End-of-life practices in Danish ICUs: development and validation of a questionnaire

Withholding and withdrawal of life-sustaining treatments in intensive care units in Lebanon: a cross-sectional survey of intensivists and interviews of professional societies, legal and religious leaders

Background

Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU).

Methods

A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders.

Results

Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect” (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate).

Conclusion

Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.

Developing a Tool for Evaluation of Causes of Futile Care in Intensive Care Units

Background:

In Iran, futile care has become a challenge for intensive care nurses. The aim of the study was to develop a tool for assessing the reasons of futile care at intensive care units (ICUs).

Materials and Methods:

A sequential mixed method in three stages was applied. In the first stage, a phenomenological study was performed with van Manen's method by interviewing 25 nurses at ICUs of 11 hospitals in Qazvin. To extract the items of the tool in the second stage, the concept of futile care in ICUs and its reasons were defined. Ultimately, the psychometric properties of the questionnaire were evaluated with face validity, content validity (quantitative and qualitative), construct validity (exploratory factor analysis), internal consistency (Cronbach's alpha), and test–retest reliability.

Results:

The initial tool had 119 questions. After validation, 39 items remained in the final questionnaire. Five extracted factors were as follows: professional competence (14 items), organizational policy (9 items), socio-cultural factors (7 items), personal beliefs and values (4 items), and legal issues (5 items). Cronbach's alpha for the whole questionnaire was 0.91 (range: 0.71–0.96). The test–retest reliability was 0.87 (p < 0.001).

Conclusions:

Nursing managers and clinical nurses can use this tool to identify the causes of futile care and reduce it in their clinical settings. Policy makers can use this tool for improving the management of ICUs.

Is the current level of training in the use of equipment for prehospital radio communication sufficient? A cross-sectional study among prehospital physicians in Denmark

BACKGROUND

Physicians working in prehospital care are expected to handle radio communication both within their own sector as well as with other divisions of the National Emergency Services. To date, no study has been conducted on the level of training received by physicians in the use of the equipment provided or on the level of competency acquired by physicians.

METHODS

In order to investigate the self-assessed skill level acquired in the use of the TETRA (TErrestrial Trunked RAdio) authority radio for communication in a prehospital setting, a cross-sectional study was conducted by questionnaire circulated to all 454 physicians working in the Danish Emergency Medical Services.

RESULTS

A lack of training was found among physicians working in prehospital care in Denmark in relation to the proper use of essential communication equipment. Prior to starting their first shift in a prehospital setting 38% of physicians reported having received no training in the use of the equipment, while 80% of physicians reported having received one1 hour of training or less. Among the majority of physicians their current level of training was sufficient for their everyday needs for prehospital communication but for 28% of physicians their current level of training was insufficient as they were unable to handle communication at this level.

CONCLUSION

As the first study in its field, this study investigated the training received in the use of essential communication equipment among physicians working in prehospital care in Denmark. The study found that competency does not appear to have been prioritised as highly as other technical skills needed to function in these settings. For the majority of physicians their current level of training was sufficient for everyday use but for a substantial minority further training is required, especially if the redundancy of the prehospital system is to be preserved.

Families' experiences of intensive care unit quality of care: Development and validation of a European questionnaire (euroQ2)

PURPOSE

The purpose of the study is to adapt and provide preliminary validation for questionnaires evaluating families' experiences of quality of care for critically ill patients in the intensive care unit (ICU).

MATERIALS AND METHODS

This study took place in 2 European ICUs. Based on literature and qualitative interviews, we adapted 2 previously validated North American questionnaires: "Family Satisfaction with the ICU" and "Quality of Dying and Death." Family members were asked to assess relevance and understandability of each question. Validation also included test-retest reliability and construct validity.

RESULTS

A total of 110 family members participated. Response rate was 87%. For all questions, a median of 97% (94%-99%) was assessed as relevant, and a median of 98% (97%-100%), as understandable. Median ceiling effect was 41% (30%-47%). There was a median of 0% missing data (0%-1%). Test-retest reliability showed a median weighted κ of 0.69 (0.53-0.83). Validation showed significant correlation between total scores and key questions.

CONCLUSIONS

The questions were assessed as relevant and understandable, providing high face and content validity. Ceiling effects were comparable to similar instruments; missing data, low; and test-retest reliability, acceptable. These measures are promising for use in research, but further validation is needed before they can be recommended for routine clinical use.

Guidelines for withholding and withdrawing therapy in the ICU: impact on decision-making process and interdisciplinary collaboration

INTRODUCTION

Interdisciplinary collaboration in end-of-life decision-making is challenging. Guidelines developed within the interdisciplinary team may help to clarify, describe, and obtain consensus on standards for end-of-life decision-making and care. The aim of the study was to develop, implement, and evaluate guidelines for withholding and withdrawing therapy in the intensive care unit.

METHODS

An intervention study in two Danish intensive care units, evaluated in a pre-post design by a retrospective hospital record review and a questionnaire survey. The hospital record review included 1,665 patients at baseline (12-month review) and 897 patients after the intervention (6-month review). The questionnaire survey included 273 nurses, intensivists, and primary physicians at baseline and 229 post-intervention.

RESULTS

For patients with therapy withdrawn, the median time from admission to first consideration on level of therapy decreased from 1.1 to 0.4 days (p=0.03), and the median time from admission to a withdrawal decision decreased from 3.1 to 1.1 days (p=0.02). Sixty-five percent of the participants who used the guidelines concerning end-of-life decision-making considered them helpful to high or very high extent. No significant changes were found in satisfaction with interdisciplinary collaboration or in withholding or withdrawing decisions being changed or unnecessarily postponed. The healthcare professionals' perception of the care following withdrawal of therapy increased significantly after implementation of the guidelines.

CONCLUSIONS

The study indicates that working with guidelines for withholding and withdrawing therapy in the intensive care unit may facilitate improvements in end-of-life decision-making and patient care, but further studies are needed to provide robust evidence.