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Imai L, Gray MM, Kim BJH, Lyle ANJ, Bock A, Weiss EM. Clinician perception of care at the end of life in a quaternary neonatal intensive care unit. Front Pediatr 2023; 11:1197360. [PMID: 37384313 PMCID: PMC10293892 DOI: 10.3389/fped.2023.1197360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/16/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Care for neonates at the end of life (EOL) is often challenging for families and medical teams alike, performed suboptimally, and requires an experienced and compassionate clinician. Much literature exists on adult and pediatric EOL care, but limited studies examine the neonatal process. Methods We aimed to describe clinicians' experiences around EOL care in a single quaternary neonatal intensive care unit as we implemented a standard guideline using the Pediatric Intensive Care Unit-Quality of Dying and Death 20 tool. Results Surveys were completed by 205 multidisciplinary clinicians over three time periods and included 18 infants at EOL. While most responses were high, a meaningful minority were below goal (<8 on 0-10 scale) for troubling symptom management, conflict between parents and staff, family access to resources, and parent preparation of symptoms. Comparison between Epochs revealed improvement in one symptom management and four communication categories. Satisfaction scores related to education around EOL were better in later Epochs. Neonatal Pain, Agitation, and Sedation Scale scores were low, with few outliers. Discussion These findings can guide those aiming to improve processes around neonatal EOL by identifying areas with the greatest challenges (e.g., conflict management) and areas that need further study (e.g., pain management around death).
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Affiliation(s)
- Lauren Imai
- Division of Neonatology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Megan M. Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Brennan J. H. Kim
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Allison N. J. Lyle
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Amber Bock
- Department of Hospital Medicine, Seattle Children’s Hospital, Seattle, WA, United States
| | - Elliott Mark Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, United States
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Hicks KG, Downey L, Elketami A, Nielsen EL, Engelberg RA, Jennerich AL. Before-After Study of a Checklist to Improve Acute Care to ICU Handoffs. Am J Med Qual 2023; 38:37-46. [PMID: 36350159 PMCID: PMC9805500 DOI: 10.1097/jmq.0000000000000091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Transferring care of a patient is a critical process. The objective of this study was to evaluate a checklist to standardize handoffs from acute care to the intensive care unit (ICU). This was a single-center, before-after study of a checklist to standardize transfers of patients from acute care to the medical-cardiac ICU. Clinicians completed surveys about handoffs before and after checklist implementation. The association between study period and survey data was analyzed using multivariable logistic regression with cross-classified multilevel models. Surveys were completed by 179 clinicians. After checklist implementation, handoffs were more likely to occur in the ICU (OR 17.23; 95% CI, 1.81-164.19) and cover patient treatment preferences (OR 2.73; 95% CI, 1.12-6.66). However, checklist uptake was suboptimal (30% of responses indicated checklist use). Implementation of a checklist during acute care to ICU transfers is challenging. Signals suggesting process improvement warrant additional study.
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Affiliation(s)
- Katherine G. Hicks
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Addy Elketami
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ann L. Jennerich
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Kinder D, Thorpe J, Smith D, Wachterman M, Kutney-Lee A. Psychometric Evaluation of the Veterans Affairs Bereaved Family Survey in Community Nursing Homes. J Pain Symptom Manage 2022; 64:e317-e322. [PMID: 36103938 DOI: 10.1016/j.jpainsymman.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT For over a decade, the Department of Veterans Affairs (VA) has used the Bereaved Family Survey (BFS) to measure the quality of end-of-life (EOL) care in VA inpatient settings. In 2019, VA developed a revised version of the BFS to evaluate the quality of EOL care for Veterans who received hospice services in VA-contracted community nursing homes (CNHs). OBJECTIVES The purpose of this analysis was to evaluate the psychometric properties and factor structure of the BFS-CNH. METHODS The BFS-CNH was administered to the next-of-kin of Veterans who died in a VA-contracted CNH with hospice care between October 2019 and April 2020. Exploratory factor analysis (EFA) was used with the 10 core items of the BFS-CNH that were derived from the inpatient BFS to evaluate whether the BFS-CNH exhibited a similar factor structure to the inpatient version. Cronbach's alpha was used to assess internal consistency/reliability of the identified factors and linear regression models were used to evaluate construct validity of the identified BFS-CNH factor scores and individual items. RESULTS The EFA revealed a three-dimension solution that corresponded to factors on the inpatient BFS, including Care and Communication, Emotional and Spiritual Support and Death Benefits. Cronbach's alpha coefficients for all three factors indicated acceptable internal consistency. CONCLUSION Our findings provide support for use of the BFS-CNH to evaluate the quality of EOL care provided to Veterans in CNHs and lay the foundation for future comparisons of BFS ratings between VA inpatient and CNH settings.
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Affiliation(s)
- Daniel Kinder
- Veteran Experience Center (D.K.,D.S.,A.K-L.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
| | - Joshua Thorpe
- Center for Health Equity Research and Promotion (J.T,), Pittsburgh VA Medical Center, Pittsburgh, Pennsylyania, USA; UNC Eshelman School of Pharmacy (J.T.), Chapel Hill, North Carolina, USA
| | - Dawn Smith
- Veteran Experience Center (D.K.,D.S.,A.K-L.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Melissa Wachterman
- Veterans Affairs Boston Healthcare System (M.W.), Boston, Massachusetts, USA; Division of General Internal Medicine and Primary Care, Department of Medicine (M.W.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (M.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ann Kutney-Lee
- Veteran Experience Center (D.K.,D.S.,A.K-L.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing (A.K-L.), Philadelphia, Pennsylyania, USA
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Dzeng E, Merel SE, Kross EK. J. Randall Curtis's Legacy and Scientific Contributions to Palliative Care in Critical Care. J Pain Symptom Manage 2022; 63:e587-e593. [PMID: 35595372 DOI: 10.1016/j.jpainsymman.2022.02.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine (E.D.), Department of Medicine, University of California, San Francisco, California, USA; Cicely Saunders Institute (E.D.), King's College London, London, UK.
| | - Susan E Merel
- Division of General Internal Medicine (S.E.M.), Department of Medicine, University of Washington, Seattle, Washington State, USA; Cambia Palliative Care Center of Excellence at UW Medicine (S.E.M., E.K.K.), Seattle, Washington State, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at UW Medicine (S.E.M., E.K.K.), Seattle, Washington State, USA; Division of Pulmonary (E.K.K.), Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington State, USA
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Tang ST, Huang CC, Hu TH, Lo ML, Chou WC, Chuang LP, Chiang MC. End-of-Life-Care Quality in ICUs Is Associated With Family Surrogates' Severe Anxiety and Depressive Symptoms During Their First 6 Months of Bereavement. Crit Care Med 2021; 49:27-37. [PMID: 33116053 DOI: 10.1097/ccm.0000000000004703] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Evidence linking end-of-life-care quality in ICUs to bereaved family members' psychologic distress remains limited by methodological insufficiencies of the few studies on this topic. To examine comprehensively the associations of family surrogates' severe anxiety and depressive symptoms with end-of-life-care quality in ICUs over their first 6 months of bereavement. DESIGN Prospective, longitudinal, observational study. SETTING/PARTICIPANTS Family surrogates (n = 278) were consecutively recruited from seven medical ICUs at two academically affiliated medical centers in Taiwan. MEASUREMENTS AND STATISTICAL ANALYSIS Family surrogates' anxiety and depressive symptoms were assessed 1, 3, and 6 months postloss using the Hospital Anxiety and Depression Scale. Family satisfaction with end-of-life care in ICUs was assessed 1-month postloss by the Family Satisfaction in the ICU questionnaire. Patients' end-of-life care was documented over the patient's ICU stay. Associations of severe anxiety and depressive symptoms (scores ≥ 8 for each subscale) with end-of-life-care quality in ICUs (documented by patient care received and family satisfaction with end-of-life care in ICUs) were examined by multivariate logistic regression models with generalized estimating equation. MAIN RESULTS Prevalence of severe anxiety and depressive symptoms decreased significantly over time. Surrogates' lower likelihood of severe anxiety or depressive symptoms 3-6 month postloss was associated with death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and higher family satisfaction with end-of-life care in ICUs. Bereaved surrogates' higher likelihood of these symptoms was associated with physician-surrogate prognostic communication and conducting family meetings before patients died. CONCLUSIONS End-of-life-care quality in ICUs is associated with bereaved surrogates' psychologic well-being. Enhancing end-of-life-care quality in ICUs by improving the process of end-of-life care, for example, promoting death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and increasing family satisfaction with end-of-life care, can lighten bereaved family surrogates' severe anxiety symptoms and severe depressive symptoms.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, R.O.C
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
| | - Mei-Ling Lo
- School of Nursing, Medical College, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
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Lee RY, Engelberg RA, Curtis JR, Hough CL, Kross EK. Novel Risk Factors for Posttraumatic Stress Disorder Symptoms in Family Members of Acute Respiratory Distress Syndrome Survivors. Crit Care Med 2020; 47:934-941. [PMID: 30985448 DOI: 10.1097/ccm.0000000000003774] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Family members of ICU survivors report long-term psychologic symptoms of posttraumatic stress disorder. We describe patient- and family-member risk factors for posttraumatic stress disorder symptoms among family members of survivors of acute respiratory distress syndrome. DESIGN Prospective cohort study of family members of acute respiratory distress syndrome survivors. SETTING Single tertiary care center in Seattle, Washington. SUBJECTS From 2010 to 2015, we assembled an inception cohort of adult acute respiratory distress syndrome survivors who identified family members involved in ICU and post-ICU care. One-hundred sixty-two family members enrolled in the study, corresponding to 120 patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Family members were assessed for self-reported psychologic symptoms 6 months after patient discharge using the Posttraumatic Stress Disorder Checklist-Civilian Version, the Patient Health Questionnaire 9-item depression scale, and the Generalized Anxiety Disorder 7-item scale. The primary outcome was posttraumatic stress disorder symptoms, and secondary outcomes were symptoms of depression and anxiety. We used clustered multivariable logistic regression to identify patient- and family-member risk factors for psychologic symptoms. Posttraumatic stress disorder symptoms were present in 31% (95% CI, 24-39%) of family participants. Family member risk factors for posttraumatic stress disorder symptoms included preexisting mental health disorders (adjusted odds ratio, 3.22; 95% CI, 1.42-7.31), recent personal experience of serious physical illness (adjusted odds ratio, 3.07; 95% CI, 1.40-6.75), and female gender (adjusted odds ratio, 5.18; 95% CI, 1.74-15.4). Family members of previously healthy patients (Charlson index of zero) had higher frequency of posttraumatic stress disorder symptoms (adjusted odds ratio, 2.25; 95% CI, 1.06-4.77). Markers of patient illness severity were not associated with family posttraumatic stress disorder symptoms. CONCLUSIONS The prevalence of long-term posttraumatic stress disorder symptoms among family members of acute respiratory distress syndrome survivors is high. Family members with preexisting mental health disorders, recent experiences of serious physical illness, and family members of previously healthy patients are at increased risk for posttraumatic stress disorder symptoms.
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Affiliation(s)
- Robert Y Lee
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
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Richards CA, Hebert PL, Liu CF, Ersek M, Wachterman MW, Taylor LL, Reinke LF, O’Hare AM. Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services. JAMA Netw Open 2019; 2:e1913115. [PMID: 31603487 PMCID: PMC6804019 DOI: 10.1001/jamanetworkopen.2019.13115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/23/2019] [Indexed: 12/01/2022] Open
Abstract
Importance Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care. Objectives To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death. Design, Setting, and Participants This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019. Exposure Cessation of dialysis treatment before death. Main Outcomes and Measures Bereaved Family Survey ratings. Results Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001). Conclusions and Relevance This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Paul L. Hebert
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Chuan-Fen Liu
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center–Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Melissa W. Wachterman
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leslie L. Taylor
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
| | - Lynn F. Reinke
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- School of Nursing, Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - Ann M. O’Hare
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- University of Washington School of Medicine, Seattle
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Richards CA, Liu CF, Hebert PL, Ersek M, Wachterman MW, Reinke LF, Taylor LL, O’Hare AM. Family Perceptions of Quality of End-of-Life Care for Veterans with Advanced CKD. Clin J Am Soc Nephrol 2019; 14:1324-1335. [PMID: 31466952 PMCID: PMC6730503 DOI: 10.2215/cjn.01560219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/24/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the quality of end-of-life care for patients with advanced CKD. We describe the relationship between patterns of end-of-life care and dialysis treatment with family-reported quality of end-of-life care in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed a retrospective observational study among a national cohort of 9993 veterans with advanced CKD who died in Department of Veterans Affairs facilities between 2009 and 2015. We used logistic regression to evaluate associations between patterns of end-of-life care and receipt of dialysis (no dialysis, acute dialysis, maintenance dialysis) with family-reported quality of end-of-life care. RESULTS Overall, 52% of cohort members spent ≥2 weeks in the hospital in the last 90 days of life, 34% received an intensive procedure, and 47% were admitted to the intensive care unit, in the last 30 days, 31% died in the intensive care unit, 38% received a palliative care consultation in the last 90 days, and 36% were receiving hospice services at the time of death. Most (55%) did not receive dialysis, 12% received acute dialysis, and 34% received maintenance dialysis. Patients treated with acute or maintenance dialysis had more intensive patterns of end-of-life care than those not treated with dialysis. After adjustment for patient and facility characteristics, receipt of maintenance (but not acute) dialysis and more intensive patterns of end-of-life care were associated with lower overall family ratings of end-of-life care, whereas receipt of palliative care and hospice services were associated with higher overall ratings. The association between maintenance dialysis and overall quality of care was attenuated after additional adjustment for end-of-life treatment patterns. CONCLUSIONS Among patients with advanced CKD, care focused on life extension rather than comfort was associated with lower family ratings of end-of-life care regardless of whether patients had received dialysis.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Chuan-Fen Liu
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Paul L. Hebert
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa W. Wachterman
- Section of General Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lynn F. Reinke
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, and
| | - Leslie L. Taylor
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Ann M. O’Hare
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- School of Medicine, University of Washington, Seattle, Washington
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Turnbull AE, Bosslet GT, Kross EK. Aligning use of intensive care with patient values in the USA: past, present, and future. THE LANCET RESPIRATORY MEDICINE 2019; 7:626-638. [PMID: 31122892 DOI: 10.1016/s2213-2600(19)30087-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 10/26/2022]
Abstract
For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Department of Epidemiology, Bloomberg School of Public Health, and Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Gabriel T Bosslet
- Division of Pulmonary, Allergy, Critical Care, Occupational, and Sleep Medicine, and Charles Warren Fairbanks Center for Medical Ethics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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Long AC, Kross EK, Curtis JR. Family-centered outcomes during and after critical illness: current outcomes and opportunities for future investigation. Curr Opin Crit Care 2018; 22:613-620. [PMID: 27685849 DOI: 10.1097/mcc.0000000000000360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Family-centered outcomes during and after critical illness assess issues that are most important to family members. An understanding of family-centered outcomes is necessary to support the provision of family-centered care and to foster development of interventions to improve care and communication in the ICU. RECENT FINDINGS Current family-centered outcomes in critical care include satisfaction with care, including end-of-life care, symptoms of psychological distress, and health-related quality of life. Novel measures include assessments of decisional conflict, decision regret, therapeutic alliance, and caregiver burden, as well as positive adaptations and resilience. SUMMARY Critical illness places a significant burden on family members. A wide variety of family-centered outcomes are available to guide improvements in care and communication. Future research should focus on developing sensitive and responsive measures that capture key elements of the family member experience during and after critical illness.
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Affiliation(s)
- Ann C Long
- aDivision of Pulmonary and Critical Care Medicine, Harborview Medical Center bCambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Willemse S, Smeets W, van Leeuwen E, Janssen L, Foudraine N. Spiritual Care in the ICU: Perspectives of Dutch Intensivists, ICU Nurses, and Spiritual Caregivers. JOURNAL OF RELIGION AND HEALTH 2018; 57:583-595. [PMID: 28801715 PMCID: PMC5854753 DOI: 10.1007/s10943-017-0457-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Since there are no scientific data available about the role of spiritual care (SC) in Dutch ICUs, the goal of this quantitative study was twofold: first, to map the role of SC as a part of daily adult ICU care in The Netherlands from the perspective of intensivists, ICU nurses, and spiritual caregivers and second, to identify similarities and differences among these three perspectives. This study is the quantitative part of a mixed methods approach. To conduct empirical quantitative cohort research, separate digital questionnaires were sent to three different participant groups in Dutch ICUs, namely intensivists, ICU nurses, and spiritual caregivers working in academic and general hospitals and one specialist oncology hospital. Overall, 487 participants of 85 hospitals (99 intensivists, 290 ICU nurses, and 98 spiritual caregivers) responded. The majority of all respondents (>70%) considered the positive effects of SC provision to patients and relatives: contribution to mental well-being, processing and channeling of emotions, and increased patient and family satisfaction. The three disciplines diverged in their perceptions of how SC is currently evolving in terms of information, assessment, and provision. Nationwide, SC is not implemented in daily ICU care. The majority of respondents, however, attached great importance to interdisciplinary collaboration. In their view SC contributes positively to the well-being of patients and relatives in the ICU. Further qualitative research into how patients and relatives experience SC in the ICU is required in order to implement and standardize SC as a scientifically based integral part of daily ICU care.
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Affiliation(s)
- Suzan Willemse
- Spiritual Care Department, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
| | - Wim Smeets
- Department of Spiritual and Pastoral Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, The Netherlands
| | - Evert van Leeuwen
- Department of Ethics, Philosophy and History of Medicine, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, EZ 6525 Nijmegen, The Netherlands
| | - Loes Janssen
- Department of Clinical Epidemiology, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
| | - Norbert Foudraine
- Department of Critical Care, VieCuri Medical Centre, P.O. Box 1926, 5900 BX Venlo, The Netherlands
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Hunt KJ, Richardson A, Darlington ASE, Addington-Hall JM. Developing the methods and questionnaire (VOICES-SF) for a national retrospective mortality follow-back survey of palliative and end-of-life care in England. BMJ Support Palliat Care 2017; 9:e5. [PMID: 29101120 DOI: 10.1136/bmjspcare-2016-001288] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 07/31/2017] [Accepted: 09/15/2017] [Indexed: 11/04/2022]
Abstract
The National Survey of Bereaved People was conducted by the Office for National Statistics on behalf of NHS England for the first time in 2011, and repeated annually thereafter. It is thought to be the first time that nationally representative data have been collected annually on the experiences of all people who have died, regardless of cause and setting, and made publicly available informing palliative and end-of-life policy, service provision and development, and practice. This paper describes the development of the questionnaire used in the survey, VOICES-SF, a short-form of the VOICES (Views Of Informal Carers-Evaluation of Services) questionnaire, adapted specifically to address the aims of the national survey. The pilot study to refine methods for the national survey is also described. The paper also reports on the development of the retrospective, after-death or mortality follow-back method in palliative and end-of-life care, and reviews its strengths and weaknesses.
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Affiliation(s)
- Katherine J Hunt
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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Dotolo D, Nielsen EL, Curtis JR, Engelberg RA. Strategies for Enhancing Family Participation in Research in the ICU: Findings From a Qualitative Study. J Pain Symptom Manage 2017; 54:226-230.e1. [PMID: 28438584 PMCID: PMC5557665 DOI: 10.1016/j.jpainsymman.2017.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/23/2017] [Accepted: 03/22/2017] [Indexed: 11/17/2022]
Abstract
CONTEXT Family members of critically ill patients who participate in research focused on palliative care issues have been found to be systematically different from those who do not. These differences threaten the validity of research and raise ethical questions about worsening disparities in care by failing to represent diverse perspectives. OBJECTIVES This study's aims were to explore: 1) barriers and facilitators influencing family members' decisions to participate in palliative care research; and 2) potential methods to enhance research participation. METHODS Family members who were asked to participate in a randomized trial testing the efficacy of a facilitator to improve clinician-family communication in the intensive care unit (ICU). Family members who participated (n = 17) and those who declined participation (n = 7) in Family Communication Study were interviewed about their recruitment experiences. We also included family members of currently critically ill patients to assess current experiences (n = 4). Interviews were audio-recorded and transcribed. Investigators used thematic analysis to identify factors influencing family members' decisions. Transcripts were co-reviewed to synthesize codes and themes. RESULTS Three factors influencing participants' decisions were identified: Altruism, Research Experience, and Enhanced Resources. Altruism and Research Experience described intrinsic characteristics that are less amenable to strategies for improving participation rates. Enhanced Resources reflects families' desires for increased access to information and logistical and emotional support. CONCLUSION Family members found their recruitment experiences to be positive when staff were knowledgeable about the ICU, sensitive to the stressful circumstances, and conveyed a caring attitude. By training research staff to be supportive of families' emotional needs and need for logistical knowledge about the ICU, recruitment of a potentially more diverse sample of families may be enhanced.
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Affiliation(s)
- Danae Dotolo
- School of Social Work, University of Washington, Seattle, Washington, USA.
| | - Elizabeth L Nielsen
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
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14
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Long AC, Downey L, Engelberg RA, Nielsen E, Ciechanowski P, Curtis JR. Understanding Response Rates to Surveys About Family Members' Psychological Symptoms After Patients' Critical Illness. J Pain Symptom Manage 2017; 54:96-104. [PMID: 28552830 PMCID: PMC5523827 DOI: 10.1016/j.jpainsymman.2017.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/06/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Achieving adequate response rates from family members of critically ill patients can be challenging, especially when assessing psychological symptoms. OBJECTIVES To identify factors associated with completion of surveys about psychological symptoms among family members of critically ill patients. METHODS Using data from a randomized trial of an intervention to improve communication between clinicians and families of critically ill patients, we examined patient-level and family-level predictors of the return of usable surveys at baseline, three months, and six months (n = 181, 171, and 155, respectively). Family-level predictors included baseline symptoms of psychological distress, decisional independence preference, and attachment style. We hypothesized that family with fewer symptoms of psychological distress, a preference for less decisional independence, and secure attachment style would be more likely to return questionnaires. RESULTS We identified several predictors of the return of usable questionnaires. Better self-assessed family member health status was associated with a higher likelihood and stronger agreement with a support-seeking attachment style with a lower likelihood, of obtaining usable baseline surveys. At three months, family-level predictors of return of usable surveys included having usable baseline surveys, status as the patient's legal next of kin, and stronger agreement with a secure attachment style. The only predictor of receipt of surveys at six months was the presence of usable surveys at three months. CONCLUSION We identified several predictors of the receipt of surveys assessing psychological symptoms in family of critically ill patients, including family member health status and attachment style. Using these characteristics to inform follow-up mailings and reminders may enhance response rates.
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Affiliation(s)
- Ann C Long
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Elizabeth Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Paul Ciechanowski
- Department of Psychiatry, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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15
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van der Plas AGM, Francke AL, Deliens L, Jansen WJJ, Vissers KC, Onwuteaka-Philipsen BD. Informal care givers' experiences with support in primary palliative care when a case manager is involved: A descriptive study in the Netherlands. INTERNATIONAL JOURNAL OF CARE COORDINATION 2016. [DOI: 10.1177/2053434516685738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Case managers have been introduced in primary palliative care in the Netherlands; these are nurses with expertise in palliative care who offer support to patients and informal care givers. The case manager provides support in addition to the care provided by the home care nurse and general practitioner, potentially leading to more complexities in care coordination. This study describes what informal care givers think about the number of professionals involved in primary palliative care and what support is and is not provided by the general practitioner, the community nurse and the case manager according to the informal care givers. Methods A questionnaire was filled in by the case manager upon referral, and the informal care giver ( n = 178) completed a questionnaire two months after the patient had died. Frequencies (the number of professionals) and cross tabs (for support) were calculated. Results The number of healthcare professionals involved was appropriate according to the vast majority (91%) of informal care givers. Support was provided by all three professionals, but a small proportion (14%) of informal care givers did not receive sufficient information on possibilities of care and support from any of the care providers. Discussion Reluctance to involve a case manager is unnecessary, as long as the role of each professional is explained to patients and informal care givers. At all times, support should be offered to the informal care givers as well as to the patient. Added value of the case manager is found in offering specific knowledge of palliative care.
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Affiliation(s)
| | - Anneke L Francke
- VU University Medical Center, the Netherlands
- NIVEL Netherlands Institute for Health Services Research
| | - Luc Deliens
- Vrije Universiteit Brussel and Ghent University, Belgium
| | | | - Kris C Vissers
- Radboud University Nijmegen Medical Centre, the Netherlands
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16
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Disruptive Technology. Can Electronic Portals Promote Communication in the Intensive Care Unit? Ann Am Thorac Soc 2016; 13:309-10. [PMID: 26963352 DOI: 10.1513/annalsats.201512-807ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Calanzani N, Higginson IJ, Koffman J, Gomes B. Factors Associated with Participation, Active Refusals and Reasons for Not Taking Part in a Mortality Followback Survey Evaluating End-of-Life Care. PLoS One 2016; 11:e0146134. [PMID: 26745379 PMCID: PMC4706352 DOI: 10.1371/journal.pone.0146134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 12/14/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Examination of factors independently associated with participation in mortality followback surveys is rare, even though these surveys are frequently used to evaluate end-of-life care. We aimed to identify factors associated with 1) participation versus non-participation and 2) provision of an active refusal versus a silent refusal; and systematically examine reasons for refusal in a population-based mortality followback survey. METHODS Postal survey about the end-of-life care received by 1516 people who died from cancer (aged ≥18), identified through death registrations in London, England (response rate 39.3%). The informant of death (a relative in 95.3% of cases) was contacted 4-10 months after the patient died. We used multivariate logistic regression to identify factors associated with participation/active refusals and content analysis to examine refusal reasons provided by 205 nonparticipants. FINDINGS The odds of partaking were higher for patients aged 90+ (AOR 3.48, 95%CI: 1.52-8.00, ref: 20-49yrs) and female informants (AOR 1.70, 95%CI: 1.33-2.16). Odds were lower for hospital deaths (AOR 0.62, 95%CI: 0.46-0.84, ref: home) and proxies other than spouses/partners (AORs 0.28 to 0.57). Proxies of patients born overseas were less likely to provide an active refusal (AOR 0.49; 95% CI: 0.32-0.77). Refusal reasons were often multidimensional, most commonly study-related (36.0%), proxy-related and grief-related (25.1% each). One limitation of this analysis is the large number of nonparticipants who did not provide reasons for refusal (715/920). CONCLUSIONS Our survey better reached proxies of older patients while those dying in hospitals were underrepresented. Proxy characteristics played a role, with higher participation from women and spouses/partners. More information is needed about the care received by underrepresented groups. Study design improvements may guide future questionnaire development and help develop strategies to increase response rates.
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Affiliation(s)
- Natalia Calanzani
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
- University of Edinburgh, The Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, Medical School, Edinburgh, United Kingdom
- * E-mail:
| | - Irene J Higginson
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
| | - Jonathan Koffman
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
| | - Barbara Gomes
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
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18
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Turley M, Wang S, Meng D, Kanter MH, Garrido T. An information model for automated assessment of concordance between advance care preferences and care delivered near the end of life. J Am Med Inform Assoc 2015; 23:e118-24. [PMID: 26567328 DOI: 10.1093/jamia/ocv149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 08/29/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To develop an information model for automating evaluation of concordance between patient preferences and end-of-life care. METHODS We modeled and validated 15 end-of-life care preference option domains, to which we mapped preferences recorded in standardized advance care planning documents and 232 end-of-life care events defined by procedure and medication codes. Patient preferences and end-of-life care events were available in electronic health records. Data from Kaiser Permanente Southern California modeling and testing populations were evaluated for concordance between patients' preferences and the end-of-life care events they experienced. RESULTS The information model successfully assessed concordance between patient preferences and end-of-life care events. Among 388 expired patients in the modeling population, 4164 care events occurred, 4100 (98%) of which were preference-concordant, and 64 (2%) of which were preference-discordant. Including end-of-life care events that did not occur increased the number of observations to 6029; 99% were preference-concordant. At the level of individuals, 72% (278) of patients experienced only preference-concordant care events, 13% (50) experienced at least one preference-discordant care event, and 15% (60) experienced no preference-related care events. DISCUSSION Model limitations pertain to assumptions that are required to match advance care planning documents with patient preference options and exclusion of preferred care that did not occur. Further research is required to apply the model to larger populations and to investigate the need for additional preference options. CONCLUSION An information model for automating the assessment of the concordance between patients' advance care planning preferences and the end-of-life care they received was effective in a small population and has the potential to assess population-level preference-concordance on an ongoing basis.
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Affiliation(s)
- Marianne Turley
- Health Information Technology Transformation and Analytics, Kaiser Permanente, Portland OR 97210, USA
| | - Susan Wang
- Southern California Permanente Medical Group, Los Angeles, CA 90027, USA
| | - Di Meng
- Health Information Technology Transformation and Analytics, Kaiser Permanente, Oakland, CA 94612, USA
| | - Michael H Kanter
- Southern California Permanente Medical Group, Pasadena, CA 91188, USA
| | - Terhilda Garrido
- Health Information Technology Transformation and Analytics, Kaiser Permanente, Oakland, CA 94612, USA
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Smith D, Kuzla N, Thorpe J, Scott L, Ersek M. Exploring Nonresponse Bias in the Department of Veterans Affairs' Bereaved Family Survey. J Palliat Med 2015; 18:858-64. [DOI: 10.1089/jpm.2015.0050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dawn Smith
- PROMISE Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Natalie Kuzla
- PROMISE Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Joshua Thorpe
- PROMISE Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Laura Scott
- PROMISE Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Mary Ersek
- PROMISE Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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20
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Questionnaires on Family Satisfaction in the Adult ICU: A Systematic Review Including Psychometric Properties. Crit Care Med 2015; 43:1731-44. [PMID: 25821917 DOI: 10.1097/ccm.0000000000000980] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To perform a systematic review of the literature to determine which questionnaires are currently available to measure family satisfaction with care on the ICU and to provide an overview of their quality by evaluating their psychometric properties. DATA SOURCES We searched PubMed, Embase, The Cochrane Library, Web of Science, PsycINFO, and CINAHL from inception to October 30, 2013. STUDY SELECTION Experimental and observational research articles reporting on questionnaires on family satisfaction and/or needs in the ICU were included. Two reviewers determined eligibility. DATA EXTRACTION Design, application mode, language, and the number of studies of the tools were registered. With this information, the tools were globally categorized according to validity and reliability: level I (well-established quality), II (approaching well-established quality), III (promising quality), or IV (unconfirmed quality). The quality of the highest level (I) tools was assessed by further examination of the psychometric properties and sample size of the studies. DATA SYNTHESIS The search detected 3,655 references, from which 135 articles were included. We found 27 different tools that assessed overall or circumscribed aspects of family satisfaction with ICU care. Only four questionnaires were categorized as level I: the Critical Care Family Needs Inventory, the Society of Critical Care Medicine Family Needs Assessment, the Critical Care Family Satisfaction Survey, and the Family Satisfaction in the Intensive Care Unit. Studies on these questionnaires were of good sample size (n ≥ 100) and showed adequate data on face/content validity and internal consistency. Studies on the Critical Care Family Needs Inventory, the Family Satisfaction in the Intensive Care Unit also contained sufficient data on inter-rater/test-retest reliability, responsiveness, and feasibility. In general, data on measures of central tendency and sensitivity to change were scarce. CONCLUSIONS Of all the questionnaires found, the Critical Care Family Needs Inventory and the Family Satisfaction in the Intensive Care Unit were the most reliable and valid in relation to their psychometric properties. However, a universal "best questionnaire" is indefinable because it depends on the specific goal, context, and population used in the inquiry.
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Rajamani A, Barrett E, Weisbrodt L, Bourne J, Palejs P, Gresham R, Huang S. Protocolised Approach to End-of-Life Care in the ICU—The ICU PALCare Pilot Project. Anaesth Intensive Care 2015; 43:335-40. [DOI: 10.1177/0310057x1504300309] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
International literature on end-of-life care in intensive care units (ICUs) supports the use of ‘protocol bundles’, which is not common practice in our 18-bed adult general ICU in Sydney, New South Wales. We conducted a prospective observational study to identify problems related to end-of-life care practices and to determine whether there was a need to develop protocol bundles. Any ICU patient who had ‘withdrawal’ of life-sustaining treatment to facilitate a comfortable death was eligible. Exclusion criteria included organ donors, unsuitable family dynamics and lack of availability of research staff to obtain family consent. Process-of-care measures were collected using a standardised form. Satisfaction ratings were obtained using de-identified questionnaire surveys given to the healthcare staff shortly after the withdrawal of therapy and to the families 30 days later. Twenty-three patients were enrolled between June 2011 and July 2012. Survey questionnaires were given to 25 family members and 30 healthcare staff, with a high completion rate (24 family members [96%] and 28 staff [93.3%]). Problems identified included poor documentation of family meetings (39%) and symptom management. Emotional/spiritual support was not offered to families (39.1%) or ICU staff (0%). The overall level of end-of-life care was good. The overwhelming majority of families and healthcare staff were highly satisfied with the care provided. Problems identified related to communication documentation and lack of spiritual/emotional support. To address these problems, targeted measures would be more useful than the adoption of protocol bundles. Alternate models of satisfaction surveys may be needed.
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Affiliation(s)
- A. Rajamani
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - E. Barrett
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - L. Weisbrodt
- Intensive Care Nursing and Clinical Research Management, Nepean Hospital, Kingswood, New South Wales
| | - J. Bourne
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - P. Palejs
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - R. Gresham
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - S. Huang
- Nepean Hospital, Kingswood, New South Wales
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Sellers DE, Dawson R, Cohen-Bearak A, Solomond MZ, Truog RD. Measuring the quality of dying and death in the pediatric intensive care setting: the clinician PICU-QODD. J Pain Symptom Manage 2015; 49:66-78. [PMID: 24878067 PMCID: PMC4247362 DOI: 10.1016/j.jpainsymman.2014.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 04/21/2014] [Accepted: 05/06/2014] [Indexed: 12/25/2022]
Abstract
CONTEXT In the pediatric intensive care setting, an accurate measure of the dying and death experience holds promise for illuminating how critical care nurses, physicians, and allied psychosocial staff can better manage end-of-life care for the benefit of children and their families, as well as the caregivers. OBJECTIVES The aim was to assess the reliability and validity of a clinician measure of the quality of dying and death (Pediatric Intensive Care Unit-Quality of Dying and Death 20 [PICU-QODD-20]) in the pediatric intensive care setting. METHODS In a retrospective cohort study, five types of clinicians (primary nurse, bedside nurse, attending physician, and the psychosocial clinician and critical care fellow most involved in the case) were asked to complete a survey for each of the 94 children who died over a 12 month period in the pediatric intensive care units of two children's hospitals in the northeast U.S. Analyses were conducted within type of clinician. RESULTS In total, 300 surveys were completed by 159 clinicians. Standard item analyses and substantive review led to the selection of 20 items for inclusion in the PICU-QODD-20. Cronbach alpha for the PICU-QODD-20 ranged from 0.891 for bedside nurses to 0.959 for attending physicians. For each type of clinician, the PICU-QODD-20 was significantly correlated with the quality of end-of-life care and with meeting the family's needs. In addition, when patient/family or team barriers were encountered, the PICU-QODD-20 score tended to be significantly lower than for cases in which the barrier was not encountered. CONCLUSION The PICU-QODD-20 shows promise as a valid and reliable measure of the quality of dying and death in pediatric intensive care.
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Affiliation(s)
- Deborah E Sellers
- Bronfenbrenner Center for Translational Research, Cornell University, Ithaca, New York, USA
| | - Ree Dawson
- Frontier Science and Technology Research Foundation, Boston, Massachusetts, USA
| | | | - Mildred Z Solomond
- The Hastings Center, Garrison, New York, USA; Division of Critical Care Medicine, Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts, USA; Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, Massachusetts, USA; Division of Medical Ethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert D Truog
- Division of Critical Care Medicine, Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts, USA; Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, Massachusetts, USA; Division of Medical Ethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
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23
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Khandelwal N, Engelberg RA, Benkeser DC, Coe NB, Curtis JR. End-of-life expenditure in the ICU and perceived quality of dying. Chest 2014; 146:1594-1603. [PMID: 25451349 PMCID: PMC4251619 DOI: 10.1378/chest.14-0182] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 06/02/2014] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Although end-of-life care in the ICU accounts for a large proportion of health-care costs, few studies have examined the association between costs and satisfaction with care. The objective of this study was to investigate the association of ICU costs with family- and nurse-assessed quality of dying and family satisfaction. METHODS This was an observational study surveying families and nurses for patients who died in the ICU or within 30 h of transfer from the ICU. A total of 607 patients from two Seattle hospitals were included in the study. Survey data were linked with administrative records to obtain ICU and hospital costs. Regression analyses assessed the association between costs and outcomes assessing satisfaction with care: nurse- and family-assessed Quality of Death and Dying (QODD-1) and Family Satisfaction in the ICU (FS-ICU). RESULTS For family-reported outcomes, patient insurance status was an important modifier of results. For underinsured patients, higher daily ICU costs were significantly associated with higher FS-ICU and QODD-1 (P < .01 and P = .01, respectively); this association was absent for privately insured or Medicare patients (P = .50 and P = .85, QODD-1 and FS-ICU, respectively). However, higher nurse-assessed QODD-1 was significantly associated with lower average daily ICU cost and total hospital cost (P < .01 and P = .05, respectively). CONCLUSIONS Family-rated satisfaction with care and quality of dying varied depending on insurance status, with underinsured families rating satisfaction with care and quality of dying higher when average daily ICU costs were higher. However, patients with higher costs were assessed by nurses as having a poorer quality of dying. These findings highlight important differences between family and clinician perspectives and the important role of insurance status.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA; Harborview Medical Center, the Department of Medicine, University of Washington, Seattle, WA
| | - David C Benkeser
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Norma B Coe
- Department of Health Services, University of Washington, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA; Harborview Medical Center, the Department of Medicine, University of Washington, Seattle, WA
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Verceles AC, Corwin DS, Afshar M, Friedman EB, McCurdy MT, Shanholtz C, Oakjones K, Zubrow MT, Titus J, Netzer G. Half of the family members of critically ill patients experience excessive daytime sleepiness. Intensive Care Med 2014; 40:1124-31. [PMID: 24898893 PMCID: PMC4500523 DOI: 10.1007/s00134-014-3347-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Sleepiness and fatigue are commonly reported by family members of intensive care unit (ICU) patients. Sleep deprivation may result in cognitive deficits. Sleep deprivation and cognitive blunting have not been quantitatively assessed in this population. We sought to determine the proportion of family members of ICU patients that experience excessive daytime sleepiness, sleep-associated functional impairment, and cognitive blunting. METHODS Multicenter, cross-sectional survey of family members of patients admitted to ICUs at the University of Maryland Medical Center, Johns Hopkins University Hospital, and Christiana Hospital. Family members of ICU patients were evaluated using the Epworth Sleepiness Scale, a validated survey assessing sleepiness in everyday situations (normal, less than 10); the Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10), a questionnaire quantifying the impact of sleepiness on daily activities (normal, at least 17.9); and psychomotor vigilance testing, a test of cognitive function, in relation to sleep deprivation (normal mean reaction time less than 500 ms). RESULTS A total of 225 family members were assessed. Of these, 50.2 % (113/225) had Epworth scores consistent with excessive daytime sleepiness. Those with sleepiness experienced greater impairment in performing daily activities by FOSQ-10 (15.6 ± 3.0 vs 17.4 ± 2.2, p < 0.001). Cognitive blunting was found in 13.3 % (30/225) of family members and 15.1 % (14/93) of surrogate decision-makers. Similar rates of cognitive blunting as reported by mean reaction time of at least 500 ms were found among family members whether or not they reported sleepiness (15.0 % (17/113) vs. 11.6 % (13/112), p = 0.45). CONCLUSIONS Half of the family members of ICU patients suffer from excessive daytime sleepiness. This sleepiness is associated with functional impairment, but not cognitive blunting.
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Affiliation(s)
- Avelino C Verceles
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Maryland School of Medicine, 110 S. Paca St., Second Floor, Baltimore, MD, 21201, USA,
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Kross EK, Engelberg RA, Downey L, Cuschieri J, Hallman MR, Longstreth WT, Tirschwell DL, Curtis JR. Differences in end-of-life care in the ICU across patients cared for by medicine, surgery, neurology, and neurosurgery physicians. Chest 2014; 145:313-321. [PMID: 24114410 DOI: 10.1378/chest.13-1351] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Some of the challenges in the delivery of high-quality end-of-life care in the ICU include the variability in the characteristics of patients with certain illnesses and the practice of critical care by different specialties. METHODS We examined whether ICU attending specialty was associated with quality of end-of-life care by using data from a clustered randomized trial of 14 hospitals. Patients died in the ICU or within 30 h of transfer and were categorized by specialty of the attending physician at time of death (medicine, surgery, neurology, or neurosurgery). Outcomes included family ratings of satisfaction, family and nurse ratings of quality of dying, and documentation of palliative care in medical records. Associations were tested using multipredictor regression models adjusted for hospital site and for patient, family, or nurse characteristics. RESULTS Of 3,124 patients, the majority were cared for by an attending physician specializing in medicine (78%), with fewer from surgery (12%), neurology (3%), and neurosurgery (6%). Family satisfaction did not vary by attending specialty. Patients with neurology or neurosurgery attending physicians had higher family and nurse ratings of quality of dying than patients of attending physicians specializing in medicine (P < .05). Patients with surgery attending physicians had lower nurse ratings of quality of dying than patients with medicine attending physicians (P < .05). Chart documentation of indicators of palliative care differed by attending specialty. CONCLUSIONS Patients cared for by neurology and neurosurgery attending physicians have higher family and nurse ratings of quality of dying than patients cared for by medicine attending physicians and have a different pattern of indicators of palliative care. Patients with surgery attending physicians had fewer documented indicators of palliative care. These findings may provide insights into potential ways to improve the quality of dying for all patients. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Erin K Kross
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA.
| | - Ruth A Engelberg
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
| | - Lois Downey
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Matthew R Hallman
- Department of Anesthesiology & Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA
| | - W T Longstreth
- Department of Neurology, University of Washington, Harborview Medical Center, Seattle, WA
| | - David L Tirschwell
- Department of Neurology, University of Washington, Harborview Medical Center, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
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Gallagher R, Krawczyk M. Family members' perceptions of end-of-life care across diverse locations of care. BMC Palliat Care 2013; 12:25. [PMID: 23870101 PMCID: PMC3750390 DOI: 10.1186/1472-684x-12-25] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 07/18/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The goal of the study was to assess perceived level of satisfaction with end-of-life care, focusing on the last 48 hours of life. METHODS A previously validated instrument was used in a telephone survey with bereaved family members (n=90) of patients who died within an organization in British Columbia. RESULTS Bereaved family members had many unmet needs for information about the patient's changing condition, the process of dying, how symptoms would be managed and what to do at the time of death. In addition, many bereaved relatives felt that the patient or resident had an unmet need for emotional support and that their own emotional needs were not addressed adequately. The last place of care had the most significant effect on all of these variables, with acute care and residential care having the most unmet needs. Hospice had the fewest unmet needs, followed by the palliative and the intensive care units. CONCLUSIONS We discuss these findings in relation to overall satisfaction with care, focus on individual, ethno-cultural and diversity issues, information and decision-making, symptom management and attending to the family. We conclude by offering possible practices address the end-of-life needs of patients and family members.
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Affiliation(s)
- Romayne Gallagher
- Division of Palliative Care, Department of Family and Community Medicine, Providence Health Care, University of British Columbia.
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Jongerden IP, Slooter AJ, Peelen LM, Wessels H, Ram CM, Kesecioglu J, Schneider MM, van Dijk D. Effect of intensive care environment on family and patient satisfaction: a before–after study. Intensive Care Med 2013; 39:1626-34. [DOI: 10.1007/s00134-013-2966-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 05/13/2013] [Indexed: 10/26/2022]
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Osborn TR, Curtis JR, Nielsen EL, Back AL, Shannon SE, Engelberg RA. Identifying elements of ICU care that families report as important but unsatisfactory: decision-making, control, and ICU atmosphere. Chest 2013; 142:1185-1192. [PMID: 22661455 DOI: 10.1378/chest.11-3277] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND One in fi ve deaths in the United States occurs in the ICU, and many of these deaths are experienced as less than optimal by families of dying people. The current study investigated the relationship between family satisfaction with ICU care and overall ratings of the quality of dying as a means of identifying targets for improving end-of-life experiences for patients and families. METHODS This multisite cross-sectional study surveyed families of patients who died in the ICU in one of 15 hospitals in western Washington State. Measures included the Family Satisfaction in the ICU (FS-ICU) and the Single-Item Quality of Dying (QOD-1) questionnaires. Associations between FS-ICU items and the QOD-1 were examined using multivariate linear regression controlling for patient and family demographics and hospital site. RESULTS Questionnaires were returned for 1,290 of 2,850 decedents (45%). Higher QOD-1 scores were significantly associated (all P < .05) with (1) perceived nursing skill and competence (β= 0.15), (2) support for family as decision-makers ( β= 0.10), (3) family control over the patient’s care( β= 0.18), and (4) ICU atmosphere (β= 0.12). FS-ICU items that received low ratings and correlated with higher QOD-1 scores (ie, important items with room for improvement) were (1) support of family as decision-maker, (2) family control over patient’s care, and (3) ICU atmosphere. CONCLUSIONS Increased support for families as decision-makers and for their desired level of control over patient care along with improvements in the ICU atmosphere were identified as aspects of the ICU experience that may be important targets for quality improvement. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.
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Affiliation(s)
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seattle, WA
| | - Elizabeth L Nielsen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seattle, WA
| | - Anthony L Back
- Seattle Cancer Care Alliance, Division of Medical Oncology, Department of Medicine, Seattle, WA
| | - Sarah E Shannon
- Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle, WA
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seattle, WA.
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Oprescu F, Campo S, Lowe J, Andsager J, Morcuende JA. Managing uncertainty in the context of clubfoot care: exploring the value of uncertainty management theory and the sense of virtual community. THE IOWA ORTHOPAEDIC JOURNAL 2013; 33:142-148. [PMID: 24027474 PMCID: PMC3748870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Serious health conditions, such as clubfoot, could be a major source of uncertainty and stress for parents of children affected. How parents deal with uncertainty and stress as related to their child's health condition is of interest for medical professionals and health communicators alike. While physicians remain a preferred source of health information, during medical encounters or via phone and email communication, many individuals seek out health information on the Internet, including in online support communities. This study explored the connections between Uncertainty Management Theory (UMT) constructs and the potential contribution of the sense of virtual community (SOVC) to the UMT framework. The results of this research suggest that the UMT needs to be adapted for use in online contexts. One way is to include theoretical constructs, such as the sense of virtual community, specifically developed to measure online interactions. A modified and updated Uncertainty Management Theory could be useful in exploring, analyzing and understanding online behaviors related to health conditions such as clubfoot and thus contribute substantially to what we know about caregivers in their role as uncertainty managers.
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Affiliation(s)
- Florin Oprescu
- University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | | | - John Lowe
- University of the Sunshine Coast, Sippy Downs, QLD, Australia
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Kross EK, Nielsen EL, Curtis JR, Engelberg RA. Survey burden for family members surveyed about end-of-life care in the intensive care unit. J Pain Symptom Manage 2012; 44:671-80. [PMID: 22762964 PMCID: PMC3488148 DOI: 10.1016/j.jpainsymman.2011.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 11/10/2011] [Accepted: 11/13/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT Family surveys are an important source of information about quality of end-of-life care in the intensive care unit (ICU). The burden associated with completing such surveys is not well studied. OBJECTIVES 1) To assess the predictors of burden that families report with completing surveys for patients who died in the ICU and 2) to examine associations between quality-of-care ratings and survey burden. METHODS Data were collected from 14 hospitals as part of a cluster randomized trial to integrate palliative care into the ICU. Survey questions included demographics, quality of dying, satisfaction with care, and overall level of burden associated with survey completion. Patient characteristics were identified from chart abstraction and death certificates. Multivariable linear regression with robust SEs was used to examine associations between survey burden, subject characteristics, and family ratings of quality of care. RESULTS Of the families surveyed, 62% rated the survey to be no or low burden. Family members of older patients reported less survey burden (P = 0.016), and those who lived with the patient reported higher survey burden (P = 0.043). Family members reporting lower ratings of satisfaction with care and quality of dying reported higher survey burden (P < 0.001). CONCLUSION Most families reported no to low burden. Family members who live with their loved one are particularly vulnerable to survey burden and those of older patients report less burden. The association between low quality-of-care ratings and survey burden suggests that the response bias in this type of research is toward overestimating quality of care.
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Affiliation(s)
- Erin K Kross
- Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA.
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Abstract
OBJECTIVE There are numerous challenges to successfully integrating palliative care in the intensive care unit. Our primary goal was to describe and compare the quality of palliative care delivered in an intensive care unit as rated by physicians and nurses working in that intensive care unit. DESIGN Multisite study using self-report questionnaires. SETTING Thirteen hospitals throughout the United States. PARTICIPANTS Convenience sample of 188 physicians working in critical care (attending physicians, critical care fellows, resident physicians) and 289 critical care nurses. MEASUREMENTS AND MAIN RESULTS Clinicians provided overall ratings of the care delivered by either nurses or physicians in their intensive care unit for each of seven domains of intensive care unit palliative care using a 0-10 scale (0 indicating the worst possible and 10 indicating the best possible care). Analyses included descriptive statistics to characterize measurement characteristics of the ten items, paired Wilcoxon tests comparing item ratings for the domain of symptom management with all other item ratings, and regression analyses assessing differences in ratings within and between clinical disciplines. We used p < .001 to denote statistical significance to address multiple comparisons. The ten items demonstrated good content validity with few missing responses or ceiling or floor effects. Items receiving the lowest ratings assessed spiritual support for families, emotional support for intensive care unit clinicians, and palliative-care education for intensive care unit clinicians. All but two items were rated significantly lower than the item assessing symptom management (p < .001). Nurses rated nursing care significantly higher (p < .001) than physicians rated physician care in five domains. In addition, although nurses and physicians gave comparable ratings to palliative care delivered by nurses, nurses' and physicians' ratings of physician care were significantly different with nurse ratings of this care lower than physician ratings on all but one domain. CONCLUSION Our study supports the content validity of the ten overall rating items and supports the need for improvement in several aspects of palliative care, including spiritual support for families, emotional support for clinicians, and clinician education about palliative care in the intensive care unit. Furthermore, our findings provide some preliminary support for surveying intensive care unit clinicians as one way to assess the quality of palliative care in the intensive care unit.
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Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest 2011; 139:1025-1033. [PMID: 21292758 DOI: 10.1378/chest.10-3011] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status. METHODS We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services. RESULTS Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care. CONCLUSIONS We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Sarah Muni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA
| | - Ruth A Engelberg
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Patsy D Treece
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Danae Dotolo
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - J Randall Curtis
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA.
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Casarett D, Smith D, Breslin S, Richardson D. Does nonresponse bias the results of retrospective surveys of end-of-life care? J Am Geriatr Soc 2010; 58:2381-6. [PMID: 21087223 DOI: 10.1111/j.1532-5415.2010.03175.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the effect of nonresponse bias on reports of the quality of end-of-life care that older adults receive. DESIGN Nationwide retrospective survey of end-of-life care. SETTING Sixty-two Veterans Affairs Medical Centers. PARTICIPANTS Patients were eligible if they died in a participating facility. One family member per patient was selected from medical records and invited to participate. MEASUREMENTS The telephone survey included 14 items describing important aspects of the patient's care in the last month of life. Scores (0-100) reflect the percentage of items for which the family member reported that the patient received the best possible care, and a global item defined the proportion of families who said the patient received "excellent" care. To examine the effect of nonresponse bias, a model was created to predict the likelihood of response based on patient and family characteristics; then this model was used to apply weights that were equivalent to the inverse of the probability of response for that individual. RESULTS Interviews were completed with family members of 3,897 of 7,110 patients (55%). Once results were weighted to account for nonresponse bias, the change in mean individual scores was 2% of families reporting "excellent" care. Of the 62 facilities in the sample, the scores of only 19 facilities (31%) changed more than 1% in either direction, and only 10 (16%) changed more than 2%. CONCLUSION Although nonresponse bias is a theoretical concern, it does not appear to have a significant effect on the facility-level results of this retrospective family survey.
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Affiliation(s)
- David Casarett
- Philadelphia Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania, USA.
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Tung EE, Vickers KS, Lackore K, Cabanela R, Hathaway J, Chaudhry R. Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting. Am J Hosp Palliat Care 2010; 28:230-5. [DOI: 10.1177/1049909110386045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Physicians are often unable to guide patients through the advance care planning (ACP) process due to cost and time constraints. We conducted a retrospective analysis in the primary care setting targeting older adults without an advance medical directive (AMD). An ACP educational packet was sent to intervention patients before their health maintenance examination (HME). Additionally, their physicians had access to a computerized clinical decision support system on AMD completion at the time of the HME. Control participants’ physicians had access to the computerized decision support system and traditional resources only. All participants who received the packet were sent a follow-up survey. In all, 21.6% of intervention participants completed an AMD, compared with 4.1% of control participants. Combining clinical decision support systems and standardized processes enhances the ACP process.
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Affiliation(s)
- Ericka E. Tung
- Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine,
Rochester, MN, USA,
| | - Kristin S. Vickers
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine,
Rochester, MN, USA
| | - Kandace Lackore
- Healthcare Policy and Research, Mayo Clinic College of Medicine, Rochester, MN,
USA
| | - Rosa Cabanela
- Healthcare Policy and Research, Mayo Clinic College of Medicine, Rochester, MN,
USA
| | - Julie Hathaway
- Department of Patient and Health Education, Mayo Clinic College of Medicine,
Rochester, MN, USA
| | - Rajeev Chaudhry
- Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine,
Rochester, MN, USA
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Curtis JR, Nielsen EL, Treece PD, Downey L, Dotolo D, Shannon SE, Back AL, Rubenfeld GD, Engelberg RA. Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med 2010; 183:348-55. [PMID: 20833820 DOI: 10.1164/rccm.201006-1004oc] [Citation(s) in RCA: 206] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Because of high mortality, end-of-life care is an important component of intensive care. OBJECTIVES We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care. METHODS We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics. MEASUREMENTS AND MAIN RESULTS All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81). CONCLUSIONS We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).
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Affiliation(s)
- J Randall Curtis
- Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle Washington, USA.
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Kross EK, Engelberg RA, Gries CJ, Nielsen EL, Zatzick D, Curtis JR. ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU. Chest 2010; 139:795-801. [PMID: 20829335 DOI: 10.1378/chest.10-0652] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Psychologic symptoms of posttraumatic stress disorder (PTSD) and depression are relatively common among family members of patients who die in the ICU. The patient-level risk factors for these family symptoms are not well understood but may help to target future interventions. METHODS We performed a cohort study of family members of patients who died in the ICU or within 30 h of ICU transfer. Outcomes included self-reported symptoms of PTSD and depression. Predictors included patient demographics and elements of palliative care. RESULTS Two hundred twenty-six patients had chart abstraction and family questionnaire data. Family members of older patients had lower scores for PTSD (P = .026). Family members that were present at the time of death (P = .021) and family members of patients with early family conferences (P = .012) reported higher symptoms of PTSD. When withdrawal of a ventilator was ordered, family members reported lower symptoms of depression (P = .033). There were no other patient characteristics or elements of palliative care associated with family symptoms. CONCLUSIONS Family members of younger patients and those for whom mechanical ventilation is not withdrawn are at increased risk of psychologic symptoms and may represent an important group for intervention. Increased PTSD symptoms among family members present at the time of death may reflect a closer relationship with the patient or more involvement with the patient's ICU care but also suggests that family should be offered the option of not being present.
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Affiliation(s)
- Erin K Kross
- Department of Medicine, Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA.
| | - Ruth A Engelberg
- Department of Medicine, Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA
| | - Cynthia J Gries
- Department of Medicine, Division of Pulmonary and Critical Care, University of Washington Medical Center, University of Washington, Seattle, WA
| | - Elizabeth L Nielsen
- Department of Medicine, Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington, Seattle, WA
| | - J Randall Curtis
- Department of Medicine, Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gries CJ, Engelberg RA, Kross EK, Zatzick D, Nielsen EL, Downey L, Curtis JR. Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest 2009; 137:280-7. [PMID: 19762549 DOI: 10.1378/chest.09-1291] [Citation(s) in RCA: 211] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients' deaths in the ICU have been associated with a high burden of psychologic symptoms in families. This study identifies characteristics associated with psychologic symptoms in family members. METHODS Families of patients dying in the ICU or within 30 h of ICU discharge in 11 hospitals previously participated in a randomized trial. In the current study, we assessed these families for symptoms of posttraumatic stress disorder (PTSD) and depression with follow-up surveys. Outcomes included validated measures of PTSD (PTSD Checklist) and depressive (Patient Health Questionnaire) symptoms. Predictors included family member mental-health history, involvement in decision making, and demographics. RESULTS Surveys were completed by 226 families. Response rate was 46% in the original randomized trial and 82% in this study. Prevalence (95% CI) of PTSD and depressive symptoms were 14.0% (9.7%-19.3%) and 18.4% (13.5%-24.1%), respectively. Family characteristics associated with increased symptoms included: female gender (PTSD, P = .020; depression, P = .005), knowing the patient for a shorter duration (PTSD, P = .003; depression, P = .040), and discordance between family members' preferences for decision making and their actual decision-making roles (PTSD, P = .005; depression, P = .049). Depressive symptoms were also associated with lower educational level (P = .002). Families with psychologic symptoms were more likely to report that access to a counselor (PTSD, P < .001; depression, P = .003) and information about spiritual services might have been helpful while the patient was in the ICU (PTSD, P = .024; depression, P = .029). CONCLUSIONS Families demonstrated a high prevalence of psychologic symptoms after a death in the ICU. Characteristics associated with symptoms may help target interventions to reduce these symptoms. TRIAL REGISTRATION clinicaltrials.gov; Identifier: NCT00685893.
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Affiliation(s)
- Cynthia J Gries
- University of Washington, Division of Pulmonary and Critical Care, Seattle, WA 98104, USA.
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