Improving Family Communications at the End of Life: Implications for Length of Stay in the Intensive Care Unit and Resource Use

Intensive care unit interventions to improve quality of dying and death: scoping review

BACKGROUND

Intensive care units (ICUs) have mortality rates of 10%-29% owing to illness severity. Postintensive care syndrome-family affects bereaved relatives, with a prevalence of 26% at 3 months after bereavement, increasing the risk for anxiety and depression. Complicated grief highlights issues such as family presence at death, inadequate physician communication and urgent improvement needs in end-of-life care. However, no study has comprehensively reviewed strategies and components of interventions to improve end-of-life care in ICUs.

AIM

This scoping review aimed to analyse studies on improvement of the quality of dying and death in ICUs and identify interventions and their evaluation measures and effects on patients.

METHODS

MEDLINE, CINAHL, PsycINFO and Central Journal of Medicine databases were searched for relevant studies published until December 2023, and their characteristics and details were extracted and categorised based on the Joanna Briggs model.

RESULTS

A total of 24 articles were analysed and 10 intervention strategies were identified: communication skills, brochure/leaflet/pamphlet, symptom management, intervention by an expert team, surrogate decision-making, family meeting/conference, family participation in bedside rounds, psychosocial assessment and support for family members, bereavement care and feedback on end-on-life care for healthcare workers. Some studies included alternative assessment by family members and none used patient assessment of the intervention effects.

CONCLUSION

This review identified 10 intervention strategies to improve the quality of dying and death in ICUs. Many studies aimed to enhance the quality by evaluating the outcomes through proxy assessments. Future studies should directly assess the quality of dying process, including symptom evaluation of the patients.

Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

BACKGROUND

There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources.

METHODS

A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice.

RESULTS

At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept.

CONCLUSIONS

This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis

BACKGROUND

Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income.

METHODS

We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level.

RESULTS

We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention ( P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase ( P = .17) or postintervention change in slope difference ( P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes ( P = .43) or proportions ( P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04).

CONCLUSIONS

Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.

The Role of the Palliative Medicine Clinician in the Family Conference

Facilitating a family conference is a core skill for a palliative medicine clinician, yet the role of the palliative medicine consultant in a family conference has not been clearly defined in the literature. Most educational articles describe a structured approach to a family conference that focuses on the role of the person leading the conference, who may be a palliative medicine specialist or a member of the primary team caring for the patient. For the palliative medicine clinician, balancing the roles of communication facilitator and palliative consultant is nuanced and requires a specific framework and set of skills. In this article, we review the literature on family conferences focusing on facilitation and communication by the palliative care consultant during the conferences, and outline specific ways the palliative medicine clinician can contribute to family conferences. Our hope is that this framework helps guide palliative medicine clinicians and others seeking more specialized training in palliative medicine to be more intentional with their contributions to family conferences in the future. We also hope that this framework will help palliative medicine educators training future specialists.

Interprofessional Interventions to Improve Serious Illness Communication in the Intensive Care Unit: A Scoping Review

Serious illness communication is fundamental to the provision of quality care for patients in the intensive care unit (ICU). Evidence suggests that including interprofessional team members in such communication is beneficial. This scoping review--conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines-maps existing evidence regarding interprofessional interventions to improve serious illness communication in the ICU. The review yielded 14 studies for inclusion, which were organized by 3 thematic categories of strategies implemented: training curriculum, scheduled meetings, and liaison role. Most used a combination of intervention strategies. Outcome measures varied across the studies but could be broadly categorized as patient/family-focused, provider-focused, or systems-focused. Great heterogeneity between studies exists. More research is needed.

Interventions for interpersonal communication about end of life care between health practitioners and affected people

BACKGROUND

Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.

OBJECTIVES

To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.

SELECTION CRITERIA

This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.

MAIN RESULTS

Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.

AUTHORS' CONCLUSIONS

Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Family-clinician shared decision making in intensive care units: Cluster randomized trial in China

OBJECTIVE

To investigate if a Family-Clinician Shared Decision-Making (FCSDM) intervention benefits patients, families and intensive care units (ICUs) clinicians.

METHODS

Six ICUs in China were allocated to intervention or usual care. 548 patients with critical illness, 548 family members and 387 ICU clinicians were included into the study. Structured FCSDM family meetings were held in the intervention group. Scales of SSDM, HADS, QoL2 and CSACD were used to assess families' satisfaction and distress, patients' quality of life, and clinicians' collaboration respectively.

RESULTS

Comparing the intervention group with the control group at post-intervention, there were significant differences in the families' satisfaction (P = 0.0001), depression level (P = 0.005), and patients' quality of life (P = 0.0007). The clinicians' mean CSCAD score was more positive in the intervention group than controls (P < 0.05). There was no significant between-group differences on ICU daily medical cost, but the intervention group demonstrated shorter number of days' stay in ICU (P = 0.0004).

CONCLUSION

The FCSDM intervention improved families' satisfaction and depression, shortened patients' duration of ICU stay, and enhanced ICU clinicians' collaboration.

PRACTICE IMPLICATIONS

Further improvement and promotion of the FCSDM model are needed to provide more evidence to this field in China.

Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans

Racial disparities, including decreased hospice utilization, lower quality symptom management, and poor-quality end-of-life care have been well documented in Black Americans. Improving health equity and access to high-quality serious illness care is a national palliative care (PC) priority. Accomplishing these goals requires clinician reflection, engagement, and large-scale change in clinical practice and health-related policies. In this article, we provide an overview of key concepts that underpin racism in health care, discuss common serious illness disparities in Black Americans, and propose steps to promote the delivery of antiracist PC.

Parent perspectives on facilitating decision-making around pediatric home ventilation

RATIONALE

Deciding about pediatric home ventilation is exceptionally challenging for parents. Understanding the decision-making needs of parents who made different choices for their children could inform clinician counseling that better supports parents' diverse values and goals.

OBJECTIVES

To determine how clinicians can meet the decisional needs of parents considering home ventilation using a balanced sample of families who chose for or against intervention.

METHODS

We conducted semi-structured interviews of parents who chose for or against home ventilation for their child within the previous 5 years. Parents were recruited from three academic centers across the United States. Interviews focused on parent-clinician communication during decision-making and how clinicians made the process easier or more difficult. Qualitative analysis was used to generate themes and identify key results.

RESULTS

Thirty-eight parents were interviewed; 20 chose for and 18 chose against home ventilation. Five themes described their perspectives on how clinicians can facilitate high-quality decision-making: demonstrating dedication to families, effectively managing the medical team, introducing the concept of home ventilation with intention, facilitating meaningful conversation about the treatment options, and supporting and respecting the family's decision.

CONCLUSIONS

High-quality decision-making around home ventilation depends on individual clinician actions and the complex operations of large academic settings. Strong working relationships with parents, collaborative alliances with colleagues, and appropriate delivery of key content can help meet the needs of parents considering invasive breathing supports for their children.

COMFORT communication in the ICU: Pilot test of a nurse-led communication intervention for surrogates

AIM

This study was designed to investigate the feasibility, acceptability, and preliminary efficacy of a nurse-led communication intervention among surrogates in the intensive care unit (ICU) guided by the COMFORT (Connect; Options; Making meaning; Family caregivers; Openings; Relating; Team) communication model.

BACKGROUND

As frontline communicators, nurses experience communication difficulties with surrogates who face complex informational and emotional barriers when making decisions for critically ill patients in the ICU. However, research on effective nurse communication focusing on both curative and end-of-life (EOL) care is lacking in the literature.

DESIGN

A single-centre two-group pretest-posttest quasi-experiment.

METHOD

The total sample included 41 surrogates of adult ventilated patients. Twenty participants were allocated to the intervention group who received a daily 20-min telephone call with content based on the COMFORT communication model. Twenty-one participants comprised the control group who received usual care. Participants completed a questionnaire before and after the study measuring satisfaction, anxiety and depression, decisional conflict, and quality of communication. The Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) checklist was followed for nonrandomised controlled trials.

RESULT

The intervention was feasible, with 19 of 20 surrogates completing the follow-up surveys, and 48 telephone conversations completed (48% of the planned phone calls). Surrogates' satisfaction was higher in the intervention group than in the control group after adjusting for the selected covariates (25.43 and 24.15, respectively; p = .512). Preliminary efficacy outcomes favouring the intervention included quality of communication with healthcare providers, but not surrogates' perceived depression/anxiety and decisional conflicts.

CONCLUSION

Implementation of the intervention is feasible, acceptable, and favourable among surrogates to improve quality of communication with healthcare providers in the ICU. Further research is needed to determine whether the intervention could be implemented by nurses to improve surrogates' outcomes in other ICUs.

Communication as a High-Stakes Clinical Skill: "Just-in-Time" Simulation and Vicarious Observational Learning to Promote Patient- and Family-Centered Care and to Improve Trainee Skill

Patient-provider communication is a hallmark of high-quality care and patient safety; however, the pace and increasingly complex challenges that face overextended teams strain even the most dedicated clinicians. The COVID-19 pandemic has further disrupted communication between clinicians and their patients and families. The dependence on phone communication and the physical barriers of protective gear limit nonverbal communication and diminish clinicians' ability to recognize and respond to emotion. Developing new approaches to teach communication skills to trainees who are often responsible for communicating with patients and their families is challenging, especially during a pandemic or other crisis. "Just-in-time" simulation-simulation-based training immediately before an intervention-provides the scaffolding and support trainees need for conducting difficult conversations, and it enhances patients' and families' experiences. Using a realistic scenario, the author illustrates key steps for effectively using just-in-time simulation-based communication training: assessing the learner's understanding of the situation; determining what aspects of the encounter may prove most challenging; providing a script as a cognitive aid; refreshing or teaching a specific skill; preparing learners emotionally through reflection and mental rehearsal; coaching on the approach, pace, and tone for a delivery that conveys empathy and meaning; and providing specific, honest, and curious feedback to close a performance gap. Additionally, the author acknowledges that clinical conditions sometimes require learning by observing rather than doing and has thus provided guidance for making the most of vicarious observational learning: identify potential challenges in the encounter and explicitly connect them to trainee learning goals, explain why a more advanced member of the team is conducting the conversation, ask the trainee to observe and prepare feedback, choose the location carefully, identify everyone's role at the beginning of the conversation, debrief, share reactions, and thank the trainee for their feedback and observations.

Palliative care interventions in intensive care unit patients

PURPOSE

The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear.

METHODS

We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries.

RESULTS

Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies.

CONCLUSION

Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.

Surrogate Decision Maker Stress in Advance Care Planning Conversations: A Mixed-Methods Analysis From a Randomized Controlled Trial

CONTEXT

Spokespersons serving as surrogate decision makers for their loved ones report high levels of stress. Despite known benefits, advance care planning (ACP) conversations often do not occur. More information is needed to understand spokesperson stress during ACP.

OBJECTIVES

To explore if and how spokespersons perceive stress related to ACP conversations; compare factors related to stress; and assess whether ACP intervention impacted stress.

METHODS

Secondary and mixed-methods analysis with data transformation of semistructured interviews occurring during a 2 × 2 factorial (four armed) randomized controlled trial that compared standard online ACP to a comprehensive online ACP decision aid. Tools were completed by patients with advanced illness (n = 285) alone or with their spokesperson (n = 285). About 200 spokesperson interviews were purposively sampled from each of the four arms (50 per arm).

RESULTS

ACP conversations were reported as stressful by 54.41% (74 of 136) and nonstressful by 45.59% (62 of 136). Five themes impacting spokesperson stress were the nature of the relationship with their loved one; self-described personality and belief systems; knowledge and experience with illness and ACP conversations; attitude toward ACP conversations; and social support in caregiving and decision making. No significant differences in stress were associated with arm assignment.

CONCLUSION

Identifying what factors impact spokesperson stress in ACP conversations can be used to help design ACP interventions to more appropriately address the needs and concerns of spokespersons.

Decision-making regarding withdrawal of life-sustaining treatment and the role of intensivists in the intensive care unit: a single-center study

Background

This study examined the experience of withholding or withdrawing life-sustaining treatment in patients hospitalized in the intensive care units (ICUs) of a tertiary care center. It also considers the role that intensivists play in the decision-making process regarding the withdrawal of life-sustaining treatment.

Methods

We retrospectively analyzed the medical records of 227 patients who decided to withhold or withdraw life-sustaining treatment while hospitalized at Ewha Womans University Medical Center Mokdong between April 9 and December 31, 2018.

Results

The 227 hospitalized patients included in the analysis withheld or withdrew from life-sustaining treatment. The department in which life-sustaining treatment was withheld or withdrawn most frequently was hemato-oncology (26.4%). Among these patients, the most common diagnosis was gastrointestinal tract cancer (29.1%). A majority of patients (64.3%) chose not to receive any life-sustaining treatment. Of the 80 patients in the ICU, intensivists participated in the decision to withhold or withdraw life-sustaining treatment in 34 cases. There were higher proportions of treatment withdrawal and ICU-to-ward transfers among the cases in whom intensivists participated in decision making compared to those cases in whom intensivists did not participate (50.0% vs. 4.3% and 52.9% vs. 19.6%, respectively).

Conclusions

Through their participation in end-of-life discussions, intensivists can help patients’ families to make decisions about withholding or withdrawing life-sustaining treatment and possibly avoiding futile treatments for these patients.

Dilemmas Adult Children Face in Discussing End-of-Life Care Preferences with Their Parents

This study explored the perceived goals, barriers, and strategies that characterize family interactions about advance care planning (ACP), which is instrumental in guiding end-of-life care. Discussions within the family context can significantly improve end-of-life decision making but are complicated, partly because participants are attempting to achieve multiple, and often competing, goals. Participants (n = 75) responded to a hypothetical scenario about a conversation with a parent about ACP by completing an anonymous online survey. Respondents described their conversational goals, anticipated barriers, and strategies they thought would be helpful. Thematic data analysis identified four dilemmas participants faced while attempting to achieve multiple, conflicting goals: (1) the desire to make the parent feel wanted while discussing them not being around; (2) the need to be gentle but still direct; (3) the practical necessity of designating one decision-maker without provoking family conflict; and (4) the desire to lessen the burden on the designated decision-maker by providing necessary information while still placing them in a decision-making role. Participants reported using several strategies to manage these complex dilemmas. These findings provide support for the utility of Goldsmith's normative theory of social support in the context of discussions about ACP. The results also provide a foundation for developing conversational guides to facilitate high-quality family conversations about ACP between adult children and their parents.

Aligning use of intensive care with patient values in the USA: past, present, and future

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.

Clinicians' Perceptions of Futile or Potentially Inappropriate Care and Associations with Avoidant Behaviors and Burnout

Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or "possibly" provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p < 0.05) associated with compensatory and avoidant behaviors, but more strongly associated with avoidant behaviors. Provision of PIC increased the likelihood of avoiding the patient's loved ones by a factor of 2.40 (1.82-3.19), avoiding the patient by a factor of 1.83 (1.32-2.55), and avoiding colleagues by a factor of 2.56 (1.57-4.20) (all p < 0.001). Avoiding the patient's loved ones (β = 0.55, SE = 0.12, p < 0.001), avoiding the patient (β = 0.38, SE = 0.17; p = 0.03), and avoiding colleagues (β = 0.78, SE = 0.28; p = 0.01) were significantly associated with burnout. Conclusions: Futile/PIC, provided or observed, is associated with avoidance of patients, families, and colleagues and those behaviors are associated with burnout.

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments

BACKGROUND

Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent.

METHODS

We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days.

RESULTS

Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001).

CONCLUSION

Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

Complexity Analysis of Decision-Making in the Critically Ill

RATIONALE

Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life.

OBJECTIVE

To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness.

METHODS

A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death.

MEASUREMENTS

Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan.

MAIN RESULTS

Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential.

CONCLUSION

Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.

Implementation of a Nurse-Led Family Meeting in a Neuroscience Intensive Care Unit

PURPOSE/OBJECTIVES

The aims of this study were to develop, implement, and evaluate the impact of early intensive care unit (ICU) nurse-led family meetings on nurse-family communication, family decision making, and satisfaction of family members.

BACKGROUND

Intensive care unit nurses are in an ideal position to meet family needs, and family members may cope better with the crisis of an ICU admission if consistent honest information is provided by nurses; however, there are no early ICU family meetings led by bedside nurses.

METHODS

This quality improvement project was implemented in a 10-bed neuroscience ICU over a 3-month period. A convenience sample of 23 nurses participated in the project. Following development of a communication protocol to facilitate nurse-led meetings, the nurses received education and then implemented the protocol. Thirty-one family members participated in the project. Family members were surveyed before and after the meetings.

RESULTS

Mean meeting time was 26 (SD, 14) minutes. Following implementation of the meetings, findings demonstrated that families felt that communication improved (P = .02 and P = .008), they had appropriate information for decision making allowing them to feel in control (P = .002), and there was an increase in family satisfaction (P = .001).

CONCLUSION

Early ICU nurse-led family meetings were feasible, improved communication between ICU nurses and family members, facilitated decision making in ICU families, and increased satisfaction of family members.

Factors Affecting the Length of Stay in the Intensive Care Unit: Our Clinical Experience

Background and Aim

Long hospital days in intensive care unit (ICU) due to life-threatening diseases are increasing in the world. The primary goal in ICU is to decrease length of stay in order to improve the quality of medical care and reduce cost. The aim of our study is to identify and categorize the factors associated with prolonged stays in ICU.

Materials and Method

We retrospectively analyzed 3925 patients. We obtained the patients' demographic, clinical, diagnostic, and physiologic variables; mortality; lengths of stay by examining the intensive care unit database records.

Results

The mean age of the study was 61.6 ± 18.9 years. The average length of stay in intensive care unit was 10.2 ± 25.2 days. The most common cause of hospitalization was because of multiple diseases (19.5%). The length of stay was positively correlated with urea, creatinine, and sodium. It was negatively correlated with uric acid and hematocrit levels. Length of stay was significantly higher in patients not operated on than in patients operated on (p < 0.001).

Conclusion

Our study showed a significantly increased length of stay in patients with cardiovascular system diseases, multiple diseases, nervous system diseases, and cerebrovascular diseases. Moreover we showed that when urea, creatinine, and sodium values increase, in parallel the length of stay increases.

Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review

BACKGROUND

Advance care planning and goals of care discussions involve the exploration of what is most important to a person, including their values and beliefs in preparation for health-care decision-making. Advance care planning conversations focus on planning for future health care, ensuring that an incapable person's wishes are known and can guide the person's substitute decision maker for future decision-making. Goals of care discussions focus on preparing for current decision-making by ensuring the person's goals guide this process.

AIM

To provide evidence regarding tools and/or practices available for use by health-care providers to effectively facilitate advance care planning conversations and/or goals of care discussions.

DATA SOURCES

A systematic review was conducted focusing on guidelines, randomized trials, comparative studies, and noncomparative studies. Databases searched included MEDLINE, EMBASE, and the proceedings of the International Advance Care Planning Conference and the American Society of Clinical Oncology Palliative Care Symposium.

CONCLUSIONS

Although several studies report positive findings, there is a lack of consistent patient outcome evidence to support any one clinical tool for use in advance care planning or goals of care discussions. Effective advance care planning conversations at both the population and the individual level require provider education and communication skill development, standardized and accessible documentation, quality improvement initiatives, and system-wide coordination to impact the population level. There is a need for research focused on goals of care discussions, to clarify the purpose and expected outcomes of these discussions, and to clearly differentiate goals of care from advance care planning.

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes

BACKGROUND

Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members.

OBJECTIVE

The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps.

METHODS

We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future.

RESULTS

We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions.

CONCLUSIONS

The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.

End-of-Life Decision Support in the ICU: Where Are We Now?

Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.

Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine whether patient- and family-centered care interventions in the ICU improve outcomes.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.

STUDY SELECTION

We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.

DATA EXTRACTION

We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.

DATA SYNTHESIS

There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.

CONCLUSIONS

Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

A survey of next of kin needs of trauma patients admitted to Intensive Care Units in South Africa

AIM

To conduct a cross-sectional survey of next of kin needs of critically injured trauma patients admitted to Intensive Care Units in South Africa.

METHODS

The needs of next of kin of trauma patients (in public and private hospitals) who were critically injured and required admission to Intensive Care Units were surveyed at two points: on admission within first 24hours and on Day 3/day of transfer if earlier.

RESULTS

A total of 162 next of kin participated (114 from state and 48 from private) and Critical Care Family Needs Inventory subscale scores obtained at admission and at Day 3/day of transfer if earlier indicated a trend toward reporting increased needs. In all the needs ratings, the top domains were those of Assurance and Information.

CONCLUSION

The next of kin have a great number of needs that are currently not being met (both in the state and the private hospital and these needs actually increase over time. This study can help nurses understand the needs of next of kin in the Intensive Care Unit and that these needs change over the hospitalization period.

End-of-life discussions: Who's doing the talking?

PURPOSE

To determine, in a tertiary academic medical center, the reported frequency of end-of-life discussions among nurses and the influence of demographic factors on these discussions.

METHODS

Survey of nurses on frequency of end-of-life discussions in two urban academic medical centers. Chi-square tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, "Do you regularly talk with your patients about end-of-life wishes?"

RESULTS

Overall, more than one-third of respondents reported rarely or never discussing end-of-life wishes with their patients. Only specialty expertise (p<0.001) was statistically significantly associated with discussing end-of-life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion "always" or "most of the time." However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end-of-life discussions with patients.

CONCLUSIONS

In a survey conducted in two tertiary care institutions, more than one-third of nurses from all disciplines responded that they never or almost never discuss end-of-life issues with their patients. Specialty influenced the likelihood of discussing end-of-life issues with patients.

Evaluation of the Decisional Fatigue Scale Among Surrogate Decision Makers of the Critically Ill

Intense emotional distress and impaired information processing have been implicated in reducing a surrogate decision maker's ability to formulate informed health care decisions for a critically ill patient. The heightened intensity of negative emotions, mental effort, and impaired judgment is consistent with the manifestation of decision fatigue. The aim of this article is to describe the validity and reliability of the Decision Fatigue Scale (DFS) among surrogate decision makers of the critically ill. A convenience sample of 101 surrogate decision makers were administered the DFS and a battery of psychosocial instruments at two time points. The DFS was specified as a unidimensional measure with adequate internal consistency (Cronbach's αs = .87, .90) and stability reliability. Discriminant validity was established with measures of emotion regulation, anxiety, and depressive symptoms. The DFS is the first subjective measure of decision fatigue for surrogate decision makers of the critically ill that demonstrates satisfactory psychometric properties.

Developing and testing a comprehensive tool to assess family meetings: Empirical distinctions between high- and low-quality meetings

BACKGROUND

The heterogeneity with regard to findings on family meetings (or conferences) suggests a need to better understand factors that influence family meetings. While earlier studies have explored frequency or timing of family meetings, little is known about how factors (such as what is said during meetings, how it is said, and by whom) influence family meeting quality.

OBJECTIVES

(1) To develop an evaluation tool to assess family meetings (Phase 1); (2) to identify factors that influence meeting quality by evaluating 34 family meetings (Phase 2).

MATERIALS AND METHODS

For Phase 1, methods included developing a framework, cognitive testing, and finalizing the evaluation tool. The tool consisted of Facilitator Characteristics (i.e., gender, experience, and specialty of the person leading the meeting), and 22 items across 6 Meeting Elements (i.e., Introductions, Information Exchanges, Decisions, Closings, Communication Styles, and Emotional Support) and sub-elements. For Phase 2, methods included training evaluators, assessing family meetings, and analyzing data. We used Spearman's rank-order correlations to calculate meeting quality. Qualitative techniques were used to analyze free-text.

RESULTS

No Facilitator Characteristic had a significant correlation with meeting quality. Sub-elements related to communication style and emotional support most strongly correlated with high-quality family meetings, as well as whether "next steps" were outlined (89.66%) and whether "family understanding" was elicited (86.21%). We also found a significant and strong positive association between overall proportion scores and evaluators' ratings (r_s=0.731, p<0.001).

CONCLUSIONS

We filled a gap by developing an evaluation tool to assess family meetings, and we identified how what is said during meetings impacts quality.

Across the Continuum: How Inpatient Palliative Care Consultations Are Reported in Hospital Discharge Summaries

BACKGROUND

Inpatient Palliative Care (PC) consultations help develop a patient-centered and quality-of-life-focused plan of care for patients with serious illness. Discharge summaries (DSs) are an essential tool to maintain continuity of these care plans across multiple locations and providers.

METHODS

We conducted a retrospective chart review of selected DSs of patients who received inpatient PC consultations at the University of Kansas Hospital from July 2011 to May 2015. The study included patients 18 years or older, patients who were discharged alive, and patients who were not discharged with hospice care. Code words and their related phrases, developed by an expert panel of geriatric medicine and palliative medicine physicians, were used to evaluate the DSs. They were categorized into PC, symptom management, hospice and palliative home health, decision making, and plan of care. We also identified whether there was communication between the primary team and PC team, as well as family meeting status in the PC consultation and notes.

RESULTS

Of the 961 chart reviews, no code words were found in 22.8% of the DSs. PC was mentioned in only 63.3% and was the only code word in 5.3%.

CONCLUSION

More than one in five DSs lacked any code words of the completed PC consultation and more than one in three DSs lacked mention of PC. As DSs are the main source of provider communication, it is critical they reflect the key discussion points from the PC consultation, which will improve the transition of care and provider communication.

Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness

OBJECTIVES

To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness.

DESIGN AND SETTING

Decision analysis using literature estimates and inpatient administrative data from Premier.

PATIENTS

Patients with chronic, life-limiting illness admitted to a hospital within the Premier network.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Using Premier data (2008-2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions' efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients.

CONCLUSIONS

In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers.

Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis

OBJECTIVE

Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality.

METHOD

A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence.

RESULTS

Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively.

SIGNIFICANCE OF RESULTS

Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.

End-of-Life Decision Making and Communication of Bereaved Family Members of African Americans with Serious Illness

OBJECTIVE

The study objective was to examine factors that influence African American (AA) family members' end-of-life care decision outcomes for a relative who recently died from serious illness.

METHODS

A cross-sectional descriptive study design was used. Binary logistic and linear regressions were used to identify factors associated with decision regret and decisional conflict. Forty-nine bereaved AA family members of AA decedents with serious illness who died two to six months prior to enrollment were recruited from the palliative care program in a safety net hospital and a metropolitan church in the Midwest. Measurements used were the Decisional Conflict, Decision Regret, Beliefs and Values, and Quality of Communication scales.

RESULTS

Family members who reported higher quality of communication with health care providers had lower decisional conflict. Family members of decedents who received comfort-focused care (CFC) had significantly less decision regret than family members of those who received life-prolonging treatment (LPT). Family members who reported stronger beliefs and values had higher quality of communication with providers and lower decisional conflict.

CONCLUSIONS

This research adds to a small body of literature on correlates of end-of-life decision outcomes among AAs. Although AAs' preference for aggressive end-of-life care is well-documented, we found that receipt of CFC was associated with less decision regret. To reduce decisional conflict and decision regret at the end of life, future studies should identify strategies to improve family member-provider communication, while considering relevant family member and decedent characteristics.

Withholding and withdrawing life prolonging treatment in the intensive care unit: a current European perspective

Background:Many deaths are now preceded by an end of life decision, particularly in the intensive care unit (ICU), but such practices vary considerably between countries, ICUs and individuals, depending on many factors including cultural and religious background, family and peer pressure and local practice. Aims:In this review, we will discuss the application of the four key ethical principles-beneficence, nonmaleficence, autonomy and distributive justice - to withdrawing/withholding decisions. Methods: Drawing data from several national and international studies, we then summarize the current situation across Europe regarding such practices before making some suggestions as to how we could facilitate the often difficult decision making process by improved communication between staff, patient and relatives.

Experiences of healthcare professionals as caregivers of a dying family member: an exploratory study

BACKGROUND

Many health-care professionals also take on a caregiver role at home, usually by caring for a dying relative. Very little is known about the perceptions, experiences and needs of this specific group of carers.

OBJECTIVE

To understand the perceptions and experiences of healthcare professionals as caregivers and identify their needs.

METHODS

Health-care professionals working at one health unit in Portugal participated in a semi-structured interview (n=9). Data were analysed and organised thematically.

RESULTS

Four key themes emerged from the analysis: (i) the perception of the caregiver role, (ii) the difficulties experienced in the caregiver role, (iii) the rewards obtained by carrying out the caregiver role and (iv) the healthcare professional's needs as a caregiver.

CONCLUSION

Healthcare professionals' needs as caregivers are not assessed and addressed holistically, creating room for improvement. Participants felt emotionally pressured by their families to get answers and find solutions during caregiving. Despite it being a complex and painful process, participants still gave examples of rewards experienced during caregiving.

Moral distress in Turkish intensive care nurses

BACKGROUND

Moral distress is a common problem among professionals working in the field of healthcare. Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by nurses working in intensive care units varies from one country/culture/institution to another. However, in Turkey, there is neither a measurement tool used to assess moral distress suffered by nurses nor a study conducted on the issue.

AIM/OBJECTIVE

The study aims to (a) validate the Turkish version of the Moral Distress Scale-Revised to be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale, and (b) explore Turkish intensive care nurses' moral distress level.

METHOD

The sample of this methodological, descriptive, and cross-sectional design study comprises 200 nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The Turkish Version of Moral Distress Scale-Revised. Ethical considerations: The study proposal was approved by the ethics committee of the Faculty of Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured of data confidentiality.

RESULTS

In parallel with the original scale, Turkish version of Moral Distress Scale-Revised consists of 21 items, and shows a one-factor structure. It was determined that the moral distress total and item mean scores of the nurses participating in the study were 70.81 ± 48.23 and 3.36 ± 4.50, respectively.

CONCLUSION

Turkish version of Moral Distress Scale-Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by nurses working in intensive care units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress. However, factors which caused the nurses in our study to experience higher levels of moral distress are inadequate communication within the team, working with professionals they considered as incompetent, and futile care.

Palliative care in neonatal neurology: robust support for infants, families and clinicians

Infants with neurological injury and their families face unique challenges in the neonatal intensive care unit. As specialty palliative care support becomes increasingly available, we must consider how to intentionally incorporate palliative care principles into the care of infants with neurological injury. Here, we review data regarding neonatal symptom management, prognostic uncertainty, decision making, communication and parental support for neonatal neurology patients and their families.

Applicability of the Calgary-Cambridge Guide to Dog and Cat Owners for Teaching Veterinary Clinical Communications

Effective communication in health care benefits patients. Medical and veterinary schools not only have a responsibility to teach communication skills, the American Veterinary Medical Association (AVMA) Council on Education (COE) requires that communication be taught in all accredited colleges of veterinary medicine. However, the best strategy for designing a communications curriculum is unclear. The Calgary-Cambridge Guide (CCG) is one of many models developed in human medicine as an evidence-based approach to structuring the clinical consultation through 71 communication skills. The model has been revised by Radford et al. (2006) for use in veterinary curricula; however, the best approach for veterinary educators to teach communication remains to be determined. This qualitative study investigated if one adaptation of the CCG currently taught at Midwestern University College of Veterinary Medicine (MWU CVM) fulfills client expectations of what constitutes clinically effective communication. Two focus groups (cat owners and dog owners) were conducted with a total of 13 participants to identify common themes in veterinary communication. Participants compared communication skills they valued to those taught by MWU CVM. The results indicated that while the CCG skills that MWU CVM adopted are applicable to cat and dog owners, they are not comprehensive. Participants expressed the need to expand the skillset to include compassionate transparency and unconditional positive regard. Participants also expressed different communication needs that were attributed to the species of companion animal owned.

Communication tools for end-of-life decision-making in the intensive care unit: a systematic review and meta-analysis

BACKGROUND

For many patients admitted to the intensive care unit (ICU), preferences for end-of-life care are unknown, and clinicians and substitute decision-makers are required to make decisions about the goals of care on their behalf. We conducted a systematic review to determine the effect of structured communication tools for end-of-life decision-making, compared to usual care, upon the number of documented goals of care discussions, documented code status, and decisions to withdraw life-sustaining treatments, in adult patients admitted to the ICU.

METHODS

We searched multiple databases including MEDLINE, Embase, CINAHL, ERIC, and Cochrane from database inception until July 2014. Two reviewers independently screened articles, assessed eligibility, verified data extraction, and assessed risk of bias using the tool described by the Cochrane Collaboration and the Newcastle Ottawa Scale. Pooled estimates of effect (relative risk, standardized mean difference, or mean difference), were calculated where sufficient data existed. GRADE was used to evaluate the overall quality of evidence for each outcome.

RESULTS

We screened 5785 abstracts and reviewed the full text of 424 articles, finding 168 eligible articles, including 19 studies in the ICU setting. The use of communication tools increased documentation of goals-of-care discussions (RR 3.47, 95% CI 1.55, 7.75, p = 0.020, very low-quality evidence), but did not have an effect on code status documentation (RR 1.03, 95% CI 0.96, 1.10, p = 0.540, low-quality evidence) or decisions to withdraw or withhold life-sustaining treatments (RR 0.98, 95% CI 0.89, 1.08, p = 0.70, low-quality evidence). The use of such tools was associated with a decrease in multiple measures of health care resource utilization, including duration of mechanical ventilation (MD -1.9 days, 95% CI -3.26, -0.54, p = 0.006, very low-quality evidence), length of ICU stay (MD -1.11 days, 95% CI -2.18, -0.03, p = 0.04, very low-quality evidence), and health care costs (SMD -0.32, 95% CI -0.5, -0.15, p < 0.001, very low-quality evidence).

CONCLUSIONS

Structured communication tools may improve documentation of EOL decision making and may result in lower resource use. The supporting evidence is low to very low in quality. Further high-quality randomized studies of simple communication interventions are needed to determine whether structured, rather than ad hoc, approaches to end-of-life decision-making improve patient-level, family-level, and system-level outcomes.

TRIAL REGISTRATION

PROSPERO CRD42014012913.

A systematic review of evidence for end-of-life communication interventions: Who do they target, how are they structured and do they work?

OBJECTIVE

To identify and synthesise evidence for interventions targeting end-of-life communication.

METHODS

Database, reference list and author searches were conducted to identify evaluations of end-of-life communication-focussed interventions. Data were extracted, synthesised and QUALSYST quality analyses were performed.

RESULTS

Forty-five studies met inclusion criteria. Interventions targeted patients (n=6), caregivers (n=3), healthcare professionals (HCPs n=24) and multiple stakeholders (n=12). Interventions took various forms including communication skills training, education, advance care planning and structured practice changes. Substantial heterogeneity in study designs, outcomes, settings and measures was apparent and study quality was variable.

CONCLUSION

A substantial number of end-of-life communication interventions have been evaluated. Interventions have particularly targeted HCPs in cancer settings, though patient, caregiver and multi-focal interventions have also been evaluated. While some interventions were efficacious in well-designed RCTs, most evidence was from less robust studies. While additional interventions targeting patients and caregivers are needed, multi-focal interventions may more effectively remove barriers to end-of-life communication.

PRACTICE IMPLICATIONS

Despite the limitations evident in the existing literature, healthcare professionals may still derive useful insights into effective approaches to end-of-life communication if appropriate caution is exercised. However, additional RCTs, implementation studies and cost-benefit analyses are required to bolster arguments for implementing and resourcing communication interventions.

Benefits and resource implications of family meetings for hospitalized palliative care patients: research protocol

BACKGROUND

Palliative care focuses on supporting patients diagnosed with advanced, incurable disease; it is 'family centered', with the patient and their family (the unit of care) being core to all its endeavours. However, approximately 30-50% of carers experience psychological distress which is typically under recognised and consequently not addressed. Family meetings (FM) are recommended as a means whereby health professionals, together with family carers and patients discuss psychosocial issues and plan care; however there is minimal empirical research to determine the net effect of these meetings and the resources required to implement them systematically. The aims of this study were to evaluate: (1) if family carers of hospitalised patients with advanced disease (referred to a specialist palliative care in-patient setting or palliative care consultancy service) who receive a FM report significantly lower psychological distress (primary outcome), fewer unmet needs, increased quality of life and feel more prepared for the caregiving role; (2) if patients who receive the FM experience appropriate quality of end-of-life care, as demonstrated by fewer hospital admissions, fewer emergency department presentations, fewer intensive care unit hours, less chemotherapy treatment (in last 30 days of life), and higher likelihood of death in the place of their choice and access to supportive care services; (3) the optimal time point to deliver FM and; (4) to determine the cost-benefit and resource implications of implementing FM meetings into routine practice.

METHODS

Cluster type trial design with two way randomization for aims 1-3 and health economic modeling and qualitative interviews with health for professionals for aim 4.

DISCUSSION

The research will determine whether FMs have positive practical and psychological impacts on the family, impacts on health service usage, and financial benefits to the health care sector. This study will also provide clear guidance on appropriate timing in the disease/care trajectory to provide a family meeting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000200583.

Life after the Liverpool Care Pathway (LCP): a qualitative study of critical care practitioners delivering end-of-life care

AIM

To explore the experiences, challenges and practices of critical care practitioners since the discontinuation of the Liverpool Care Pathway in critical care settings.

BACKGROUND

The Liverpool Care Pathway was widely used with an aim to improve communication and care for dying individuals and their relatives. However, widespread media criticism prompted a review, which resulted in the discontinuation of the Liverpool Care Pathway across all UK clinical settings.

DESIGN

A qualitative study.

METHOD

The study was carried out in two large acute hospitals in England. Semi-structured interviews were conducted with 14 critical care practitioners, 6 months after discontinuation of the Liverpool Care Pathway. Transcribed verbatim data were analysed using framework analysis.

RESULTS

Three key themes emerged: 'lessons learned', 'uncertainties and ambivalences' and 'the future'. Critical care practitioners reported that life after the Liverpool Care Pathway in critical care settings often involved various clinical ambivalences, uncertainties and inconsistencies in the delivery of end-of-life care, especially for less experienced practitioners. Critical care practitioners had 'become accustomed' to the components of the Liverpool Care Pathway, which still guide them in principle to ensure quality end-of-life care. The Liverpool Care Pathway's structured format was perceived to be a useful clinical tool, but was also criticized as a 'tick-box exercise' and for lacking in family involvement.

CONCLUSIONS

This study posits two key conclusions. Despite experienced critical care practitioners being able to deliver quality end-of-life care without using the Liverpool Care Pathway, junior nursing and medical staff need clear guidelines and support from experienced mentors in practice. Evidence-based guidelines related to family involvement in end-of-life care planning in critical care settings are also needed to avoid future controversies.

Enhancing student communication during end-of-life care: A pilot study

Background:

Quality end-of-life care requires effective communication skills, yet medical and nursing students report limited opportunities to develop these skills, and that they lack confidence and the related competence.

Objectives:

Our purpose was to design, implement, and evaluate an educational intervention employing simulated patient actors to enhance students' abilities to communicate with dying patients and their families.

Methods:

A study employing a mixed-methods design was conducted with prequalification nursing and medical students recruited from a London university. The first phase involved focus groups with students, which informed the development of an educational intervention involving simulated patient actors. Questionnaires measuring students' perceptions of confidence and competence levels when communicating with dying patients and their families were administered before and after the intervention.

Results:

The themes from focus groups related to responding to grief and anger, difficulties dealing with emotions, knowing the “right thing” to say, and a lack of experience. A significant increase (p< 0.5) in competence and confidence from baseline levels followed participation in the simulated scenarios.

Significance of Results:

Simulation was found to be an effective means of preparing students to communicate with dying patients and their families. The opportunity to develop communication skills was valued. Integration of educational interventions employing simulated patient actors into nursing and medical curricula may assist in improving the care provided to patients at the end of life.

Evidence-based palliative care in the intensive care unit: a systematic review of interventions

BACKGROUND

Over the last 20 years, multiple interventions to better integrate palliative care and intensive care unit (ICU) care have been evaluated. This systematic review summarizes these studies and their outcomes.

METHODS

We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, and the Web of Science; performed a search of articles published by opinion leaders in the field; and reviewed hand-search articles as of August 13, 2012. The terms "palliative care" and "intensive care unit" were mapped to MeSH subject headings and "exploded." We included trials of adult patients that evaluated an ICU intervention and addressed Robert Wood Johnson group-identified domains of high-quality end-of-life care in the ICU. We excluded case series, editorials, and review articles. We compared two types of interventions, integrative and consultative, focusing on the outcomes of patient and family satisfaction, mortality, and ICU and hospital length of stay (LOS), because these were most prevalent among studies.

RESULTS

Our search strategy yielded 3328 references, of which we included 37 publications detailing 30 unique interventions. Interventions and outcome measures were heterogeneous, and many studies were underpowered and/or subject to multiple biases. Most of the interventions resulted in a decrease in hospital and ICU LOS. Few interventions significantly affected satisfaction. With one exception, the interventions decreased or had no effect on mortality. There was no evidence of harm from any intervention.

CONCLUSIONS

Heterogeneity of interventions made comparison of ICU-based palliative care interventions difficult. However, existing evidence suggests proactive palliative care in the ICU, using either consultative or integrative palliative care interventions, decrease hospital and ICU LOS, do not affect satisfaction, and either decrease or do not affect mortality.

A tool to aid talking about dementia and dying--development and evaluation

BACKGROUND

Health professionals often avoid talking about death and dying with patients and relatives, and this avoidance is compounded in cases of dementia by lack of knowledge of trajectory and prognosis. Unfortunately, this impacts on care, with many terminally ill dementia clients receiving inadequate palliation and excessive intervention at end-of-life. This study developed and evaluated a tool to facilitate conversations about death and dying in aged care facilities.

METHODS

This study utilised available best-practice evidence, feedback from aged care facility nursing and care staff and specialist input to develop the 'discussion tool', which was subsequently trialled and qualitatively evaluated, via thematic analysis of data from family interviews and staff diaries. The study was part of a larger mixed method study, not yet reported. The tool provided knowledge and also skills-based 'how to' information and specific examples of 'what to say'.

RESULTS

The tool facilitated a more open dialogue between dementia palliation resource nurses (a role specifically developed during this project) and family members. Both resource nurses and family members gained confidence in discussing the death of their relative with dementia, and in relevant cases discussed specific decisions around future care. Family members and nurses reported satisfaction with these discussions.

CONCLUSION

Providing specific skills-based support, such as the 'discussion tool' can help staff to gain confidence and change practice in situations where unfamiliar and uncomfortable practices might normally be avoided. As our populations age, health professionals will increasingly need to be able to openly discuss care options towards end-of-life.