Family involvement in the end-of-life decisions of competent intensive care patients

Critical care nurses' experiences of ethical challenges in end-of-life care

BACKGROUND

In Swedish intensive care units, nine percent of patients do not survive despite receiving advanced life-sustaining treatments. As these patients transition to end-of-life care, ethical considerations may become paramount.

AIM

To explore the ethical challenges that critical care nurses encounter when caring for patients at the end of life in an intensive care context.

RESEARCH DESIGN

The study used a qualitative approach with an interpretive descriptive design.

RESEARCH CONTEXT AND PARTICIPANTS

Twenty critical care nurses from eight intensive care units in an urban region in Sweden were interviewed, predominately women with a median age of fifty-one years.

ETHICAL CONSIDERATIONS

This study was approved by The Swedish Ethics Review Authority.

FINDINGS

Critical care nurses described encountering ethical challenges when life-sustaining treatments persisted to patients with minimal survival prospects and when administering pain-relieving medications that could inadvertently hasten patients' deaths. Challenges also arose when patients expressed a desire to withdraw life-sustaining treatments despite the possibility of recovery, or when family members wanted to shield patients from information about a poor prognosis; these wishes occasionally conflicted with healthcare guidelines. The critical care nurses also encountered ethical challenges when caring for potential organ donors, highlighting the balance between organ preservation and maintaining patient dignity.

CONCLUSION

Critical care nurses encountered ethical challenges when caring for patients at the end of life. They described issues ranging from life-sustaining treatments and administration of pain-relief, to patient preferences and organ donation considerations. Addressing these ethical challenges is essential for delivering compassionate person-centered care, and supporting family members during end-of-life care in an intensive care context.

A scheduling-based methodology for improving patient perceptions of quality of care in intensive care units

Research has found that hospitals with better scores on patient experience of care surveys have better patient safety records and outcomes. Therefore, targeting ways of improving patient experience of care is becoming relevant for hospitals not only for the patient health outcomes but also for the financial implications. Therefore, the goal of this paper is to develop new operation management strategies for improving patient experience of care in intensive care units (ICUs). A new scheduling-based methodology is developed that considers two of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey dimensions, doctor communication and discharge information. Two hypotheses are studied. The first hypothesis postulates that to improve doctor communication with the patient, a nurse must be present in the patient room when the doctor performs ward rounds. The second hypotheses states that to improve the patient-doctor communication of discharge information aspect, doctors must see the patient expected to be discharged early in the day. A computational study is performed to gather insights and to measure the performance of the scheduling-based methodology on a case study from an intensive care unit located in a hospital in central Texas. The results show hospital improvement in the studied dimensions of the HCAHPS survey after 1 year of the hospital adoption of the study recommendations.

Enhancing Communication With Family Members in the Intensive Care Unit: A Mixed-Methods Study

Background

Nurses in the intensive care unit are central to clinical care delivery and are often the staff members most accessible to family members for communication. Family members’ ratings of satisfaction with the intensive care unit admission are affected more by communication quality than by the level of care for the patient. Family members may feel that communication in the intensive care unit is inconsistent.

Objectives

To use a shared decision-making model to deliver a communication education program for intensive care unit nurses, evaluate the confidence levels of nurses who undertook the education, and examine changes in family members’ satisfaction with communication from intensive care unit nurses after the nurses received the education.

Methods

A mixed-methods design was used. Seventeen nurses and 81 family members participated.

Results

Staff members were overall very confident with communicating with family members of critically ill patients. This finding was likely linked to staff members’ experience in the position, with 88% of nurses having more than 11 years’ experience. Family members were happy with care but dissatisfied with the environment.

Conclusions

Environmental factors can negatively affect communication with family members in the intensive care unit.

Family Outcomes and Perceptions of End-of-Life Care in the Intensive Care Unit: A Mixed-Methods Review

The purpose of this review was to evaluate end-of-life care (EOLC) in the intensive care unit (ICU) from the perspective of family members. Sandelowski's segregated approach from Joanna Briggs Institute (JBI) Mixed-Methods Systematic Reviews guided this review. A search was conducted in PubMed, CINAHL, PsycINFO, EMBASE, and ProQuest databases and identified 50 papers (33 quantitative, 15 qualitative, and 2 mixed-methodology studies). Five synthesized themes (distressing emotions, shared decision-making, proactive communication, personalized end-of- life care, and valuing of nursing care) were identified. For quantitative results, study methodologies and interventions were heterogeneous and did not always improve family members' perceived quality of care and family members' psychological distress. Configuration of qualitative and quantitative data revealed ICU end-of-life interventions were ineffective because they were not guided by family members' reported needs and perceptions. To fulfill the family members' needs for the patients' EOLC in the ICU, researchers should develop a theory to explicitly explain how the family members experience ICU EOLC and implement a theory-based intervention to improve family psychological outcomes.

Do published patient decision aids for end-of-life care address patients' decision-making needs? A systematic review and critical appraisal

BACKGROUND

Many decisions are made by patients in their last months of life, creating complex decision-making needs for these individuals. Identifying whether currently existing patient decision aids address the full range of these patient decision-making needs will better inform end-of-life decision support in clinical practice.

AIMS AND DESIGN

This systematic review aimed to (a) identify the range of patients' decision-making needs and (b) assess the extent to which patient decision aids address these needs.

DATA SOURCES

MEDLINE, PsycINFO and CINAHL electronic literature databases were searched (January 1990-January 2017), supplemented by hand-searching strategies. Eligible literature reported patient decision-making needs throughout end-of-life decision-making or were evaluations of patient decision aids. Identified decision aid content was mapped onto and assessed against all patient decision-making needs that were deemed 'addressable'.

RESULTS

Twenty-two studies described patient needs, and seven end-of-life patient decision aids were identified. Patient needs were categorised, resulting in 48 'addressable' needs. Mapping needs to patient decision aid content showed that 17 patient needs were insufficiently addressed by current patient decision aids. The most substantial gaps included inconsistent acknowledgement, elicitation and documentation of how patient needs varied individually for the level of information provided, the extent patients wanted to participate in decision-making, and the extent they wanted their families and associated healthcare professionals to participate.

CONCLUSION

Patient decision-making needs are broad and varied. Currently developed patient decision aids are insufficiently addressing patient decision-making needs. Improving future end-of-life patient decision aid content through five key suggestions could improve patient-focused decision-making support at the end of life.

Do physicians discuss end-of-life decisions with family members? A mortality follow-back study

OBJECTIVE

Deaths from chronic illness are often preceded by a potentially life-shortening end-of-life decision (ELD). Involving family in these ELDs may have psychosocial benefits for them and the dying person. This study aims to examine how often ELDs are discussed with relatives of the dying person and which characteristics determine their involvement in those ELDs.

METHODS

A questionnaire survey was conducted in 2013 among physicians attending a large, stratified and representative sample of deaths (n = 6188) in Flanders.

RESULTS

In 72.3% of ELDs preceding death, family of the dying person were involved. Discussion of an ELD with family members was more likely when the decision was also discussed with the dying person, the ELD was made with the explicit intention to shorten life, specialized palliative care was provided or death occurred in an ICU.

CONCLUSIONS

Involving family in end-of-life decision making appears to be related to the type of formal care services involved, communication with the dying person and the motives behind the decision.

PRACTICE IMPLICATIONS

Our findings suggest a need to further expand a palliative care approach with a focus on both the dying person and their family within and across a variety of health care services.

A Typology of ICU Patients and Families from the Clinician Perspective: Toward Improving Communication

This paper presents an exploratory case study of clinician-patient communications in a specific clinical environment. It describes how intensive care unit (ICU) clinicians' technical and social categorizations of patients and families shape the flow of communication in these acute care settings. Drawing on evidence from a year-long ethnographic study of four ICUs, we develop a typology of patients and families as viewed by the clinicians who care for them. Each type, or category, of patient is associated with differing communication strategies, with compliant patients and families engaged in greater depth. In an era that prioritizes patient engagement through communication for all patients, our findings suggest that ICU teams need to develop new strategies for engaging and communicating with not just compliant patients and families, but those who are difficult as well. We discuss innovative methods for developing such strategies.

Being a legal guardian - the nursing perspective

BACKGROUND

Surrogate decision making is common in public healthcare worldwide. In Israel any incompetent adult patient requires a Legal Guardian (LG), appointed by the court, for approval of invasive none-life saving procedures. Usually, the LG is a close family member of the patient. Nurses are the most available healthcare providers to the families and the LG during the process of appointment and afterwards. The patient's family is often anxious or even depressed, and thus the perceptions and behavior of nurses charged with providing support are crucial. In a previous study based on interviews of LGs we found that the most difficult issues for the LGs were decision related issues, family related issues and appointment bureaucracy issues.

OBJECTIVE

To qualitatively assess nurses attitudes regarding the difficulties that families and LGs face during and after appointments and to compare the findings to previously accessed LG attitudes.

RESEARCH DESIGN

After IRB approval, demographic and semi-structured questionnaires were used to assess the attitudes of a convenience sample of 34 nurses who were participating in a critical care training course (41 % of the respondents were from the ICU, 47 % from medical or surgical wards, and 12 % from other departments at secondary and tertiary hospitals in Israel.) regarding LGs difficulties. After reading and analyzing the responses provided by the nurses, the authors categorized the pertinent topics raised using content analysis. Nurses' perceptions were also compared to those of LGs reported in previous research by the authors.

RESULTS

Three main themes emerged: 1. Decision related issues; namely coping with the complexity of end of life decision issues; 2. Family related issues; namely, family dynamics related to the various decisions regarding LG identity and patient care; and 3. Bureaucracy issues; namely, the formal process related to LG appointment and decisions. Regarding the first two themes, the feelings of the nurse respondents were quite similar to those of LG respondents from our earlier research. The third theme - bureaucracy issues - was never mentioned by the nurses, as opposed to LGs who mentioned it frequently. This suggests that the nurses did not consider it to be an important issue.

CONCLUSIONS

The difficulties of decision making as well as family support and responsibility of LGs are well known by nurses. The appointment and bureaucracy issues were neglected by nurses, although they are very important to the LGs. Improvement of this parameter of care is needed. Possible directions for improvement include raising awareness of nurses regarding the appointment process and alleviation of bureaucracy. Further research is required to identify appropriate strategies for improving these aspects of care.

Trust and autonomy in end of life: considering the interrelation between patients and their relatives

PURPOSE OF REVIEW

Patients' autonomy is seen as a major issue in modern medicine but requires the ability to understand and rate an issue without being influenced by others. However, near the end of life, patients often decide considering the consequences for their relatives.

RECENT FINDINGS

Our study results and recent literature suggest that existing relational patterns determine experiences, family dynamics, and decision-making processes at the end of life. Relatives as a resource can promote patients' autonomy. In doubt of the patients' judgment or prioritizing their own needs, relatives can undermine patient's autonomy in a paternalistic way. Trust in others should be seen as a reciprocal process.

SUMMARY

With respect to the patient's autonomy, healthcare providers need to consider the family structure and its relations.

Decisiones sobre el soporte vital: aspectos éticos objetivos y subjetivos

Los avances en biomedicina amplían cada vez más las posibilidades de curar a enfermos críticos. Las decisiones sobre terapias por aplicar deben tener presente el riesgo de caer en el llamado “encarnizamiento terapéutico”. Aunque ya se ha escrito bastante sobre los criterios básicos que se deben tener en cuenta, aún quedan numerosas dudas a la hora de tomar las decisiones. Un aspecto no menor es la necesidad de objetivar los distintos elementos por ponderar, sin olvidar que hay aspectos subjetivos que son muy importantes. En el presente artículo se presenta una manera de combinar los aspectos objetivos y subjetivos, para llegar a un equilibro adecuado y práctico, que sea razonable y respete la autonomía del paciente.