice and ensure it has consistent quality, irrespective of diagnosis, education and implementation of palliative care principles are necessary.

Next of kin's experiences of sudden and unexpected death from stroke - a study of narratives

BACKGROUND

Death always evokes feelings in those close to the afflicted person. When death comes suddenly the time for preparation is minimal and the next of kin have to cope with the situation despite their own sorrow. The suddenness is found to be stressful for the next of kin and communication both with healthcare professionals and information about what has happened has been found helpful. The aim of this study was to illuminate the experiences of next of kin from the sudden and unexpected death of a relative from acute stroke.

METHODS

Data was collected over a 12-month period in 2009-2010. Twelve next of kin of patients cared for in stroke units who died suddenly and unexpectedly from stroke were interviewed using a narrative method. The narratives were analyzed using narrative thematic analysis.

RESULTS

Three themes emerged showing facets of next of kin's experiences of a relative's sudden and unexpected death from stroke: Divided feelings about the sudden and unexpected death; Perception of time and directed attention when keeping vigil; Contradictions and arbitrary memories when searching for understanding.

CONCLUSIONS

To have to live in the aftermath of severe stroke is absolute horror in people's imagination and death is seen as the lesser of two evils. The sudden and unexpected death totally pervades the next of kin's life, directs their attention to the dying person and even causes them to forget themselves and their own needs, and leads to difficulties in information intake. It is a challenge for the healthcare professionals to be able to identify the individual needs of the next of kin in this situation.

Strategies for handling ethical problems in sudden and unexpected death

How ethical praxis is shaped by different contexts and situations has not been widely studied. We performed a follow-up study on stroke team members’ experiences of ethical problems and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. A number of ways for handling ethical problems emerged, which we have now explored further. Data were collected through a three-part form used as base for individual interviews with 15 stroke team members and analyzed using both quantitative and qualitative content analysis. In the analysis, the approaches in the form were condensed into strategies, and the two different ways those strategies were preferred and used by the team members were shown. Hindrances perceived by the team members to impede them from working the preferred way were also revealed and grouped into eight categories.