Variations in reporting of nurse involvement in end-of-life practices in intensive care units worldwide (ETHICUS-2): A prospective observational study

BACKGROUND

ICU nurses are most frequently at the patient's bedside, providing care for both patients and family members. They perform an essential role and are involved in decision-making. Despite this, research suggests that nurses have a limited role in the end-of-life decision-making process and are occasionally not involved.

OBJECTIVE

Explore global ICU nurse involvement in end of life decisions based on the physician's perceptions and sub-analyses from the ETHICUS-2 study.

DESIGN

This is a secondary analysis of a prospective multinational, observational study of the ETHICUS-2 study.

SETTING

End of life decision-making processes in ICU patients were studied during a 6-month period between Sept 1, 2015, and Sept 30, 2016, in 199 ICUs in 36 countries.

INTERVENTION

None.

METHODS

The ETHICUS II study instrument contained 20 questions. This sub-analysis addressed the four questions related to nurse involvement in end-of-life decision-making: Who initiated the end-of-life discussion? Was withholding or withdrawing treatment discussed with nurses? Was a nurse involved in making the end-of-life decision? Was there agreement between physicians and nurses? These 4 questions are the basis for our analysis. Global regions were compared.

RESULTS

Physicians completed 91.8 % of the data entry. A statistically significant difference was found between regions (p < 0.001) with Northern Europe and Australia/New Zealand having the most discussion with nurses and Latin America, Africa, Asia and North America the least. The percentages of end-of-life decisions in which nurses were involved ranged between 3 and 44 %. These differences were statistically significant. Agreement between physicians and nurses related to decisions resulted in a wide range of responses (27-86 %) (p < 0.001). There was a wide range of those who replied "not applicable" to the question of agreement between physicians and nurses on EOL decisions (0-41 %).

CONCLUSION

There is large variability in nurse involvement in end-of-life decision-making in the ICU. The most concerning findings were that in some regions, according to physicians, nurses were not involved in EOL decisions and did not initiate the decision-making process. There is a need to develop the collaboration between nurses and physicians. Nurses have valuable contributions for best possible patient-centered decisions and should be respected as important parts of the interdisciplinary team.

TWEETABLE ABSTRACT

Wide global differences were found in nurse end of life decision involvement, with low involvement in North and South America and Africa and higher involvement in Europe and Australia/New Zealand.

What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries? A systematic review

BACKGROUND

As many patients are spending their last days in critical care units, it is essential that they receive appropriate end-of -life care. However, cultural differences, ethical dilemmas and preference practices can arise in the intensive care settings during the end of life. Limiting therapy for dying patients in intensive care is a new concept with no legal definition and therefore there may be confusion in interpreting the terms 'no resuscitation' and 'comfort care' among physicians in Middle East. Therefore, the research question is 'What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries?'

METHODS

The authors conducted a comprehensive systematic literature review using five electronic databases. We identified primary studies from Medline, Embase, CINAHL, Psycinfo and Scopus. The team assessed the full-text papers included in the review for quality using the Joanna Briggs Institute checklist (JBI). We completed the literature search on the first of April 2022 and was not limited to a specific period.

RESULTS

We identified and included nine relevant studies in the review. We identified five main themes as end-of-life care challenges and/or facilitators: organisational structure and management, (mis)understanding of end-of-life care, spirituality and religious practices for the dying, communication about end-of-life care, and the impact of the ICU environment.

CONCLUSIONS

This review has reported challenges and facilitators to providing end-of-life care in ICU and made initial recommendations for improving practice. These are certainly not unique to the Middle East but can be found throughout the international literature. However, the cultural context of Middle East and North Africa countries gives these areas of practice special challenges and opportunities. Further observational research is recommended to confirm or modify the results of this review, and with a view to developing and evaluating comprehensive interventions to promote end-of-life care in ICUs in the Middle East.

Intensive Care Nurses' Experiences Related to Dying Patients: A Qualitative Study

OBJECTIVE

To describe intensive care nurses' experiences of caring for dying patients.

METHOD

This study was carried out between July 15, 2019, and September 15, 2019, in a university hospital's intensive care unit. We conducted in-depth semi-structured interviews with a purposive sample of 14 intensive care nurses to describe their experiences related to patient deaths. Qualitative thematic analysis was used to identify, analyse and report the identified themes.

RESULTS

Four themes were identified: (I) Emotions experienced the first time their patient passed away; (II) feelings and thoughts on impact of death; (III) difficulties encountered when providing care and (IV) coping methods with this situation.

CONCLUSION

Despite the passage of time, nurses are unable to forget their death experiences when they first encountered. They oftentimes use ineffective methods of coping and were negatively affected physically and emotionally.

Communication of Code Status Escalation for Nurses and Physicians in the Intensive Care Unit: A Case Study

BACKGROUND

Interprofessional teams working in the Intensive Care Unit (ICU) care for patients requiring varying degrees of life sustaining therapy. A patient's code status can help clinicians to understand the appropriate life support measures to deliver to patients in this setting. Members of the interprofessional team, such as physicians and nurses, can experience challenges related to communication when the code status is unclear.

PURPOSE

The purpose of this study was to explore how nurses and physicians in the ICU experience communication of code status escalations.

METHODS

A qualitative case study approach was used. Participants were physicians and nurses, working in the medical-surgical ICU of a large, urban academic hospital. Data were collected using semi-structured interviews, observations of health care rounds and a chart review. Data were analyzed using qualitative content analysis.

RESULTS

Thematic findings include: (1) engaging in an interprofessional discussion, (2) finding consistent documentation, (3) revisiting the code status, and (4) telling the patient story. The study findings also provide contextual information about participants' experiences of code status communication during the first wave (February 2020 to May 2020) of the COVID-19 pandemic.

CONCLUSIONS

The results of this study could inform standard communication frameworks or practices related to dissemination of code status decisions among members of the ICU team.

Critical care nurses’ moral sensitivity during cardiopulmonary resuscitation: Qualitative perspectives

Background

Cardiopulmonary Resuscitation (CPR) is one of the areas in which moral issues are of great significance, especially with respect to the nursing profession, because CPR requires quick decision-making and prompt action and is associated with special complications due to the patients’ unconsciousness. In such circumstances, nurses’ ability in terms of moral sensitivity can be determinative in the success of the procedure. Identifying the components of moral sensitivity in nurses in this context can promote moral awareness and improve moral performance.

Objective

This study was conducted to explore and identify the experiences of critical care nurses about moral sensitivity components in CPR.

Research design and methods

This study was implemented with a qualitative approach. Data were collected via 22 in-depth semi-structured interviews held with 20 eligible participants with maximum variation. The data were then analyzed using the grounded theory approach.

Participants and research context

In total, thirteen clinical nurses, three head nurses, two educational supervisors, and two faculty members from different universities of Iran were interviewed.

Ethical considerations

This study was conducted with the ethical approval (IR.UMSU.REC.1399.337) of the Ethics Committee of Urmia University of Medical Sciences.

Findings

Four themes and 12 sub-themes were extracted from the analysis of the data, including “Consciously and compassionate attention to resuscitate the patient,” “Awareness of families’ anxiety,” “Understanding the teamwork and interactive guidance of the CPR process,” and “Compulsory violation of moral principles.”

Discussion

It is anticipated that this discussion will prompt further debate, raise awareness and help clarify the dimensions of moral sensitivity in unconscious patients especially during CPR, so that it can be more clearly named and defended as a moral authority in CPR.

Conclusion

identifying the components of moral sensitivity in nurses, facilitates their encounter with moral issues and can improve their moral performance and encourage right decisions.

Health Care Providers' Attitudes and Beliefs on Providing Palliative Care to Patients in Bahrain: Findings From a Qualitative Study

CONTEXT

Present studies suggested that cultural and religious factors, as well as law and policy, may have impeded the advancement of palliative care in the Middle East. Little is known about health care providers' perceptions of palliative care and the barriers to its development in the Gulf Cooperation Council.

OBJECTIVES

To understand health care professionals' attitudes and beliefs regarding palliative care and highlight current practice barriers in Bahrain.

METHODS

Semistructured interviews with 16 health care providers (physicians and nurses) were conducted. Thematic analysis was then performed after interviews were transcribed verbatim.

RESULTS

Health care professionals perceived palliative care as a service only delivered to patients at the end of life. Palliative care was only offered to patients who have been diagnosed with cancer and had exhausted all curative treatments. Do-not-resuscitate orders and code status discussions are not currently practiced. Palliative care decisions are usually decided by patients' families. Middle Eastern culture, health care law and policy, conservative interpretations of Islam, and a lack of professional expertise were identified as barriers.

CONCLUSION

This study unveiled the perceptions of palliative care among health care professionals in a Gulf Cooperation Council country. Six major barriers that hindered palliative care practice were identified. Future health care policy in the region needs to address these barriers within the current health care system while taking culture, religion, and social factors into consideration.

Telling their story: A qualitative descriptive study of the lived experience of expatriate palliative care nurses in the United Arab Emirates

PURPOSE

To explore the experiences of expatriate nurses caring for Muslim patients near end-of-life in a palliative care unit in the United Arab Emirates.

METHODS

A qualitative descriptive study, with data collected through semi structured individual interviews with nine expatriate nurses working in a palliative care unit in one hospital in the United Arab Emirates. Thematic analysis of the data transcripts used a structured inductive approach.

RESULTS

Analysis of the interview transcripts yielded three themes. First, language was a significant barrier in end-of-life care but was transcended when nurses practiced authentically, using presence, empathetic touch and spiritual care. Secondly, relationships between nurses, patients and families were strengthened over time, which was not always possible due to late presentation in the palliative care unit. Finally, nurses were continually in discussions with physicians, families and other nurses, co-creating the meaning of new information and experiences within the hospital policy context.

CONCLUSION

For expatriate nurses, palliative nursing in a Muslim middle eastern country is complex, requiring nurses to be creative in their communication to co-create meaning in an emotionally intensive environment. Like other palliative care settings, time can strengthen relationships with patients and their families, but local cultural norms often meant that patients came to palliative care late in their disease trajectory. Preparing expatriate nurses for work in specialist palliative care settings requires skill development in advanced communication and spiritual practices, as well as principles of palliative care and tenets of Muslim culture.

Improving Family Intensive Care Unit Experiences at the End of Life: Barriers and Facilitators

Experiencing the end of life of a family member in the intensive care unit is clearly difficult. An important role of critical care nurses is to help family members through this challenging period. This article highlights a few clinically significant barriers and facilitators related to improving family experiences at the patient's end of life that have received less attention in the literature thus far. Facilitators include specific aspects of communication, the nurse's role as the coordinator of care, bereavement care, promoting a "good death," and caring for health care providers. Barriers include medical uncertainty and differences in values and culture.

Grief reactions and coping strategies of Muslim nurses dealing with death

BACKGROUND

An intensive care unit (ICU) features high mortality rates. Witnessing subsequent deaths may affect nurses psychologically and spiritually. Islam has an influence on Muslims' life and death. Nevertheless, little is known about Muslim intensive care nurses' experiences of grief in dealing with the deaths of patients.

AIM AND OBJECTIVES

This study aimed to describe the grief reactions and coping strategies of Muslim nurses in dealing with the death of patients.

DESIGN

This is a qualitative study with a phenomenological approach.

METHODS

Semi-structured individual interviews were conducted. Fourteen participants from an ICU in an Indonesian tertiary public hospital participated in this study. Data were analysed by thematic analysis. Trustworthiness was established by Lincoln and Guba's criteria.

RESULTS

The findings identified four reactions of grief, four factors influencing reactions of grief, and three coping strategies used in dealing with death in an ICU. The reactions of nurse's grief were crying, being sad, feeling disappointed, and feeling guilty. These reactions were related to several factors including the circumstances of the patient's death, nurse's expectation of patient's recovery, relationships with the patient, and the reactions of family. Coping management strategies used by nurses in dealing with their grief comprised: sharing with colleagues, avoiding dying and death situations, and engaging in spirituality.

CONCLUSIONS

The Muslim ICU nurse participants experienced their grieving through a variety of psychological reactions influenced by several factors. Personal coping strategies were revealed in dealing with their grief. However, avoiding dying and death situations affected their duty.

RELEVANCE TO CLINICAL PRACTICE

Attention to nurses' grief should be paid to maintain their psychological well-being and quality of end-of-life care. Providing formal support to enhance grief management is recommended.

Nurse-Family Communication During and After Family Meetings in the Intensive Care Unit

PURPOSE

To explore nurse-family communication during and after family meetings.

DESIGN

A cross-sectional study in which 36 family meetings were audio-recorded in two intensive care units in an urban, community hospital.

METHODS

Data were analyzed using conversation analysis, a qualitative method.

FINDINGS

Nurses spoke during 10 (28%) of the family meetings. During the family meetings, nurses mostly self-selected to take a turn by interrupting a physician or family member, finishing their sentences, responding to questions, and, in one instance, asking a question. Nurses were mostly selected as the next speaker to address logistical issues, but were also asked questions. Most of nurses' turns were short and simple, and aimed to provide clarification, reassurance, and information regarding the patient's status. Immediately after the family meetings, nurses offered to provide family members clarification or gestures of empathy, but these offers were met with resistance from family members.

CONCLUSIONS

Despite calls for nurses to take a more active role in surrogate decision making, nurses minimally participated during family meetings. Empowering nurses to share their expertise is one solution for nurses to contribute during family meetings. Further research is needed to explore nurse-family bedside interactions to improve our understanding of the nurse's role in the surrogate decision-making process.

CLINICAL RELEVANCE

Findings from this exploration of nurse communication during and after family meetings can inform how nurses may best assist families during surrogate decision making in the intensive care unit.

Nurses' perceptions of intensive care unit palliative care at end of life

BACKGROUND

Significant barriers can block the provision of palliative care at the end of life in the intensive care unit (ICU). However, the relationship between perceptions of ICU quality palliative care and barriers to palliative care at the end of life is not well documented.

AIMS AND OBJECTIVES

To describe ICU nurses' perceptions of quality palliative end-of-life care, barrier intensity and frequency to palliative care and their association with one another.

DESIGN

This was a descriptive, correlational, cross-sectional design.

METHODS

A convenience sample of 126 ICU nurses from two hospitals in Israel was recruited for the study. Participants completed three pencil-and-paper questionnaires (a personal characteristics questionnaire, the Quality of Palliative Care in the ICU and a revised Survey of Oncology Nurses' Perceptions of End-of-Life Care). Respondents were recruited during staff meetings or while on duty in the ICU. Ethical approval was obtained for the study from participating hospitals.

RESULTS

The item mean score of the quality of palliative end-of-life care was 7·5/10 (SD = 1·23). The item mean barrier intensity and frequency scores were 3·05/5 (SD = 0·76) and 3·30/5 (SD = 0·61), respectively. A correlation of r = 0·46, p < 0·001 was found between barrier frequency and intensity and r = -0·19, p = 0·04 between barrier frequency and quality palliative end-of-life care.

CONCLUSIONS

ICU nurses perceived the quality of palliative care at the end of life as moderate despite reports of moderate barrier levels. The frequency of barriers was weakly associated with quality palliative end-of-life care. However, barrier intensity did not correlate with quality palliative end-of-life care at a statistically significant level. Further research that investigates other factors associated with quality ICU palliative care is recommended.

RELEVANCE TO CLINICAL PRACTICE

Barriers to palliative care are still common in the ICU. Increased training and education are recommended to decrease barriers and improve the quality of ICU palliative care.

Compassionate care during withdrawal of treatment: A secondary analysis of ICU nurses' experiences

BACKGROUND:

Withdrawal of treatment is a common practice in intensive care units when treatment is considered futile. Compassion is an important aspect of care; however, it has not been explored much within the context of treatment withdrawal in intensive care units.

OBJECTIVES:

The aim was to examine how concepts of compassion are framed, utilised and communicated by intensive care nurses in the context of treatment withdrawal.

DESIGN:

The study employed a qualitative approach conducting secondary analysis of an original data set. In the primary study, 13 nurses were recruited from three intensive care units within a large hospital in United Kingdom. Deductive framework analysis was used to analyse the data in relation to compassionate care.

ETHICAL CONSIDERATIONS:

The primary study was approved by the local Research Ethics Committee and the hospital's Research and Development services.

FINDINGS:

Compassionate care was mostly directed to the patient's family and was demonstrated through care and emotional support to the family. It was predominantly expressed through attempts to maintain the patient's dignity by controlling symptoms, maintaining patient cleanliness and removing technical apparatus.

CONCLUSION:

This study's findings provide insight about compassionate care during treatment withdrawal which could help to understand and develop further clinicians' roles. Prioritising the family over the patient raised concerns among nurses, who motivated by compassion, may feel justified in taking measures that are in the interests of the family rather than the patient. Further work is needed to explore the ethics of this.