Palliative Care in Critical Care Settings: A Systematic Review of Communication-Based Competencies Essential for Patient and Family Satisfaction

Assessing palliative care practices in intensive care units and interpreting them using the lens of appropriate care concepts. An umbrella review

PURPOSE

Intensive care units (ICUs) have significant palliative care needs but lack a reliable care framework. This umbrella review addresses them by synthesising palliative care practices provided at end-of-life to critically ill patients and their families before, during, and after ICU admission.

METHODS

Seven databases were systematically searched for systematic reviews, and the umbrella review was conducted according to the guidelines laid out by the Joanna Briggs Institute (JBI).

RESULTS

Out of 3122 initial records identified, 40 systematic reviews were included in the synthesis. Six key themes were generated that reflect the palliative and end-of-life care practices in the ICUs and their outcomes. Effective communication and accurate prognostications enabled families to make informed decisions, cope with uncertainty, ease distress, and shorten ICU stays. Inter-team discussions and agreement on a plan are essential before discussing care goals. Recording care preferences prevents unnecessary end-of-life treatments. Exceptional end-of-life care should include symptom management, family support, hydration and nutrition optimisation, avoidance of unhelpful treatments, and bereavement support. Evaluating end-of-life care quality is critical and can be accomplished by seeking family feedback or conducting a survey.

CONCLUSION

This umbrella review encapsulates current palliative care practices in ICUs, influencing patient and family outcomes and providing insights into developing an appropriate care framework for critically ill patients needing end-of-life care and their families.

Mechanisms of end-of-life communication contributing to optimal care at the end of life: a review of reviews

BACKGROUND

End-of-life communication is an essential component of high-quality care, but its potential mechanisms for improving care are not well understood.

OBJECTIVES

To summarise the potential mechanisms by which end-of-life communication may contribute to enhanced end-of-life care in any setting.

DESIGN

An overview of systematic reviews, with a narrative synthesis of results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality was assessed using the AMSTAR (A MeaSurement Tool to Assess Reviews) tool.

DATA SOURCES

CINAHL, MEDLINE, Cochrane, SSCI and PsycINFO databases, were searched from inception to January 2024. Manual searches were also conducted.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews (published in English) related to end-of-life communication, where the target population was adult patients in their last year of life, relatives, caregivers and/or healthcare professionals involved in communicating with dying patients.

RESULTS

We reviewed 35 eligible studies. The reviews suggest potential mechanisms of effective end-of-life communication including collaborative decision-making, tailoring communication to individuals, using effective communication strategies and incorporating communication skills into practice. The reviews also highlighted barriers related to patients, professionals and organisations.

CONCLUSION

This review highlights a nuanced understanding of potential mechanisms of end-of-life communication, emphasising the need for tailored training, policy enhancements and interprofessional collaboration. It calls on healthcare professionals to reflect on their practices, advocating for co-designing a person-centred communication model that addresses patient preferences at the end of life. Importantly, in culturally diverse contexts, there is a need for a communication paradigm that embraces diversity to provide truly empathetic and effective end-of-life care. This concise roadmap may foster compassionate, dignified and effective end-of-life communication.

TRIAL REGISTRATION NUMBER

Protocol registered with PROSPERO (CRD42022271433, 29 March 2022).

Exploring Perceptions and Practices of Interprofessional Shared Decision-Making Education in Palliative Care Settings

Background

Palliative care teams provide support to patients and their caregivers during terminal illness, which requires interprofessional collaboration. One of the foundational skills is to assist patients with decision-making. This can be facilitated through interprofessional shared decision-making (IP-SDM). So far, IP-SDM education frameworks have only been used to a limited extent in the area of palliative care.

Aim

This study aims to explore perceptions and practices of faculty members, health professionals, and students toward IP-SDM education in palliative care and to indicate associated factors to implement an IP-SDM in undergraduate health professions education in palliative care settings.

Methods

We used a cross-sectional study design in which the data was obtained via an online self-administered questionnaire adapted from existing validated tools. The questionnaire was distributed to faculty members and health professionals (n = 125) and students (n = 334) at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The sampling technique was a non-probability convenience sampling. Bivariate statistics, such as independent sample t-tests, one-way ANOVA, correlation coefficient, and linear multiple regression were conducted.

Findings

The response rate was 54% (85 faculty members and health professionals and 164 students). Perceptions on IP-SDM did not differ between participants. From those who had previous experience with IP-SDM, the mean practices score was slightly higher for faculty members and health professionals (M = 83.1, SD = 15.9) than for students (M = 74.1, SD = 11.5), which was significant (p < 0.05). Factors such as gender, age, discipline, nationality, level of education, years of study, and previous experience that were associated with perceptions and practices were varied among participants.

Conclusion

The findings show high levels of perception with low levels of practice of IP-SDM in palliative care. Other factors that could be associated with the topic should be addressed in further studies.

Palliative and end-of-life care practices for critically ill patients and their families in a peri-intensive care setting: A protocol for an umbrella review

OBJECTIVES

This umbrella review will summarize palliative and end-of-life care practices in peri-intensive care settings by reviewing systematic reviews in intensive care unit (ICU) settings. Evidence suggests that integrating palliative care into ICU management, initiating conversations about care goals, and providing psychological and emotional support can significantly enhance patient and family outcomes.

METHODS

The Joanna Briggs Institute (JBI) methodology for umbrella reviews will be followed. The search will be carried out from inception until 30 September 2023 in the following databases: Cochrane Library, SCOPUS, Web of Science, CINAHL Complete, Medline, EMBASE, and PsycINFO. Two reviewers will independently conduct screening, data extraction, and quality assessment, and to resolve conflicts, adding a third reviewer will facilitate the consensus-building process. The quality assessment will be carried out using the JBI Critical Appraisal Checklist. The review findings will be reported per the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews statement.

RESULTS

This umbrella review seeks to inform future research and practice in critical care medicine, helping to ensure that end-of-life care interventions are optimized to meet the needs of critically ill patients and their families.

Patient and caregiver questions and clinician responses during initial outpatient neuropalliative care appointments

Objective

Open communication during appointments exemplifies person-centered care. The current study characterized questions asked by persons with neurologic illnesses and their caregivers-and clinicians' responses to those questions-during initial outpatient palliative care appointments.

Methods

We coded type (direct or indirect) and topic of questions stated by patients and their caregivers in audio recordings from 38 initial outpatient palliative care appointments. We also coded the completeness and quality features of clinicians' responses.

Results

Patients and caregivers stated 556 total questions; most were direct questions (79.7%) and primarily about symptoms, treatment, and lifestyle issues. Clinicians responded to more than 90% of all questions. Responses to both question types were similar in completeness and quality, but clinicians more frequently offered support in response to direct questions and gave recommendations in response to indirect questions.

Conclusion

Persons with neurologic illnesses and their caregivers use different question types to obtain information about symptoms and treatment during initial palliative care appointments. Results may guide clinician training and patient education for optimizing information exchange in palliative care.

Innovation

This study is the first to explore patient and caregiver use of indirect questions in neuropalliative care appointments and the quality of clinicians' responses to those questions.

Surgical Emergencies in Patients with Significant Comorbid Diseases

Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.

Supporting families of patients who die in adult intensive care: A scoping review of interventions

BACKGROUND

Families who perceive themselves as prepared for an impending death experience reduced psychological burden during bereavement. Understanding which interventions promote death preparedness in families during end-of-life care in intensive care will inform future intervention development and may help limit the burden of psychological symptoms associated with bereavement.

AIM

To identify and characterise interventions that help prepare families for the possibility of death in intensive care, incorporating barriers to intervention implementation, outcome variables and instruments used.

DESIGN

Scoping review using Joanna Briggs methodology, prospectively registered and reported using relevant guidelines.

DATA SOURCES

A systematic search of six databases from 2007 to 2023 for randomised controlled trials evaluating interventions that prepared families of intensive care patients for the possibility of death. Citations were screened against the inclusion criteria and extracted by two reviewers independently.

RESULTS

Seven trials met eligibility criteria. Interventions were classified: decision support, psychoeducation, information provision. Psychoeducation involving physician-led family conference, emotional support and written information reduced symptoms of anxiety, depression, prolonged grief, and post-traumatic stress in families during bereavement. Anxiety, depression, and post-traumatic stress were assessed most frequently. Barriers and facilitators to intervention implementation were seldom reported.

CONCLUSION

This review provides a conceptual framework of interventions to prepare families for death in intensive care, while highlighting a gap in rigorously conducted empirical research in this area. Future research should focus on theoretically informed, family-clinician communication, and explore the benefits of integrating existing multidisciplinary palliative care guidelines to deliver family conference within intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care clinicians should consider innovative communication strategies to build family-clinician connectedness in remote pandemic conditions. To prepare families for an impending death, mnemonic guided physician-led family conference and printed information could be implemented to prepare families for death, dying and bereavement. Mnemonic guided emotional support during dying and family conference after death may also assist families seeking closure.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Health Literacy of Surrogates and Communication Issues in Palliative Care Conversations in Critical Care: An Integrative Review

Worldwide, 56.8 million persons are estimated to require palliative care. Critically ill patients benefit from palliative care by improving their quality of life through symptom management. Resistance to palliative care exists from surrogate decision-makers because of low health literacy and communication issues with providers. This research reviewed the literature to identify how health literacy and health care communication influenced palliative care conversations with decision-making surrogates and health outcomes of critically ill patients. The review included articles between 2011 and 2022 using the terms communication, health literacy, palliative care, critical care, intensive care, ICU, surrogate decision maker, family, and caregiver in PubMed, CINAHL, and Google Scholar. Fourteen articles were included. Quality was assessed through Joanna Briggs Institute appraisal tools. Health literacy of surrogates was not found to be significant for patient outcomes. However, there were significant differences between clinician and surrogate communication influenced by surrogates' previous health care experiences. Early communication about prognosis was important for surrogates. Structured communication approaches were preferred by surrogates. Limitations of the review included primarily White participants, small variability of research sites, and a few number of articles. Future research needs to study the effects of surrogate health literacy of critically ill patients on willingness to accept palliative care.

An Educational Intervention to Enhance Palliative Care Training at HBCUs

CONTEXT

Primary palliative care training is important for clinicians at Historically Black Colleges and Universities (HBCUs) given the decreased access to specialty palliative care among Black patients and patients' preferences for race concordant care.

OBJECTIVES

To describe the impact of a palliative care educational intervention at two HBCUs.

METHODS

We administered a palliative care educational intervention in family and internal medicine residency programs at Morehouse School of Medicine and Howard University College of Medicine. Pre- and post-intervention surveys were sent to residents assessing attitudes toward their palliative care education and their perceived competency in specific palliative care domains. The results were analyzed using Chi-squared analysis.

RESULTS

A total of 105 of 191 (response rate 55%) residents completed pre-intervention surveys and 101 of 240 (42%) completed post-intervention surveys. Prior to the intervention, 50% of residents rated their overall preparedness in palliative care as a 7 or above (0-10 Likert scale); 78% (P < .01) of respondents reported ≥7/10 after the educational intervention. While post-intervention residents did not feel better prepared to treat symptoms, a higher percentage reported feeling well prepared to deliver bad news (41% post-intervention vs. 23% pre-intervention) and conduct a family meeting (44% post-intervention vs. 27% pre-intervention) (P < .05). Pre-intervention, 14% of residents felt their overall palliative care education was very good or excellent, while post-intervention ratings increased to 30% (P < .01).

CONCLUSION

Residents' confidence in their preparedness to provide palliative care, particularly in their communication skills increased after an intervention at two HBCUs.

Stakeholder engagement as a strategy to enhance palliative care involvement in intensive care units: A theory of change approach

BACKGROUND

Adult patients admitted to intensive care units in the terminal phase experience high symptom burden, increased costs, and diminished quality of dying. There is limited literature on palliative care engagement in ICU, especially in lower-middle-income countries. This study explores a strategy to enhance palliative care engagement in ICU through a stakeholder participatory approach.

METHODS

Theory of Change approach was used to develop a hypothetical causal pathway for palliative care integration into ICUs in India. Four facilitated workshops and fifteen research team meetings were conducted virtually over three months. Thirteen stakeholders were purposively chosen, and three facilitators conducted the workshops. Data included workshop discussion transcripts, online chat box comments, and team meeting minutes. These were collected, analysed and represented as theory of change map.

RESULTS

The desired impact of palliative care integration was good death. Potential long-term outcomes identified were fewer deaths in ICUs, discharge against medical advice, and inappropriate admissions; increased referrals to palliative care; and improved patient and family satisfaction. Twelve preconditions were identified, and eleven key interventions were developed. Five overarching assumptions related to contextual factors influencing the outcomes of interventions.

CONCLUSION

Theory of change framework facilitated the identification of proposed mechanisms and interventions underpinning palliative care integration in ICUs.

Exploring physician approaches to conflict resolution in end-of-life decisions in the adult intensive care unit: protocol for a systematic review of qualitative research

INTRODUCTION

Conflict is unfortunately well-documented in the adult intensive care unit (AICU). In the context of end-of-life (EOL) decision-making (ie, the withdrawal or withholding of life-sustaining treatment), conflict commonly occurs when a consensus cannot be reached between the healthcare team and the patient's family on the 'best interests' of the critically ill, incapacitated patient. While existing literature has identified potential methods for conflict resolution, it is less clear how these approaches are perceived and used by stakeholders in the EOL decision-making process. We aim to explore this by systematically reviewing and synthesising the published evidence, which addresses the following research question: what does existing qualitative research reveal about physician approaches to addressing conflict arising in EOL decisions in the AICU?

METHODS AND ANALYSIS

Peer-reviewed qualitative studies (retrieved from MEDLINE, Project Muse, Scopus, EMBASE, Web of Science, PsycINFO, CINAHL, and LILACS) examining conflict and dispute resolution in the context of EOL decisions in the AICU setting will be included. Two reviewers will independently screen either all or a randomly selected sample of studies, with a third reviewer independently screening studies of uncertain eligibility. The 'thematic synthesis' approach will be employed to analyse the resulting data. The quality of included papers will be assessed using the 2018 Mixed-Methods Assessment Tool. The 'Grading of Recommendations, Assessment, Development, and Evaluations-Confidence in the Evidence from Reviews of Qualitative research' approach will be used to assess our confidence in the findings.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review, as only published data will be included. We anticipate that the findings will be of interest to healthcare professionals working in AICUs and individuals working in bioethics, given the ethically contentious nature of EOL decisions. The findings will be disseminated at academic conferences and through open-access publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021193769.

How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care

PURPOSE

Intensive care is a stressful environment in which team-family conflicts commonly occur. If managed poorly, conflicts can have negative effects on all parties involved. Previous studies mainly investigated these conflicts and their management in a retrospective way. This study aimed to prospectively explore team-family conflicts, including its main topics, complicating factors, doctors' conflict management strategies and the effect of these strategies.

METHODS

Conversations between doctors in the neonatal, pediatric, and adult intensive care unit of a large university-based hospital and families of critically ill patients were audio-recorded from the moment doubts arose whether treatment was still in patients' best interest. Transcripts were coded and analyzed using a qualitative deductive approach.

RESULTS

Team-family conflicts occurred in 29 out of 101 conversations (29%) concerning 20 out of 36 patients (56%). Conflicts mostly concerned more than one topic. We identified four complicating context- and/or family-related factors: diagnostic and prognostic uncertainty, families' strong negative emotions, limited health literacy, and burden of responsibility. Doctors used four overarching strategies to manage conflicts, namely content-oriented, process-oriented, moral and empathic strategies. Doctors mostly used content-oriented strategies, independent of the intensive care setting. They were able to effectively address conflicts in most conversations. Yet, if they did not acknowledge families' cues indicating the existence of one or more complicating factors, conflicts were likely to linger on during the conversation.

CONCLUSION

This study underlines the importance of doctors tailoring their communication strategies to the concrete conflict topic(s) and to the context- and family-related factors which complicate a specific conflict.

Physicians' perceptions of patient participation and the involvement of family caregivers in the palliative care pathway

Introduction

Patient participation is essential for quality palliative care, and physicians play a crucial role in promoting participation. This study explores physicians' perceptions of patients and family caregivers' involvement in the different phases of the palliative pathway and employs a qualitative design with thematic analysis and a hermeneutic approach.

Methods

A purposive sampling included physicians who worked in different phases of the palliative pathway. In‐depth, semi‐structured interviews were conducted with 13 physicians in Norway between May and June 2020.

Results

Three main themes illustrate physicians' perceptions of patients' and family caregivers' involvement: (1) beneficence for the patient and the family caregivers in the early phase, (2) autonomy and shared decision‐making in the middle phase, and (3) family involvement in the terminal phase.

Conclusion

The physicians perceived bereavement conversations as essential, particularly if the pathway had been challenging. They also perceived patient participation and family caregivers' involvement as contextual. The results reveal that participation differs across the different phases of the palliative pathway. This type of knowledge should be included in the education of health‐care professionals. Future research should explore elements vital to successful patient participation and family involvement in the different phases of care.

Patient or Public Contributions

Family caregivers were involved in a previous study through individual interviews. The same interview guide used for the family caregivers was used when interviewing the physicians. The family caregivers' contribution led to nuanced questions in the interviews with the physicians, questions leaning on their stories told.

Shifting Provider Attitudes and Institutional Resources Surrounding Resuscitation at the Limit of Gestational Viability

OBJECTIVE

This study aimed to provide contemporary data regarding provider perceptions of appropriate care for resuscitation and stabilization of periviable infants and institutional resources available to providers.

STUDY DESIGN

A Qualtrics survey was emailed to 672 practicing neonatologists in the United States by use of public databases. Participants were asked about appropriate delivery room care for infants born at 22 to 26 weeks gestational age, factors affecting decision-making, and resources utilized regarding resuscitation. Descriptive statistics were used to analyze the dataset.

RESULTS

In total, 180 responses were received, and 173 responses analyzed. Regarding preferred course of care based on gestational age, the proportion of respondents endorsing full resuscitation decreased with decreasing gestational age (25 weeks = 99%, 24 = 64%, 23 = 16%, and 22 = 4%). Deference to parental wishes correspondingly increased with decreasing gestational age (25 weeks = 1%, 24 = 35%, 23 = 82%, and 22 = 46%). Provision of comfort care was only endorsed at 22 to 23 weeks (23 weeks = 2%, 22 = 50%). Factors most impacting decision-making at 22 weeks gestational age included: outcomes based on population data (79%), parental wishes (65%), and quality of life measures (63%). Intubation with a 2.5-mm endotracheal tube (84%), surfactant administration in the delivery room (77%), and vascular access (69%) were the most supported therapies for initial stabilization. Availability of institutional resources varied; the most limited were obstetric support for cesarean delivery at the limit of viability (37%), 2.0-mm endotracheal tube (45%), small baby protocols (46%), and a consulting palliative care teams (54%).

CONCLUSION

There appears to be discordance in provider attitudes surrounding preferred actions at 23 and 22 weeks. Provider attitudes regarding decision-making at the limit of viability and identified resource limitations are nonuniform. Between-hospital variations in outcomes for periviable infants may be partly attributable to lack of provider consensus and nonuniform resource availability across institutions.

KEY POINTS

· Within the past decade, there has been a shift in the gray zone from 23-24 to 22-23 weeks gestation.. · Attitudes around resuscitation of infants are nonuniform despite perceived standardized approaches.. · Institutional variability in resources may contribute to variation in outcomes of periviable infants..

The burden they bear: A scoping review of physician empathy in the intensive care unit

PURPOSE

Research shows that physician empathy can improve patients' reporting of symptoms, participation in care, compliance, and satisfaction; however, success in harnessing these advantages in the ICU hinges on a myriad of contextual factors. This study describes the current state of knowledge about intensivists' empathy.

METHODS

A scoping review was conducted across six databases and grey literature to clarify intensivists' experiences of empathy and identify directions of future inquiries. The search had no date limits and was specific to empathy, intensivists, and ICU environments. Results were blindly and independently reviewed by authors.

RESULTS

The search yielded 628 manuscripts; 45 met inclusion criteria. Three overarching themes connected the manuscripts: (1) the risks and benefits of empathy, (2) the spectrum of connection and distance of intensivists from patients/families, and (3) the facilitators and barriers to empathy's development.

CONCLUSION

Empathy among intensivists is not a dichotomous phenomenon. It instead exists on continua. Four steps are recommended for optimizing empathy in the ICU: clearly defining empathy, addressing risks and benefits transparently, providing education regarding reflective practice, and developing supportive environments. Overall, this review revealed that the state of knowledge about empathy as experienced by intensivists still has room to grow and be further explored.

Intensive Care Unit Nurse: Could We Call a Palliative Care Consult? Intensive Care Unit Provider: It's Too Early. Palliative Care Integration in the Intensive Care Unit: The Struggle to Translate Evidence Into Practice

Despite evidence regarding the value of palliative care, there remains a translation-to-practice gap in the intensive care setting. The purpose of this article is to describe challenges and propose solutions to palliative care integration through the presentation and discussion of a critical care patient scenario. We also present recommendations for a collaborative palliative care practice framework that holds the potential to improve quality of life for patients and families. Collaborative palliative care is characterized by close working relationships with families, interprofessional intensive care unit healthcare teams, and palliative care specialists. The shortage of palliative care specialists has become a pressing policy and practice issue and highlights the importance of increasing primary palliative care delivery by the intensive care team. Underexplored aspects of collaborative palliative care delivery include the interprofessional communication required, identification of key skills, and expected outcomes. Increased recognition of intensive care unit palliative care as a process of engagement among nurses, providers, patients, and their family members heralds a vital culture shift toward collaborative palliative care. The interprofessional palliative specialist team has the expertise to support intensive care teams in developing their primary palliative skills and recognizing when specialist palliative care support is required. Promotion of strategic palliative care delivery through this collaborative framework has the potential to decrease suffering among patients and families and reduce moral distress among healthcare professionals.

Physician-assisted suicide and physician-assisted euthanasia: evidence from abroad and implications for UK neurologists

In this article, we consider the arguments for and against physician-assisted suicide (AS) and physician-assisted euthanasia (Eu). We assess the evidence around law and practice in three jurisdictions where one or both are legal, with emphasis on data from Oregon. We compare the eligibility criteria in these different regions and review the range of approved disorders. Cancer is the most common cause for which requests are granted, with neurodegenerative diseases, mostly motor neurone disease, ranking second. We review the issues that may drive requests for a physician-assisted death, such as concerns around loss of autonomy and the possible role of depression. We also review the effectiveness and tolerability of some of the life-ending medications used. We highlight significant variation in regulatory oversight across the different models. A large amount of data are missing or unavailable. We explore physician-AS and physician-assisted Eu within the wider context of end-of-life practice.

Palliative care in its own discourse: a focused ethnography of professional messaging in palliative care

Background

Despite 50 years of modern palliative care (PC), a misunderstanding of its purpose persists. The original message that PC is focused on total care, helping to live until the person dies, is being replaced and linked to feelings of fear, anxiety and death, instead of compassion, support or appropriate care. Society is still afraid to speak its name, and specialized units are identified as “places of death” as opposed to “places of life” meant to treat suffering. This issue is prohibitive to the implementation and development of PC policies worldwide. It is imperative to identify what message PC professionals are relaying to patients and other health care specialists and how that message may condition understandings of the right to access PC.

Methods

A qualitative study, employing focused ethnography and participant observation (PO) of the daily interaction of PC professionals with patients and family members in three different PC services. Two researchers independently conducted a thematic analysis, followed by member checking with participants.

Results

A total of 242 h of participant observation revealed the following messages sent by PC professionals in their daily interaction with patients and families: i) We are focused on your wellbeing; ii) You matter: we want to get to know you; iii) Your family is important to us.

Conclusion

The complexity of PC discourses contributes to the difficulty of identifying a clear universal message between PC professionals, patients and families. The PC professionals observed transmit a simple message focused on their actions rather than their identity, which may perpetuate some social/cultural misunderstandings of PC. It seems there is a common culture, based on the same values and attitudes, within the messages that PC professionals transmit to patients and their families. PC teams are characterised by their availability.

A sense of security in palliative homecare in a Norwegian municipality; dyadic comparisons of the perceptions of patients and relatives - a quantitative study

BACKGROUND

As palliative care increasingly takes place in patients' homes, perceptions of security among patients in the late palliative phase and their relatives are important.

AIM

To describe and compare patient-relative dyads regarding their perceptions of security in palliative homecare, including the perceived security of the actual care given to the patients, as well as the subjective importance of that care.

METHODS

A cross sectional questionnaire study including 32 patient-relative dyads was conducted in an urban municipality in Norway. Patients were in a late palliative phase and received palliative homecare. Each patient proposed one relative. Data were collected using a modified version of the Quality from the Patients' Perspective instrument (QPP), which focuses on security and comprises three dimensions: medical-technical competence, identity-orientation approach and physical-technical conditions. Context-specific scales containing four aspects (competence, continuity, coordination/cooperation, availability) were added. The instrument contains two response scales; perceived reality (PR) and subjective importance (SI). Data were analysed by descriptive statistics, Chi-squared test, T-test and Wilcoxon's signed rank test.

RESULTS

Patients had high mean scores on the PR-scale for the sense of security in palliative homecare in the dimensions of medical-technical competence and physical-technical conditions. There were three low mean scores on the PR-scale: the aspect of continuity from patients and the aspects of continuity and coordination/cooperation from relatives. The patients scored the SI scale statistically significantly higher than the PR scale in the identity-orientation approach dimension and in the aspect of continuity, while relatives did so in all dimensions and aspects. The intra-dyadic patient-relative comparisons show statistically significant lower scores from relatives on the PR-scale in the dimensions of medical-technical competence, physical-technical conditions, identity-orientation approach and the aspect coordination/cooperation.

CONCLUSIONS

There are several statistically significant differences between patients and relatives' perceptions of security in the palliative homecare received (PR) compared with the subjective importance of the care (SI) and statistically significant differences in the patient-relative dyads in PR. A relatively mutual sense of security in palliative homecare is important for patient-relative dyads, as relatives often provide care and act as patients' spokespersons. What they assess as important can guide the development of palliative homecare.

Caregiver Decision-Making for Terminally Ill Children: A Qualitative Study

INTRODUCTION

Many children are born with life-limiting illnesses. Medical decision-making for these children by caregivers is complex and causes significant psychosocial distress, which can be partially alleviated by effective communication with medical providers. In order for providers to support caregivers, this study explores how caregivers make decisions regarding the medical care of their terminally ill children.

METHODS

Semistructured interviews were conducted among caregivers of terminally ill children. Participation was voluntary and confidential. The institutional review board approved the protocol. Transcripts were read and coded by 2 authors using inductive, concurrent analysis to reach thematic saturation and generate common themes.

RESULTS

Nine interviews were completed, discussing the care of 10 children. Caregivers described decision-making as impacted by their relationships with medical providers of 2 distinct types-trusting and nontrusting. Trusting relationships were notable for a longitudinal relationship with medical staff who empowered caregivers and treated the patient primarily as a child. Nontrusting relationships were noted when the medical team objectified their child as a "patient" and appeared to withhold information. Also, nontrusting relationships occurred when caregivers felt frustration with needing to educate health-care providers about their child's illness.

CONCLUSION

Decision-making by caregivers of terminally ill children is complex, and supporting families in this process is a critical role of all medical providers. A trusting relationship with medical team members was identified as an effective tool for well-supported decision-making, which can potentially alleviate the suffering of the child and distress of the caregivers during this emotionally charged time.

Content Analysis in Critical and Emergency Care: A Discussion Paper

Introduction

Content analysis, although firstly introduced in social sciences as a qualitative research method, has become a popular method for inquiry in healthcare sciences, including emergency and critical care nursing.

Aim

The aim of content analysis is to interpret qualitative data through coding and analytical identification of themes or schemas.

Results

There are different forms of content analysis, according to the aim of the study, (a) the conventional approach, (b) the direct approach, and (c) the summative approach. The depth of the analysis is defined by the degree to which the researcher reveals the covered meanings included in data. The range of the analysis is defined by the number of the identified themes and relevant categories of themes, and mainly of how abstract is the identified association among the different categories of themes. Balancing the strengths against the researcher-identified limitations and other weaknesses of the study, the researchers determine the value or trustworthiness of study findings, aiming to increase the transferability of the findings to other populations.

Conclusion

Qualitative research is under-used as a research method in emergency and critical care despite the limitless variations of clinical research questions that can be investigated through this method of inquiry and relevant study designs, including content analysis.

Selecting the Best Instrument to Measure Family Perceptions of End-of-Life Communication in Intensive Care Units

BACKGROUND

Good communication with the family is a clinical imperative for high quality end-of-life (EOL) care in intensive care unit (ICU). Many interventions aim to improve EOL communication, and the choice of an outcome instrument has important implications for evaluating interventions. The purpose of this project is to search and review available instruments' psychometric properties and determine which best measures family-clinician communication in the ICU.

METHOD

A stepwise method was used by searching 2 databases (PsycInfo and Web of Science) to identify instruments and articles that provide information about scale psychometric properties.

INSTRUMENTS

Three instruments were identified, including Family Inpatient Communication Survey, Family Perception of Physician-Family Caregiver Communication, and Quality of Communication (QOC).

RESULTS

Reliability estimates were high (≥ 0.79) in all 3 instruments. The QOC's convergent validity estimates exceed its discriminant validity values, and the QOC is an intervention-sensitive measure used to examine families' treatment response in randomized control trials.

CONCLUSION

Quality of Communication is the most suitable instrument to measure family's perceptions of EOL communication in the ICU. Quality of Communication scores provide a deeper understanding of family-clinician communication and data about how to improve EOL care in ICUs.

A Linguistic Model of Communication Types in Palliative Medicine: Effects of Multidrug-Resistant Organisms Colonization or Infection and Isolation Measures in End of Life on Family Caregivers' Knowledge, Attitude, and Practices

Background: This study examines communication profiles and associated attitudes toward health care professionals in interviews with family caregivers of hospitalized patients with confirmed multidrug-resistant organisms (e.g., methicillin-resistant Staphylococcus aureus or multiresistant gram-negative bacteria) diagnosis at the end of life. Objectives: This study aims to replicate and complement findings from a previous investigation using a different methodological framework. The benefits of linguistic research in medical contexts are highlighted. Design: Fifty interviews with family caregivers were analyzed linguistically. The considered parameters include lexical choices such as evaluative wording, metaphors, and specialized terminology, as well as higher level categories-turn-taking, sentence-length, and personal deixis. These characteristics serve to assess attitudes toward medical staff, hygiene measures, knowledge, and its transfer and general emotional states. Conclusions: Linguistic expertise adds benefits to the classical analysis of language data as used in social sciences. Family caregivers' linguistic and attitudinal profiles vary depending on whether their involvement in the overall situation is active or passive, and whether their relationship toward staff and hospital is cooperative or confrontative. Depending on the four possible combinations of those characteristics, different recommendations for communication strategies on the staff's side can be given. In all cases, clear and patient/family centeredness are considered beneficial.

Perceptions of palliative care in a lower middle-income Muslim country: A qualitative study of health care professionals, bereaved families and communities

BACKGROUND:

Palliative care has been successfully integrated into many Muslim-majority countries, most frequently in urbanised areas with developed health care systems. Less is known as to how the concept of palliative care is perceived by Muslim populations and health workers in rural, resource-limited contexts.

AIM:

This study seeks to explore whether the principles of palliative care are congruent with the perspectives of health professionals, families and communities in rural areas of the Islamic Republic of Mauritania, in West Africa.

DESIGN:

A qualitative research design was employed underpinned by a constructionist paradigm. Data were collected through 31 interviews and 8 focus groups. Data were analysed using thematic analysis.

SETTING/PARTICIPANTS:

A total of 76 participants were recruited from across rural Mauritania; 33 health care professionals, 12 recently bereaved family members and 31 community leaders. Data collection occurred during training events in the capital and visits to villages and rural health posts.

RESULTS:

Three major themes were identified. First, there is a perceived lack of congruency between an illness which limits life and the strong belief in destiny. The second theme describes the perceived barriers to communication of issues relating to palliative care. Finally, a good death is described, framed within the interplay of religious faith and cultural practices.

CONCLUSION:

The palliative care ethos is viewed positively by the majority of participants. The need to understand and respect a Muslim individual’s faith does not diminish our obligation to personalise palliative care provided for them and their family.

Health Professionals Perceived Concerns and Challenges in Providing Palliative and End-of-Life Care: A Qualitative Analysis

Background:

The Institute of Medicine identifies that quality palliative/end-of-life (EOL) care should be provided to patients with serious, life-limiting illnesses and their families by competently prepared health professionals.

Purpose:

This study assessed perceived concerns of health professionals pertaining to the delivery of palliative/EOL care in the hospital setting. The specific aim was to determine thematic concerns in the delivery of palliative/EOL care which emerged from respondents’ impressions of a memorable palliative/EOL patient experience.

Methods:

Interdisciplinary health professionals at a large academic health system in the Midwest were surveyed to reflect upon a memorable palliative/EOL life care patient situation (positive or negative). A Thematic Analysis approach was used to code qualitative responses to 4 open-ended questions and then extract themes and subthemes from the coded data.

Results:

Concerns identified by participants (N = 425) emerged around 7 themes including communication (97%), decision-making/care planning (75%), education needs (60%), EOL care (48%), ethics (24%), satisfaction with care (9%), and spiritual/cultural sensitivity (6%).

Conclusion:

Challenges exist in the delivery of quality palliative/EOL care in the hospital setting which may be addressed through educational initiatives that focus on recognition of cultural influences on care preferences, improving communication between patients/families and providers, education about the differences between palliative and EOL care, and increased competency of health providers in having EOL/goals-of-care discussions. Health professionals must recognize the benefit of collaborative palliative care in order to meet patient and family needs holistically and comprehensively.

Should End-of-Life Preferences Be Discussed Routinely before High-Risk Surgery?

Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of peritoneal dialysis. It is characterized by peritoneal neovascularization, fibrosis, and calcification ultimately leading to intestinal obstruction and eventual failure. Surgery for EPS has a mortality approaching 50% and most patients require some form of postoperative life-sustaining therapy (LST) during their admission. A 43-year-old gentleman with progressive EPS and significant comorbidities was assessed for enterolysis after a failed first attempt at another center. Because of his comorbidities, postoperative mortality was quoted above 50%. The patient favored surgery to improve his survival and quality of life, but was reluctant to receive prolonged LST in the event of failure of surgical therapy. The surgical team, in conjunction with a palliative care physician, therefore held extensive discussions with the patient and his partner regarding LST and its limitations. Clinical parameters to trigger a transition to palliative care were identified and agreed. Limitations on LST that are directly expressed by patients can represent a contraindication to surgery for many surgeons. Surgical Buy-In is a concept described as a perceived contract, or covenant, between the patient and clinician regarding implied consent for postoperative LST. Currently, preoperative discussions regarding limitations of LST are infrequent, and there can be reticence among patients and surgeons to have these conversations, leading to dissatisfaction on behalf of the patient and their family. After the Montgomery legal ruling, the provision and perception of informed consent are particularly pertinent. The palliative care physician is uniquely placed to contribute to such discussions as part of the surgical multidisciplinary team.

Patient Views on Advance Care Planning in Cirrhosis: A Qualitative Analysis

AIM

To investigate patient experiences and perceptions of advance care planning (ACP) process in cirrhosis.

METHODS

Purposive sampling was used to identify and recruit participants (N = 17) from discrete patient groups: compensated with no prior decompensation, decompensated and not yet listed for transplant, transplant wait listed, medical contraindications for transplant, and low socioeconomic status. Review and discussion of local ACP videos, documents, and experiences with ACP occurred in two individual interviews and four focus groups. Data were analyzed using inductive content analysis including iterative processes of open coding, categorization, and abstraction.

RESULTS

Three overarching categories emerged: (1) lack of understanding about disease trajectories and ACP processes, (2) roles of alternate decision makers, and (3) preferences for receiving ACP information. Most patients desired advanced care-planning conversations before the onset of decompensation (specifically hepatic encephalopathy) with a care provider with whom they had a trusting, preexisting relationship. Involvement of the alternate decision makers was of critical importance to participants, as was the use of direct, easy to understand patient education tools that address practical issues.

CONCLUSION

Our findings support the need for early advance care planning in the outpatient setting. Outpatient clinicians may play a key role in facilitating these discussions.

Speaking a Different Language: A Qualitative Analysis Comparing Language of Palliative Care and Pediatric Intensive Care Unit Physicians

BACKGROUND

Family conferences in the pediatric intensive care unit (ICU) often include palliative care (PC) providers. We do not know how ICU communication differs when the PC team is present.

AIM

To compare language used by PC team and ICU physicians during family conferences.

DESIGN

A retrospective cohort review of ICU family conferences with and without the PC team.

SETTING

Forty-four bed pediatric ICU in a tertiary medical center.

PARTICIPANTS

Nine ICU physicians and 4 PC providers who participated in 18 audio-recorded family conferences.

RESULTS

Of the 9 transcripts without the PC team, we identified 526 ICU physician statements, generating 10 thematic categories. The most common themes were giving medical information and discussing medical options. Themes unique to ICU physicians included statements of hopelessness, insensitivity, and "health-care provider challenges." Among the 9 transcripts with the PC team, there were 280 statements, generating 10 thematic categories. Most commonly, the PC team offered statements of support, giving medical information, and quality of life. Both teams promoted family engagement by soliciting questions; however, the PC team was more likely to use open-ended questions, offer support, and discuss quality of life.

CONCLUSION

Pediatric ICU physicians spend more time giving medical information, whereas the PC team more commonly offers emotional support. The addition of the PC team to ICU family conferences may provide a balanced approach to communication.