The Stresses of Surrogate Decision-Making: Contributing Factors and Clinicians' Role in Mitigation

How can family members of patients in the intensive care unit be supported? A systematic review of qualitative reviews, meta-synthesis, and novel recommendations for nursing care

Background

Families are an important part of the intensive care unit (ICU) team. Being a family member in the ICU can be distressing due to interacting factors, such as the critical condition of the patient, the responsibility of acting as the patient's advocate, and partaking in decision-making related to treatment. Nurses need to be aware of the family's well-being throughout the patient's ICU stay.

Objective

To synthesize reviews of family members' experiences and needs during patients' ICU admission and develop recommendations to support nurses in strengthening their relationships with families.

Design

Systematic review of qualitative and mixed method reviews.

Data sources

Extensive searches without time limits identified systematic reviews published until June 27, 2024 in CINAHL, PubMed, Scopus, and Web of Science. Reviews were eligible if they provided knowledge required to inform high-quality on-site family care during the patient's ICU admission.

Review methods

Quality appraisal adhered to the Joanna Briggs Institute checklist for systematic reviews and research syntheses. Themes were generated by integrating review results and narratively summarizing the main contents. Finally, findings were translated into clinical practice recommendations by using the four-component GRADE-CERQual assessment (low to high recommendation grades). Recommendations were backtracked to primary research studies for validation. All recommendations were critically reflected upon with an expert panel of ICU nurses.

Results

The nine included reviews were built on 124 original studies published between 1995 and 2021. One central theme, "Emotional limbo and extreme moments", mirrored the core of families' experiences characterized by waiting time, i.e., for the patient to get better or worse, and overwhelming emotions and confusion brought about by the patient's critical illness. Three sub-themes reflected actions to counterbalance emotional challenges: a) Responding to family members' existential needs, b) Establishing optimal grounds for reciprocal communication, and c) Enhancing a humanizing approach and atmosphere in the ICU. The meta-synthesis resulted in 11 aggregated recommendations. The findings highlighted that nurses should proactively address emotional issues to help preserve families' ability to keep going, allow families to be present and function as a part of the team, and inform families of the patient's situation and how they can practically help.

Conclusions

Nurses should use multiple adjustable approaches to alleviate family's burden during an ICU stay. Findings help nurses to prioritize care and make physical and emotional space for family caregivers. Results emphasize the need to facilitate the agency of family caregivers and reinforce their strengths through nurse-family dialogues.

Tweetable abstract

Novel recommendations to enhance nursing care of family members to patients admitted to the Intensive Care Unit.

Autonomous by Extension: Balancing Patient Autonomy and Vulnerability in Surrogate Decision-making

The experience of serious illness or injury frequently results in increased vulnerability. In cases in which decision-making capacity is compromised, this vulnerability is compounded by threats to a patient's autonomy. This case report presents an opportunity to explore the elaborately entwined relationship between autonomy and vulnerability in patients with severe impairment who are reliant on surrogate decision-makers. Expanded views of autonomy and vulnerability are applied to the case of a young woman with a severe and life-altering spinal cord injury and iatrogenic loss of decisional capacity to illustrate how one can experience enhanced autonomy despite special vulnerability and can be made less vulnerable through surrogate-mediated autonomy. Also revealed is how attitudes and actions of surrogates can potentiate pathogenic vulnerability and disturb the balance between patient autonomy and vulnerability. Through methodical review and robust deliberation, clinical ethics committees can play a stabilizing role in helping distressed care teams reconcile the two.

Palliative Care Psychiatry: Building Synergy Across the Spectrum

PURPOSE OF REVIEW

Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry.

RECENT FINDINGS

PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.