Identifying elements of ICU care that families report as important but unsatisfactory: decision-making, control, and ICU atmosphere

Family Members' Feedback on the "Quality of Death" of Adult Patients Who Died in Intensive Care Units and the Factors Affecting the Death Quality: A Systematic Review and Meta-Analysis

Intensive care units (ICUs) are designed for critically ill patients who often experience high mortality rates owing to the severity of their conditions. Although the primary goal is patient recovery, it is crucial to understand the quality of death in the ICU setting. Nevertheless, there is a notable lack of systematic reviews on measured death quality and its associated factors. This study aims to conduct a quantitative synthesis of evidence regarding the quality of death in the ICU and offers a comprehensive overview of the factors influencing this quality, including its relationship with the post-intensive care syndrome-family (PICS-F). A thorough search without any language restrictions across MEDLINE, CINAHL, PsycINFO, and Igaku Chuo Zasshi databases identified relevant studies published until September 2023. We aggregated the results regarding the quality of death care for patients who died in the ICU across each measurement tool and calculated the point estimates and 95% confidence intervals. The quantitative synthesis encompassed 19 studies, wherein the Quality of Dying and Death-single item (QODD-1) was reported in 13 instances (Point estimate: 7.0, 95% CI: 6.93-7.06). Patient demographic data, including age and gender, as well as the presence or absence of invasive procedures, such as life support devices and cardiopulmonary resuscitation, along with the management of pain and physical symptoms, were found to be associated with a high quality of death. Only one study reported an association between quality of death and PICS-F scores; however, no significant association was identified. The QODD-1 scale emerged as a frequently referenced and valuable metric for evaluating the quality of death in the ICU, and factors associated with the quality of ICU death were identified. However, research gaps persist, particularly regarding the variations in the quality of ICU deaths based on cultural backgrounds and healthcare systems. This review contributes to a better understanding of the quality of death in the ICU and emphasises the need for comprehensive research in this critical healthcare domain.

A 6-y retrospective cohort study of family satisfaction with critical care and decision-making in an Australian intensive care unit

BACKGROUND

Partnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically.

OBJECTIVE

The objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU).

METHODS

A retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from "poor" (0) to "excellent" (100).

RESULTS

In total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients' treatment in the ICU and appreciation for the care, skill, and professionalism of the staff.

CONCLUSION

Very high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards.

Predictors of Family Dissatisfaction with Support During Neurocritical Care Shared Decision-Making

BACKGROUND

There is a critical need to improve support for families making difficult shared decisions about patient care with clinicians in the neuroscience ICU (neuro-ICU). The aim of this study is to identify patient- and family-related factors associated with dissatisfaction with shared decision-making support among families of neuro-critically ill patients.

METHODS

We conducted a retrospective observational cohort study using survey data that had been collected from a consecutive sample of family members of patients in the neuro-ICU (one family member per patient) at two US academic centers. Satisfaction with shared decision-making support on ICU discharge had been measured among family members using one specific Likert scale item on the Family Satisfaction in the ICU 24 survey, a validated survey instrument for families of patients in the ICU. We dichotomized top-box responses for this particular item as an outcome variable and identified available patient- and family-related covariates associated with dissatisfaction (i.e., less than complete satisfaction) via univariate and multivariate analyses.

RESULTS

Among 355 surveys, 180 (49.5%) of the surveys indicated dissatisfaction with support during decision-making. In a multivariate model, no preexisting characteristics of families or patients ascertainable on ICU admission were predictive of dissatisfaction. However, among family factors determined during the ICU course, experiencing three or fewer formal family meetings (odds ratio 1.93 [confidence interval 1.13-3.31]; p = 0.01) was significantly predictive of dissatisfaction with decisional support in this cohort with an average patient length of stay of 8.6 days (SD 8.4). There was also a trend toward a family's decision to keep a patient as full code, without treatment limitations, being predictive of dissatisfaction (odds ratio 1.80 [confidence interval 0.93-3.51]; p = 0.08).

CONCLUSIONS

Family dissatisfaction with neuro-ICU shared decision-making support is not necessarily predicted by any preexisting family or patient variables but appears to correlate with participating in fewer formal family meetings during ICU admission. Future studies to improve family satisfaction with neurocritical care decision-making support should have broad inclusion criteria for participants and should consider promoting frequency of family meetings as a core strategy.

Family satisfaction in the intensive care unit, a cross-sectional study from Norway

BACKGROUND

Becoming critically ill represents not just a great upheaval for the patient in question, but also for the patient's closest family. In recent years, there has been a change in how the quality of the public health service is measured. There is currently a focus on how patients and their families perceive the quality of treatment and care. It can be challenging for patients to evaluate their stay in an intensive care unit (ICU) due to illness and treatment. Earlier studies show that the perceptions of the family and the patient may concur. It is important, therefore, to ascertain the family's level of satisfaction with the ICU stay. The aim of the study was to describe how the family evaluate their satisfaction with the ICU stay. A further aim was to identify which demographic variables were associated with differences in family satisfaction.

METHOD

The study had a cross-sectional design. A sample of 57 family members in two ICUs in Norway completed the questionnaire: Family satisfaction in the intensive care unit 24 (FS-ICU 24). Statistical analysis was conducted using the Mann-Whitney U test (U), Kruskal Wallis, Spearman rho and a performance-importance plot.

RESULTS

The results showed that families were very satisfied with a considerable portion of the ICU stay. Families were less satisfied with the information they received and the decision-making processes than with the nursing and care performed during the ICU stay. The results revealed that two demographic variables - relation to the patient and patient survival - significantly affected family satisfaction.

CONCLUSION

Although families were very satisfied with the ICU stay, several areas were identified as having potential for improvement. The results showed that some of the family demographic variables were significant for family satisfaction. The findings are clinically relevant since the results can strengthen intensive care nurses' knowledge when meeting the family of the intensive care patient.

Information Pamphlet Given to Relatives During the End-of-Life Decision in the ICU: An Assessor-Blinded, Randomized Controlled Trial

BACKGROUND

Symptoms of posttraumatic stress disorder (PTSD) are common in family members of patients who have died in the ICU.

RESEARCH QUESTION

Could a pamphlet describing the role of relatives in the end-of-life decision decrease their risk of developing PTSD-related symptoms?

STUDY DESIGN AND METHODS

In this assessor-blinded, randomized controlled trial, 90 relatives of adult patients for whom an end-of-life decision was anticipated were enrolled. Relatives were randomly assigned to receive oral information as well as an information pamphlet explaining that the end-of-life decision is made by physicians (Group 1; n = 45) or oral information alone (Group 2; n = 45). PTSD-related symptoms were blindly assessed at 90 days following the patient's death by using the Impact of Event Scale (scores range from 0 [indicating no symptoms] to 75 [indicating severe symptoms]). Anxiety and depression symptoms were assessed by using the Hospital Anxiety and Depression Scale score (range, 0-21 [higher scores indicate worse symptoms]).

RESULTS

On day 90, the number of relatives with PTSD-related symptoms was significantly lower in Group 1 than in Group 2: 18 of 45 vs 33 of 45 (P = .001). The risk ratio of having PTSD-related symptoms in Group 2 compared with Group 1 was 1.8 (95% CI, 1.2-2.7). The mean Impact of Event Scale and Hospital Anxiety and Depression Scale scores were significantly reduced in Group 1 compared with Group 2: 28 ± 10 vs 38 ± 14 (P < .001) and 13 ± 5 vs 17 ± 8 (P = .023), respectively.

INTERPRETATION

An information pamphlet describing the relatives' role during end-of-life decisions significantly reduced their risk of developing PTSD-related symptoms.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02329418; URL: www.clinicaltrials.gov).

Chaplaincy Care in the MICU: Examining the Association Between Spiritual Care and End-of-Life Outcomes

BACKGROUND

Seriously ill patients admitted to the Intensive Care Unit (ICU) experience severe spiritual and existential distress. Patients' surrogate decision makers face the burden of making complex decisions about their loved ones' care. Experienced chaplains may play a role in assisting with decision-making, possibly by aligning patients' values and wishes with treatment plans and avoiding non-beneficial aggressive measures.

OBJECTIVES

To identify associations between chaplaincy care and length of stay (LOS) in the medical ICU (MICU).

METHODS

This was a retrospective observational study of usual spiritual care in the adult MICUs of 4 medical centers in the United States over a 3-month period. Inclusion criteria were death in the MICU or discharge to palliative care or hospice. Measures included medical, treatment, and spiritual care information. Through bivariate and multivariable analyses associations between spiritual care and LOS were examined.

RESULTS

In multivariable analysis of the 254 patients, receiving spiritual care was associated with an increased likelihood of being in a higher LOS tertile (adjusted odds ratio = 2.94, p < .001). In post hoc bivariate analysis, cases receiving spiritual care within the first 48 hours of MICU admission revealed a trend toward lower LOS (p = .181).

CONCLUSION

Spiritual care in the MICU was associated with longer LOS. Early intervention by chaplains who are well-integrated in the ICU may assist patients and their loved ones in coming to terms with grave illness and making difficult treatment decisions. Further well-designed studies of spiritual care interventions that may affect outcomes are needed.

A phenomenological study on the lived experiences of families of ICU patients, Addis Ababa, Ethiopia

Background

Family-centered care of ICU patients is increasingly recommended as it is believed to have effect on family members’ psychosocial status and patient outcomes. Defining the nature and extent of families’ involvement in a given health care environment for different stakeholders is a challenge. Understanding the lived experiences of families of ICU patients would help strategize on how to better engage family members for improved ICU care processes and outcomes.

Objectives

The aim of this study is to explore the lived experiences of families of patients in the ICUs of hospitals in Addis Ababa, Ethiopia.

Methods

The study adopted a qualitative approach and a phenomenological research design. In-depth interviews were conducted with twelve (12) family members who were purposively sampled from two government hospitals and four private hospitals. Thematic approach with the application of hermeneutic circle of interpretation was applied to understand the meanings of their experiences.

Results

The study revealed the following major themes: financial burden, challenge in decision making, shattered family integrity and expectations, information and communication gap between family members and health professionals, lack of confidence in the service delivery of hospitals, social pressure against patient families, and families being immersed in an unfriendly environment. Though they do not explicitly mention it to the health care tram, further interpretation of the main themes elucidated that family’s need the intensive care process be cut shorter irrespective of the outcome of the patient condition.

Conclusion

The study gave an insight on the multiple and interrelated challenges faced by families of ICU patients admitted in the hospitals of Addis Ababa. Further contextualized interpretation of their experiences revealed that families were somehow in a state of despair and they implicitly need the ICU care for their family member be ended irrespective of the potential clinical consequences on the patient. The philosophy of family-centered care be advocated in hospitals. The study result affirms the need to include family members during nursing assessment of patients in ICUs and also offers the basis for guidelines development on informational support to the families of the patients hospitalized in ICUs.

End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model

BACKGROUND

Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research.

PURPOSE

To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model.

METHOD

Walker and Avant's approach to concept analysis.

FINDINGS

End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences).

DISCUSSION

Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.

Assessing physicians' and nurses' experience of dying and death in the ICU: development of the CAESAR-P and the CAESAR-N instruments

Background

As an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting. Most of these studies are centered on the patient’s and/or the relatives’ experience. Our study aimed to develop an instrument designed to assess the experience of physicians and nurses of patients who died in the ICU, using a mixed methodology and validated in a prospective multicenter study.

Methods

Physicians and nurses of patients who died in 41 ICUs completed the job strain and the CAESAR questionnaire within 24 h after the death. The psychometric validation was conducted using two datasets: a learning and a reliability cohort.

Results

Among the 475 patients included in the main cohort, 398 nurse and 417 physician scores were analyzed. The global score was high for both nurses [62/75 (59; 66)] and physicians [64/75 (61; 68)]. Factors associated with higher CAESAR-Nurse scores were absence of conflict with physicians, pain control handled with physicians, death disclosed to the family at the bedside, and invasive care not performed. As assessed by the job strain instrument, low decision control was associated with lower CAESAR score (61 (58; 65) versus 63 (60; 67), p = 0.002).

Factors associated with higher CAESAR-Physician scores were room dedicated to family information, information delivered together by nurse and physician, families systematically informed of the EOL decision, involvement of the nurse during implementation of the EOL decision, and open visitation. They were also higher when a decision to withdraw or withhold treatment was made, no cardiopulmonary resuscitation was performed, and the death was disclosed to the family at the bedside.

Conclusion

We described and validated a new instrument for assessing the experience of physicians and nurses involved in EOL in the ICU. This study shows important areas for improving practices.

Role Incongruence and Psychological Stress Symptoms in Substitute Decision Makers of Intensive Care Patients

BACKGROUND

Most intensive care patients require substitute decision makers (SDMs) to make decisions. The SDMs may prefer an active, shared, or passive decision-making role. Role incongruence is when preferred and actual roles differ.

OBJECTIVE

To evaluate the impact of decision-making role preferences and role incongruence on psychological distress symptoms in SDMs.

METHODS

A multicenter, interviewer-administered survey was conducted among SDMs of critically ill adults. The Control Preferences Scale was used to evaluate role preferences. Psychological distress was defined as anxiety, depression, or posttraumatic stress symptoms with predefined cut points on the Hospital Anxiety and Depression Scale (score > 10 on the anxiety or the depression subscale) and Impact of Events Scale (score > 30).

RESULTS

One hundred eighty SDMs were recruited; 64% responded. Most were white (71%) and female (65%); 46% were spouses. Role preferences varied: active, 24%; shared, 44%; and passive, 31%. Almost half (49%) reported incongruence. Symptom prevalence was 50% for posttraumatic stress, 32% for anxiety, and 16% for depression. Most (56%) reported some psychological distress. In multivariable logistic regression, the composite outcome of psychological distress was independently associated with patient death (odds ratio, 2.95; 95% CI, 1.08-8.02; P = .03), female sex of SDM (odds ratio, 2.96; 95% CI, 1.49-5.89; P = .002), and incongruence (odds ratio, 3.26; 95% CI, 1.67-6.36; P < .001).

CONCLUSIONS

Adverse psychological symptoms are prevalent in SDMs of critically ill patients and are related to role incongruence.

Family-Centered Communication and Acute Stress in Israeli Intensive Care Units

BACKGROUND

Intensive care unit stays can be stressful for patients' family members. Family-centered communication has 6 components: fostering relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. Whether these communication components decrease family members' stress is unknown.

OBJECTIVE

To describe levels of family-centered communication and associations with acute stress while patients are in the intensive care unit.

METHODS

A convenience sample of 130 family members of patients in 2 intensive care units in a Jerusalem, Israel, tertiary medical center received a family-centered communication questionnaire, the Perceived Stress Scale, and a personal characteristics questionnaire.

RESULTS

Most respondents were women (n = 79, 60.8%), children of the patient (n = 67, 51.9%), and familiar with the patient's diagnosis (n = 111, 85.4%). Mean (SD) participant age was 45.7 (13.6) years. Most considered the patient medically stable (n = 75, 57.7%). Mean (SD) intensive care unit stay was 7.45 (5.8) days. Mean (SD) total and item scores for family-centered communication were 98.75 (18.21) and 3.80 (0.70), respectively; for the Perceived Stress Scale, 19.63 (5.92) and 1.96 (0.59), respectively. Relationship building (r = -0.31, P = .002), participation in care management (r = -0.32, P = .001), and emotional support (r = -0.29, P = .003), and were significantly related to stress.

CONCLUSIONS

Stress levels were mild to moderate and communication scores were moderate to high. Better nurse communication with family members was associated with decreased acute stress, irrespective of personal characteristics or perceptions of the patient's medical status.

Family Satisfaction in a Medical College Multidisciplinary Intensive Care Unit (ICU)-How Can We Improve?

Background and Aims

In recent years, patient and family-centered implications are being recognized as important outcome measures and one of the quality indicators of health care system worldwide. Most of the Intensive Care Unit patients cannot make decisions themselves, accordingly family members are surrogate decision-makers and judges of care quality. This study was conducted as a prospective observational study using Family Satisfaction-Intensive Care Unit questionnaire to ascertain the level of family satisfaction of care and their involvement in the decision making process of their patient's treatment.

Materials and methods

The study was conducted over 3 months with 100 family members by FS-ICU questionnaire survey method. After 48 hours of ICU admission, the questionnaire was administered to an eligible family member by a resident who was not involved in the treatment of the patient, in a language understood by them (English/Kannada). Each question was scored using 5 point Likert response Scale and the scores were transformed into 0 (least satisfied) to100 (most satisfied) scale.

Results

Satisfaction with overall care was 65.31±23.62 (FS-ICU/Care). Satisfaction with decision making process was 73.06±22.154 (FS-ICU/ DM). Individual factors which contributed to lower scores were management of pain and agitation of the patient, waiting room atmosphere and emotional support.

Conclusion

This study identified the individual factors which contributed to the high and low satisfaction scores. With this baseline data as reference, there is scope to enhance the aspects of quality care for patients and their family members.

How to cite this article

JanardhanIyengar SM, Srinivasan R et al. Family Satisfaction in a Medical College Multidisciplinary Intensive Care Unit (ICU)-How Can We Improve? Indian J of Crit Care Med 2019;23(2):83-88.

Collaborating With Hospital Chaplains to Meet the Spiritual Needs of Critical Care Patients

There are many opportunities for critical-care nurses to collaborate with chaplains in an effort to provide spiritual care for patients and their families. By recognizing the educational requirements as well as the unique roles of board-certified chaplains (BCCs), the critical-care nurse will view them as respected members of the health care team. This collaboration positively impacts the work environment and creates a holistic space for healing for patients, as well as the health care team. As nurses, we must educate and inform novice nurses about the important role of BCCs on the interdisciplinary health care team. Critical-care nurses need to incorporate the BCCs' contributions into the patient plan of care during bedside report in a way that helps the nurse understand the connection between the patient's spiritual health and his/her experience as a patient.

AVALIAÇÃO DA SATISFAÇÃO DE FAMILIARES DE PACIENTES ATENDIDOS EM UNIDADES DE TERAPIA INTENSIVA: REVISÃO INTEGRATIVA

RESUMO Objetivo: analisar a produção científica relacionada às evidências acerca da satisfação de familiares de pacientes de UTI e os instrumentos utilizados para sua avaliação. Metodo: revisão integrativa na qual foram analisados artigos publicados entre 2005 e 2015, em inglês, português ou espanhol, nas bases de dados PUBMED/MEDLINE e LILACS e a biblioteca SciELO. Utilizou-se como estratégia de busca: personal satisfactional OR satisfaction AND family. Para coleta de dados dos artigos elaborou-se um instrumento com informações como: título, autores, ano de publicação e revista, objetivo do estudo, delineamento, participantes, local da pesquisa, temática principal e resultados. Resultados: atenderam aos critérios de inclusão 27 produções. Foram identificados quatro instrumentos utilizados para avaliar a satisfação de familiares de pacientes na UTI o Critical Care Family Satisfaction Survey, Family Satisfaction in the Intensive Care Unit, Critical Care Family Needs Inventory e o Quality of Dying and Death. Os estudos abordaram a satisfação dos familiares em relação às suas necessidades e tomadas de decisão, satisfação quanto a cuidados paliativos, evidenciou-se, ainda, estudos de adaptação transcultural e validação de instrumentos. Quanto ao nível de evidência, os estudos se concentram nos níveis II a VI. Conclusão: a análise da produção científica sobre a satisfação de familiares de pacientes de UTI permitiu evidenciar que o fator que mais contribui na promoção da satisfação da família foi a qualidade do atendimento.

[End-of-Life Care in Intensive Care Units: Nursing strategies of family involvement at the end of life]

Background: Family members of people dying in the intensive care unit (ICU) are exposed to many stress factors and they often do not experience involvement in End-of-Life (EoL) situations. For example, they criticize a low degree of participation in patients care, delayed or incomplete information and lack of privacy. Even nursing staff is facing various obstacles in EoL situations in ICUs. Aim: This study investigates strategies used by ICU nursing staff in German-speaking Switzerland to increase family members participation in situations at the end of life. Method: Data was collected by conducting 12 semi-structured interviews using an approach based on Grounded Theory. A model was developed to explain nursing strategies for family involvement in EoL situations in the ICU. Conclusions: Nurses provide personal space and tranquillity for family members and allow them to be present at any time. Against this background, they support family members and enable them to say goodbye consciously to a loved one. Subsequent work should examine the effectiveness of the strategies described, particularly in terms of stress reactions displayed by family members in the aftermath of EoL situations. In practice, family members should be provided space for privacy. The entire healthcare team is recommended to identify and pursue common values and objectives. Moreover, intradisciplinary exchange and mentoring need to be encouraged. In order to prepare future nursing staff for EoL situations in the ICU, recognizing and promoting their educational skills is mandatory.

Measuring Family Satisfaction With Care Delivered in the Intensive Care Unit

BACKGROUND

In our competitive health care environment, measuring the experience of family members of patients in the intensive care unit to ensure that health care providers are meeting families' needs is critical. Surveys from Press Ganey and the Centers for Medicare and Medicaid Services are unable to capture families' satisfaction with care in this setting.

OBJECTIVE

To implement a sustainable measure for family satisfaction in a 12-bed medical and surgical intensive care unit. To assess the feasibility of the selected tool for measuring family satisfaction and to make recommendations that are based on the results.

METHOD

A descriptive survey design using the Family Satisfaction in the Intensive Care Unit 24-item questionnaire to measure satisfaction with care and decision-making.

RESULTS

Forty family members completed the survey. Overall, the mean score for families' satisfaction with care was 72.24% (SD, 14.87%) and the mean score for families' satisfaction with decision-making was 72.03% (SD, 16.61%). Families reported that nurses put them at ease and provided understandable explanations. Collaboration, inclusion of families in clinical discussions, and timely information regarding changes in the patient's condition were the most common points brought up in free-text responses from family members. Written communication, including directions and expectations, would have improved the families' experience.

CONCLUSION

Although patients' family members reported being satisfied with their experience in the intensive care unit, there is room for improvement. Effective communication among the health care team, patients' families, and patients will be targeted for quality improvement initiatives.

Strategies used in improving and assessing the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions: A systematic review

BACKGROUND

Implementation fidelity is critical in evaluating effectiveness of interventions.

AIM

Identifying and summarising strategies to improve and assess the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions.

DESIGN

Systematic review.

DATA SOURCES

Published and completed randomised controlled trials from 2000 to current evaluating effectiveness of specialised palliative care services on patient-centred outcomes in adult patients were examined. MEDLINE was searched from 2008 to 29 September 2015 and supplemented by randomised controlled trials identified in a 2008 systematic review.

RESULTS

Altogether, 20 randomised controlled trials involving 8426 patients were reviewed using 40 subcomponents of five elements of implementation fidelity (resulting in 20 × 40 = 800 items). Over 88 strategies were identified, classified under the following elements: 'treatment design', 'training providers', 'delivery of treatment', 'receipt of treatment' and 'enactment of treatment skills'. No single overarching strategy was discovered. Strategies under 'treatment design' aimed to ensure equivalent treatment dose between and within intervention and control groups, and delivery of necessary ingredients. Ongoing 'training (of) providers' included supervision and ensuring skill acquisition. Use of treatment manuals and implementation checklists aimed to aid 'delivery of treatment'. Research teams aimed to improve 'receipt of treatment' by transmitting clear information and verifying understanding, while improving 'enactment of treatment skills' by reviewing and reinforcing prior content. Only 26% of the items received sufficient reporting; 34% were either not used or reported on.

CONCLUSION

Implementation fidelity in palliative care is under-recognised. A table to collate these strategies to improve implementation fidelity in palliative care research and clinical practice is proposed.

Developing the methods and questionnaire (VOICES-SF) for a national retrospective mortality follow-back survey of palliative and end-of-life care in England

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.

Family members' satisfaction with care and decision-making in intensive care units and post-stay follow-up needs-a cross-sectional survey study

Aim

The aim of this study was to explore family members' satisfaction with care and decision‐making during the intensive care units stay and their follow‐up needs after the patient's discharge or death.

Design

A cross‐sectional survey study was conducted.

Methods

Family members of patients recently treated in an ICU were participating. The questionnaire contented of background variables, the instrument Family Satisfaction in ICU (FS‐ICU 24) and questions about follow‐up needs. Descriptive and non‐parametric statistics and a multiple linear regression were used in the analysis.

Results

A total of 123 (47%) relatives returned the questionnaire. Satisfaction with care was higher scored than satisfaction with decision‐making. Follow‐ up needs after the ICU stay was reported by 19 (17%) of the participants. Gender and length of the ICU stay were shown as factors identified to predict follow‐up needs.

Quality indicators in intensive care medicine for Germany - third edition 2017

Quality improvement in medicine is depending on measurement of relevant quality indicators. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2013 underwent a scheduled evaluation after three years. There were major changes in several indicators but also some indicators were changed only minimally. The focus on treatment processes like ward rounds, management of analgesia and sedation, mechanical ventilation and weaning, as well as the number of 10 indicators were not changed. Most topics remained except for early mobilization which was introduced instead of hypothermia following resuscitation. Infection prevention was added as an outcome indicator. These quality indicators are used in the peer review in intensive care, a method endorsed by the DIVI. A validity period of three years is planned for the quality indicators.

Dying in the hospital setting: A meta-synthesis identifying the elements of end-of-life care that patients and their families describe as being important

BACKGROUND

Despite most expected deaths occurring in hospital, optimal end-of-life care is not available for all in this setting.

AIM

To gain a richer and deeper understanding of elements of end-of-life care that consumers consider most important within the hospital setting.

DESIGN

A meta-synthesis.

DATA SOURCES

A systematic search of Academic Search Complete, AMED, CINAHL, MEDLINE, EMBASE, PsycINFO, PubMed, Google, Google Scholar and CareSearch for qualitative studies published between 1990 and April 2015 reporting statements by consumers regarding important elements of end-of-life hospital care. Study quality was appraised by two independent researchers using an established checklist. A three-stage synthesis approach focusing on consumer quotes, rather than primary author themes, was adopted for this review.

RESULTS

Of 1922 articles, 16 met the inclusion criteria providing patient and family data for analysis. Synthesis yielded 7 patient and 10 family themes including 6 common themes: (1) expert care, (2) effective communication and shared decision-making, (3) respectful and compassionate care, (4) adequate environment for care, (5) family involvement and (6) financial affairs. Maintenance of sense of self was the additional patient theme, while the four additional family themes were as follows: (1) maintenance of patient safety, (2) preparation for death, (3) care extending to the family after patient death and (4) enabling patient choice at the end of life.

CONCLUSION

Consumer narratives help to provide a clearer direction as to what is important for hospital end-of-life care. Systems are needed to enable optimal end-of-life care, in accordance with consumer priorities, and embedded into routine hospital care.

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

BACKGROUND

There is an emerging literature on the physician competencies most meaningful to patients and their families. However, there has been no systematic review on physician competency domains outside direct clinical care most important for patient- and family-centered outcomes in critical care settings at the end of life (EOL). Physician competencies are an essential component of palliative care (PC) provided at the EOL, but the literature on those competencies relevant for patient and family satisfaction is limited. A systematic review of this important topic can inform future research and assist in curricular development.

METHODS

Review of qualitative and quantitative empirical studies of the impact of physician competencies on patient- and family-reported outcomes conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews. The data sources used were PubMed, MEDLINE, Web of Science, and Google Scholar.

RESULTS

Fifteen studies (5 qualitative and 10 quantitative) meeting inclusion and exclusion criteria were identified. The competencies identified as critical for the delivery of high-quality PC in critical care settings are prognostication, conflict mediation, empathic communication, and family-centered aspects of care, the latter being the competency most frequently acknowledged in the literature identified.

CONCLUSION

Prognostication, conflict mediation, empathic communication, and family-centered aspects of care are the most important identified competencies for patient- and family-centered PC in critical care settings. Incorporation of education on these competencies is likely to improve patient and family satisfaction with EOL care.

Establishment of a renal supportive care program: Experience from a rural community hospital in Taiwan

Renal supportive care (RSC) denotes a care program dedicated for patients with acute, chronic renal failure, and end-stage renal disease (ESRD), aiming to offer maximal symptom relief and optimize patients' quality of life. The uncertainty of prognosis for patients with chronic kidney disease and ESRD, the sociocultural issues inherent to the Taiwanese society, and the void of structured and practical RSC pathway, contributes to the underrecognition and poor utilization of RSC. Taiwanese patients rarely receive information regarding RSC as part of a standardized care and are not commonly offered this option. In National Taiwan University Hospital Jinshan branch, we started a RSC subprogram, supported by the community-based palliative/hospice care main program. We focused on understanding the need and providing the choice of RSC to suitable candidates. A three-step and four-phase protocol was designed and implemented to identify appropriate patients and to enhance the applicability of the RSC. We harnessed family visit and home-based family meeting as a vehicle to understand the patients' preferences, to discover what ESRD patients and their family value most, and to introduce the option of RSC. In the current review, we described our pilot experience of establishing a RSC program in Taiwan, and discuss its potential advantage.

Family-Reported Experiences Evaluation (FREE) study: a mixed-methods study to evaluate families’ satisfaction with adult critical care services in the NHS

Background

To improve care it is necessary to feed back experiences of those receiving care. Of patients admitted to intensive care units (ICUs), approximately one-quarter die, and few survivors recollect their experiences, so family members have a vital role. The most widely validated tool to seek their views is the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU).

Objectives

To test face and content validity and comprehensibility of the FS-ICU (phase 1). To establish internal consistency, construct validity and reliability of the FS-ICU; to describe family satisfaction and explore how it varies by family member, patient, unit/hospital and other contextual factors and by country; and to model approaches to sampling for future use in quality improvement (phase 2).

Design

Mixed methods: qualitative study (phase 1) and cohort study (phase 2).

Setting

NHS ICUs (n = 2, phase 1;n = 20, phase 2).

Participants

Health-care professionals, ex-patients, family members of ICU patients (n = 41, phase 1). Family members of ICU patients (n = 12,303, phase 2).

Interventions

None.

Main outcome measures

Key themes regarding each item of the 24-item FS-ICU (FS-ICU-24) (phase 1). Overall family satisfaction and domain scores of the FS-ICU-24 (phase 2).

Results

In phase 1, face validity, content validity and comprehensibility were good. Adaptation to the UK required only minor edits. In phase 2, one to four family members were recruited for 60.6% of 10,530 patients (staying in ICU for 24 hours or more). Of 12,303 family members, 7173 (58.3%) completed the questionnaire. Psychometric assessment of the questionnaire established high internal consistency and criterion validity. Exploratory factor analysis indicated new domains:satisfaction with care,satisfaction with informationandsatisfaction with the decision-making process. All scores were high with skewed distributions towards more positive scores. For family members of ICU survivors, factors associated with increased/decreased satisfaction were age, ethnicity, relationship to patient, and visit frequency, and patient factors were acute severity of illness and invasive ventilation. For family members of ICU non-survivors, average satisfaction was higher but no family member factors were associated with increased/decreased satisfaction; patient factors were age, acute severity of illness and duration of stay. Neither ICU/hospital factors nor seasonality were associated. Funnel plots confirmed significant variation in family satisfaction across ICUs. Adjusting for family member and patient characteristics reduced variation, resulting in fewer ICUs identified as potential outliers. Simulations suggested that family satisfaction surveys using short recruitment windows can produce relatively unbiased estimates of average family satisfaction.

Conclusions

The Family-Reported Experiences Evaluation study has provided a UK-adapted, psychometrically valid questionnaire for overall family satisfaction and three domains. The large sample size allowed for robust multilevel multivariable modelling of factors associated with family satisfaction to inform important adjustment of any future evaluation.

Limitations

Responses to three free-text questions indicate the questionnaire may not be sensitive to all aspects of family satisfaction.

Future work

Reservations remain about the current questionnaire. While formal analysis of the free-text questions did not form part of this proposal, brief analysis suggested considerable scope for improvement of the FS-ICU-24.

Study registration

Current Controlled Trials ISRCTN47363549.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Relatives' and staff's experience of patients dying in ICU

BACKGROUND

Intensive care units (ICUs) exist to support patients through acute illness that threatens their life. Although ICUs aim to save life, they are also a place where a significant proportion of patients die with international mortality rates ranging from 15% to 24%.

AIM

To explore the experience of relatives and staff of patients dying in ICU using qualitative approach.

DESIGN

Consecutive patients were identified who were dying in the ICU. The researcher met the families prior to the patient's death. The ICU nurse and doctor most involved were interviewed within 48 h of the death. The families were interviewed 2 weeks later. Interviewees described their experience of the patient's dying and death. Recruitment until data saturation and thematic analysis occurred concurrently.

RESULTS

Ten families, nurses and doctors were interviewed in relation to 10 patients. In caring for the patients who are dying in the ICU and their families, nurses practice to their satisfaction with creativity and autonomy, although concerned about continuity of care at handover. Families appreciate kindness and regular sensitive communication. Families would like more contact with the ICU doctors. Limiting access to the patient according to ICU protocol is distressing for relatives. Doctors struggle with decision making, determining prognosis and witnessing the grief of relatives. Some doctors wish to have a greater part in care of the dying patient.

CONCLUSION

Distress among nurses reported in the ICU literature and attributed to disenfranchisement by doctors was not evident. In contrast, some doctors struggle to practice what they value. Adherence to ICU protocols needs flexibility when a patient is dying.

Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important

BACKGROUND

The majority of expected deaths occur in hospitals where optimal end-of-life care is not yet fully realised, as evidenced by recent reviews outlining experience of care. Better understanding what patients and their families consider to be the most important elements of inpatient end-of-life care is crucial to addressing this gap.

AIM AND DESIGN

This systematic review aimed to ascertain the five most important elements of inpatient end-of-life care as identified by patients with palliative care needs and their families.

DATA SOURCES

Nine electronic databases from 1990 to 2014 were searched along with key internet search engines and handsearching of included article reference lists. Quality of included studies was appraised by two researchers.

RESULTS

Of 1859 articles, 8 met the inclusion criteria generating data from 1141 patients and 3117 families. Synthesis of the top five elements identified four common end-of-life care domains considered important to both patients and their families, namely, (1) effective communication and shared decision making, (2) expert care, (3) respectful and compassionate care and (4) trust and confidence in clinicians. The final domains differed with financial affairs being important to families, while an adequate environment for care and minimising burden both being important to patients.

CONCLUSION

This review adds to what has been known for over two decades in relation to patient and family priorities for end-of-life care within the hospital setting. The challenge for health care services is to act on this evidence, reconfigure care systems accordingly and ensure universal access to optimal end-of-life care within hospitals.

Questionnaires on Family Satisfaction in the Adult ICU: A Systematic Review Including Psychometric Properties

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.

Assessing the Quality of Death and Dying in an Integrated Health Care System in Rural Pennsylvania

CONTEXT

With growing emphasis on improving the value of health care, there is increased scrutiny of quality outcomes and high health expenditures during the final months of life.

OBJECTIVES

The purpose of this project is to answer 1) how do next of kin (NOK) perceive the quality of their loved ones' dying and death; 2) are there patient and NOK characteristics that predict lower quality; and 3) are there structural aspects of care associated with lower quality?

METHODS

A mailed survey was administered to a stratified random sample of NOK of Geisinger Health System patients who had died in the past year. The Quality of Death and Dying, the General Anxiety Disorder seven-item scale, the Patient Health Questionnaire eight-item depression scale, and selected questions from the Toolkit of Instruments to Measure End of Life Care were used.

RESULTS

There were 672 respondents. Significant predictors of Quality of Death and Dying score were number of doctors involved in care (P = 0.0415), location of death (P < 0.0001), frequency of receiving confusing or contradictory information (P < 0.0001), illness progression (P = 0.0343), Patient Health Questionnaire-2 score (P = 0.0148), and General Anxiety Disorder seven-item scale score (P < 0.0070).

CONCLUSION

Several findings suggest that factors such as NOK depression and anxiety, prolonged illness, dying in the hospital, receipt of conflicting information, and confusion around the doctor in charge are associated with lower quality of the dying and death experience for NOK. Further investigation is warranted to facilitate high-quality measurement and the use of measurement results to improve care.

Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers

Background

Communication gaps impact the quality of patient care. Previous research has focused on communication barriers rather than seeking solutions. Our aim was to identify strategies for effective communication and decision-making about goals of care for medical interventions in serious illness, from the perspectives of hospital-based healthcare providers.

Methods

A cross-sectional survey composed of closed- and open-ended questions about goals of care communication and decision-making was administered to healthcare providers in 13 centres in six Canadian provinces. We analyzed a portion of the open-ended survey questions, specifically (1) suggestions for overcoming barriers encountered in discussing goals of care, and (2) currently effective practices. Thematic content analysis was used to analyze responses to the open-ended questions.

Results

Of the 1,256 respondents to the larger survey, 468 responded to the open-ended questions (37 %), including 272 of 512 nurses (53 %), 153 of 484 internal medicine trainees (32 %), and 43 of 260 attending physicians (17 %). Responses to each of the two questions were similar, generating a common set of themes and subthemes. Effective strategies and ideas for improving communication and decision-making about goals of care clustered under five themes: patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources. Subthemes highlighted core elements of shared decision-making.

Conclusions

Translating our findings into multifaceted interventions that consider patient and family factors, address knowledge gaps, optimize resource utilization, and facilitate communication and collaboration between patients, families and healthcare providers may improve communication and decision-making about goals of care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0035-x) contains supplementary material, which is available to authorized users.

The relationship between nurses' perception of work environment and patient satisfaction in adult critical care

BACKGROUND

Patient satisfaction in critical care is rarely measured yet has a major impact on hospital reimbursement. The critical care setting is characterized by high patient acuity and a fast-paced work environment. Nurses' perception of work environment in relation to various patient outcomes including patient satisfaction has not been explored exclusively in critical care.

OBJECTIVES

(a) Examine patient's perception of nursing care associated with their hospitalization in the intensive care unit. (b) Describe nurses' perception of work environment within a defined sample of adult critical care units, using the Practice Environment Scale of the Nursing Work Index (PES-NWI). (c) Explore the relationships between nurses' perception of work environment and patient satisfaction in adult critical care.

METHODS

This study used existing data to address the study aims. Unit-level comparisons were examined using analysis of variance. The final aim was examined using multilevel modeling for longitudinal data.

RESULTS

Patients were very satisfied with their hospitalization (4.48 out of 5.0). Significant differences were noted among all unit level comparisons (p < .001). Nurses also reported moderate satisfaction with work environment as measured by the PES-NWI, with perception of the role of their nurse manager receiving the highest scores. Perception of nurse manager leadership and ability was significantly related to patient satisfaction (p= .018). Favorable perception of the nurse manager was associated with a .424 point increase in patient satisfaction.

CONCLUSIONS

This study offers preliminary support for the relationship between nurses' perception of work environment and patient satisfaction in critical care. It also highlights the pivotal role of the nurse manager in both nurse and patient satisfaction.

CLINICAL RELEVANCE

This study examines two important aspects that are both relevant and important to clinical nursing. The first aspect is the healthy work environment. Multiple studies have linked the nursing work environment to patient outcomes and this is an area that deserves further attention. The second aspect, patient satisfaction, is now associated with hospital reimbursement. The relationship between the nursing work environment and patient satisfaction highlights an important link to improving patient care.