Life Support Withdrawal: Communication and Conflict

Limitation of life sustaining therapy in disorders of consciousness: ethics and practice

Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.

Incorporating the Patient and Caregiver Voice in Palliative Care Quality Measure Development

CONTEXT

Despite rapid growth in outpatient palliative care, we lack an understanding of patient and caregiver experiences of care received in this context.

OBJECTIVES

As part of a national effort to develop palliative care quality metrics for use in accountability programs, we sought to develop survey items assessing patients' experiences of outpatient palliative care, incorporating the patient's voice.

METHODS

We conducted 25 one-hour telephone cognitive interviews using a convenience sample of outpatient palliative care patients and caregivers to cognitively test survey items. Guided by a semi-structured protocol, we assessed the comprehensibility, ambiguity, and adaptability of survey instructions and specific items/response options.

RESULTS

Participants generally understood the intended meaning of the question content. Some participants struggled with the stated time period of three months as a reference period for reporting their experiences. While some expressed preferences for question wording, no clear patterns emerged across participants.

CONCLUSION

In general, question wording and response options did not present challenges to understanding content. Respondents ascribed a variety of meanings to the concepts, validating that the measures capture a range of experiences. However, the referenced timeframe of three months was more difficult to answer for some questions than others. Implications for research, policy or practice: Based on the findings from the cognitive testing, the survey items are being tested as part of a national study to understand the quality of care for patients. These measures may be used in the future by Medicare to help outpatient palliative care programs improve their care.

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.

The experiences and perspectives of family surrogate decision-makers: A systematic review of qualitative studies

OBJECTIVE

Surrogate decision-makers play an increasingly important role in the lives of older adults who have lost their ability to make decisions. Currently, there is a lack of evidence to support family surrogates in making a variety of decisions. Additionally, a greater understanding of family caregivers' experiences and perspectives toward making surrogate decisions is needed.

METHODS

This study employed a qualitative systematic review and thematic synthesis of the research evidence using the methodologies of the Joanna Briggs Institute (2014) and Thomas and Harden (2008).

RESULTS

Decisions were classified per three main types: intensive care treatment, end-of-life treatment, and placement. Six themes were identified concerning surrogates' experiences: struggle and reluctance, seeking reassurance, communication with healthcare professionals, family support, older adults' wishes, and negative impact.

CONCLUSION

Family surrogates often lack adequate preparation and education regarding decision-making. Quality communication between surrogates and healthcare providers helps reduce the anxiety and guilt experienced when making surrogate decisions. Further research is required to elucidate these experiences with more cultural and racial nuances.

PRACTICE IMPLICATIONS

This review informs healthcare providers' awareness of the challenges faced by surrogates and fosters improved surrogate decision-making experiences.

Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services

Importance

Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care.

Objectives

To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death.

Design, Setting, and Participants

This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019.

Exposure

Cessation of dialysis treatment before death.

Main Outcomes and Measures

Bereaved Family Survey ratings.

Results

Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001).

Conclusions and Relevance

This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.

Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty

BACKGROUND

Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty.

METHOD

This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached.

CONCLUSION

In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.

Understanding Early Decisions to Withdraw Life-Sustaining Therapy in Cardiac Arrest Survivors. A Qualitative Investigation

RATIONALE

Early withdrawal of life-sustaining therapy contributes to the majority of deaths following out-of-hospital cardiac arrest (OHCA), despite current recommendations for delayed neurological prognostication (≥72 h) after treatment with targeted temperature management. Little is known about clinicians' experiences of early withdrawal of life support decisions in patients with OHCA.

OBJECTIVES

To explore clinicians' experiences and perceptions of early withdrawal of life support decisions and barriers to guideline-concordant neurological prognostication in comatose survivors of OHCA treated with targeted temperature management.

METHODS

We conducted qualitative interviews with intensive care unit (ICU) physicians and nurses following withdrawal of life support in comatose patients with OHCA treated with targeted temperature management. The study was carried out across 18 academic and community hospitals participating in a multicenter, stepped-wedge, cluster-randomized controlled trial designed to improve quality-of-care processes for patients after OHCA in Ontario, Canada. We used a focused thematic analysis to capture barriers to guideline-concordant neurological prognostication and used these barriers to identify potentially modifiable issues.

MEASUREMENTS AND MAIN RESULTS

The core thematic finding was a high emotional burden of ICU family-team communication in which strong feelings inhibited information transfer and delayed decision making following OHCA. Four subthemes describing sources of communication strain were identified: (1) requests from family members to provide early outcome predictions, (2) incomplete family comprehension of critical care, (3) family requests for early withdrawal of life support based on their understanding of patients' preferences and values, and (4) family-team communication gaps related to prognostic uncertainty. Participants worried that gaps in timely and clear prognostic information contributed to surrogates' perceptions of a poor outcome and to inappropriately early decisions to withdraw life support.

CONCLUSIONS

Family-team communication difficulties may be an underestimated factor leading to early withdrawal of life support in ICUs for individuals who initially survive OHCA.

Medical Record Quality Assessments of Palliative Care for Intensive Care Unit Patients. Do They Match the Perspectives of Nurses and Families?

RATIONALE

To understand how well palliative care is provided in the intensive care unit (ICU) and to direct improvements, measurement of the quality of care delivered is requisite.

OBJECTIVES

To measure the quality of palliative care delivered in the ICU, using chart review-derived process quality measures of palliative care in critically ill patients, and to compare these measures with family and nursing perspectives on the quality of care provided.

METHODS

We developed and operationalized a comprehensive quality evaluation measure set from previously endorsed palliative care measure statements, using a rigorous multidisciplinary Delphi process focused on optimizing the validity and feasibility of chart review-derived metrics. Fourteen process measures assessed the quality of care delivered across established domains of palliative care for the ICU. We assessed the quality of care for ICU patients with ICU length of stay exceeding 2 days from three perspectives: medical record reviews, family satisfaction reports, and nurse ratings from those providing care in the ICU.

MEASUREMENTS AND MAIN RESULTS

We evaluated the care over a 7-month period of 150 patients (mean age, 63.9 yr [SD 13.4], average ICU length of stay, 7.5 d [SD 7.2]). Overall, ICU patients received 53.1% of recommended palliative care. The Family Satisfaction with Care in the Intensive Care Unit total scores from 136 family members (response rate, 91%) were high, 85.7 (SE 2.0) and 86.0 (SE 1.6), at the two sites but not correlated to measured quality delivered. Nurses rated the quality of care higher than medical record review (mean, 77.3% [SD 13.4]; n = 135) and similarly correlation with chart based process measures was poor.

CONCLUSIONS

Delivering high-quality palliative care in the ICU requires assessing key patient-centered domains. However, assessments from different perspectives do not always agree with technical quality of care as measured through chart-based metrics. We found deficits across seven domains of technical quality that were not correlated with either nurse or family ratings. Despite care gaps, families were generally satisfied with the care delivered. We conclude that each measurement perspective provides an independent view that can guide quality improvement and innovation work as well as subsequent research.

Validation of the Family Inpatient Communication Survey

CONTEXT

Although many family members who make surrogate decisions report problems with communication, there is no validated instrument to accurately measure surrogate/clinician communication for older adults in the acute hospital setting.

OBJECTIVES

The objective of this study was to validate a survey of surrogate-rated communication quality in the hospital that would be useful to clinicians, researchers, and health systems.

METHODS

After expert review and cognitive interviewing (n = 10 surrogates), we enrolled 350 surrogates (250 development sample and 100 validation sample) of hospitalized adults aged 65 years and older from three hospitals in one metropolitan area. The communication survey and a measure of decision quality were administered within hospital days 3 and 10. Mental health and satisfaction measures were administered six to eight weeks later.

RESULTS

Factor analysis showed support for both one-factor (Total Communication) and two-factor models (Information and Emotional Support). Item reduction led to a final 30-item scale. For the validation sample, internal reliability (Cronbach's alpha) was 0.96 (total), 0.94 (Information), and 0.90 (Emotional Support). Confirmatory factor analysis fit statistics were adequate (one-factor model, comparative fit index = 0.981, root mean square error of approximation = 0.62, weighted root mean square residual = 1.011; two-factor model comparative fit index = 0.984, root mean square error of approximation = 0.055, weighted root mean square residual = 0.930). Total score and subscales showed significant associations with the Decision Conflict Scale (Pearson correlation -0.43, P < 0.001 for total score). Emotional Support was associated with improved mental health outcomes at six to eight weeks, such as anxiety (-0.19 P < 0.001), and Information was associated with satisfaction with the hospital stay (0.49, P < 0.001).

CONCLUSION

The survey shows high reliability and validity in measuring communication experiences for hospital surrogates. The scale has promise for measurement of communication quality and is predictive of important outcomes, such as surrogate satisfaction and well-being.

Feeling Heard and Understood: A Patient-Reported Quality Measure for the Inpatient Palliative Care Setting

CONTEXT

As endorsed by the palliative care "Measuring What Matters" initiative, capturing patients' direct assessment of their care is essential for ongoing quality reporting and improvement. Fostering an environment where seriously ill patients feel heard and understood is of crucial importance to modern health care.

OBJECTIVES

To describe the development and performance of a self-report field measure for seriously ill patients to report how well they feel heard and understood in the hospital environment.

METHODS

As part of a larger ongoing cohort study of inpatient palliative care, we developed and administered the following point-of-care item: "Over the past two days, how much have you felt heard and understood by the doctors, nurses and hospital staff?" (completely, quite a bit, moderately, slightly, not at all). Participants completed the measure before and the day after palliative care consultation. For the postconsultation version, we changed the time frame from "past two days" to "today."

RESULTS

One hundred sixty patients with advanced cancer completed the preconsultation assessment, and 87% of them completed the postconsultation version. Responses encompassed full use of the ordinal scale, did not exhibit ceiling or floor effects, and showed improvement from preassessment to postassessment. The item was quick to administer and easy for patients to complete.

CONCLUSION

The "Heard & Understood" item is a promising self-report quality measure for the inpatient palliative care setting.

Developing a simulation to study conflict in intensive care units

RATIONALE

Although medical simulation is increasingly being used in healthcare education, there are few examples of how to rigorously design a simulation to evaluate and study important communication skills of intensive care unit (ICU) clinicians.

OBJECTIVES

To use existing best practice recommendations to develop a medical simulation to study conflict management in ICUs, then assess the feasibility, acceptability, and realism of the simulation among ICU clinicians.

METHODS

The setting was a medical ICU of a tertiary care, university hospital. Participants were 36 physicians who treat critically ill patients: intensivists, palliative medicine specialists, and trainees. Using best-practice guidelines and an iterative, multidisciplinary approach, we developed and refined a simulation involving a critically ill patient, in which the patient had a clear advance directive specifying no use of life support, and a surrogate who was unwilling to follow the patient's preferences. ICU clinicians participated in the simulation and completed surveys and semistructured interviews to assess the feasibility, acceptability, and realism of the simulation.

MEASUREMENTS AND MAIN RESULTS

All participants successfully completed the simulation, and all perceived conflict with the surrogate (mean conflict score, 4.2 on a 0-10 scale [SD, 2.5; range, 1-10]). Participants reported high realism of the simulation across a range of criteria, with mean ratings of greater than 8 on a 0 to 10 scale for all domains assessed. During semistructured interviews, participants confirmed a high degree of realism and offered several suggestions for improvements.

CONCLUSIONS

We used existing best practice recommendations to develop a simulation model to study physician-family conflict in ICUs that is feasible, acceptable, and realistic.

Factors Predicting Bereaved Caregiver Perception of Quality of Care in the Final Week of Life: Implications for Health Care Providers

BACKGROUND

Cancer caregivers are key stakeholders in the final weeks of life and in bereavement. Research has highlighted end-of-life (EOL) factors important to caregivers, as well as factors contributing to caregiver mental health and bereavement outcomes. There has been limited data on factors predicting caregiver perceptions of quality of EOL care.

OBJECTIVE

This study's purpose was to identify modifiable predictors of caregivers' Caregiver Evaluation of Quality of End of Life Care (CEQUEL) scores, with the broader aim of informing clinical interventions to improve caregiver impressions of care and subsequent bereavement adjustment.

METHODS

Study data came from Coping with Cancer I (CwC1). CwC1 investigators interviewed advanced cancer patients and caregivers prior to the patient's death (Wave 1) and reinterviewed caregivers following the death (Wave 2) (N=275 dyads). The authors identified potential Wave 1 predictors of CEQUEL scores and performed a series of linear regression analyses to identify a parsimonious predictive model using corrected Akaike's Information Criterion (AICc) values.

RESULTS

In adjusted analyses, caregivers rated quality of care as poorer when patients died in a hospital (B=-1.40, SE=0.40, p=0.001) (B, unstandardized regression coefficient; SE, standard error) or had less than one week of inpatient hospice care (B=-1.98, SE=-0.70, p=0.006). Whole-person physician care and caregiver religiosity were associated with perceived higher quality of care in unadjusted, but not adjusted, analyses.

CONCLUSIONS

Findings suggest that place of death and hospice length of stay best predict bereaved caregiver evaluations of quality of EOL care. These findings equip health care providers with modifiable targets to improve caregivers' experience of EOL care and subsequent bereavement.

A scoping review of family experience and need during end of life care in intensive care

AIM

To scope systematically and collate qualitative studies on family experience and need during end of life care in intensive care, from the perspective of family members.

DESIGN

Scoping review of qualitative research.

METHODS

Standardized processes of study identification, data extraction and data synthesis were used. Multiple bibliographic databases were accessed during 2011 and updated in 2013.

RESULTS

From an initial 876 references, 16 studies were identified for inclusion. These were predominantly single site, North American studies that explored issues relating to the temporal stages in the end of life trajectory and the requirement for information and emotional support at end of life. With a strong focus on family need and experience during the transition from active treatment to end of life care, more work is required to understand how doctors and nurses can support families from treatment withdrawal through to death.

The power of the liver transplant waiting list: a case presentation

End-stage liver disease (ESLD), the final stage of chronic liver disease, is treated with liver transplant. Many patients have serious ESLD-related complications and are admitted to the intensive care unit for treatment. Such patients are temporarily unsuitable to undergo transplant surgery and are placed into a temporarily inactive category, "status 7," on the transplant waiting list. Status 7 patients account for about 15% of all patients on the list. To describe the experience of a status 7 patient on the liver transplant waiting list from the perspectives of family members, 38 hours of bedside observation of participants, 9 semistructured interviews with 6 family members, and 9 semistructured interviews with 8 health care professionals from nursing, medicine, and other health care disciplines were done. Data were analyzed via conventional content analysis. Family members' perspectives fit into 3 phases that correspond to the progression of the patient's clinical condition: dealing with crisis, confusion and frustration, and back on the road to transplant. All 3 phases related to 1 goal: getting the patient's status reactivated on the liver transplant waiting list. This case exposes the struggles that patients with ESLD and their families may go through during the status 7 period and could serve as a starting point for further examination of this period.

Attitudes of legal guardians in the ICU - a qualitative report

Decision-making in intensive care units (ICUs) is often made by surrogates, since patients are unconscious or incompetent. In Israel, Legal Guardians (LGs), appointed by the court, are required to make these decisions.

OBJECTIVE

To qualitatively assess the attitudes of LGs required to make decisions on behalf of their relatives.

RESEARCH DESIGN

Demographic and semi-structured questionnaires were used to assess the attitudes of LGs regarding difficulties, positive aspects and areas for improvement with regard to surrogate decision-making. The study sampled sixty-four LGs in two large Israeli hospitals. After reading and analysing the responses provided by the LGs, the authors categorised the pertinent topics raised using a thematic analysis.

RESULTS

Themes were: bureaucratic and legal issues, unclear or unknown patient preferences and fear of outcomes. Family and medical staff support was stated as the most beneficial. Suggestions for improvement included alleviation of bureaucracy and improved communication with the medical staff.

CONCLUSIONS

The importance of communication and bureaucratic difficulties, making the best decision for the patient and uncertainty regarding decision outcomes were found to be important issue for the LGs. The healthcare team should try and alleviate some of these burdens, mostly by improving communication with relatives, stressing and educating the importance of advance directives. Reporting the problems found in the decision making process of LGs to the legislators in order to revise and simplify the current legal requirements is advised.

Caregiver evaluation of the quality of end-of-life care (CEQUEL) scale: the caregiver's perception of patient care near death

Purpose

End-of-life (EOL) measures are limited in capturing caregiver assessment of the quality of EOL care. Because none include caregiver perception of patient suffering or prolongation of death, we sought to develop and validate the Caregiver Evaluation of Quality of End-of-Life Care (CEQUEL) scale to include these dimensions of caregiver-perceived quality of EOL care.

Patients and Methods

Data were derived from Coping with Cancer (CwC), a multisite, prospective, longitudinal study of advanced cancer patients and their caregivers (N = 275 dyads). Caregivers were assessed before and after patient deaths. CEQUEL's factor structure was examined; reliability was evaluated using Cronbach's α, and convergent validity by the strength of associations between CEQUEL scores and key EOL outcomes.

Results

Factor analysis revealed four distinct factors: Prolongation of Death, Perceived Suffering, Shared Decision-Making, and Preparation for the Death. Each item loaded strongly on only a single factor. The 13-item CEQUEL and its subscales showed moderate to acceptable Cronbach's α (range: 0.52–0.78). 53% of caregivers reported patients suffering more than expected. Higher CEQUEL scores were positively associated with therapeutic alliance (ρ = .13; p≤.05) and hospice enrollment (z = −2.09; p≤.05), and negatively associated with bereaved caregiver regret (ρ = −.36, p≤.001) and a diagnosis of Posttraumatic Stress Disorder (z = −2.06; p≤.05).

Conclusion

CEQUEL is a brief, valid measure of quality of EOL care from the caregiver's perspective. It is the first scale to include perceived suffering and prolongation of death. If validated in future work, it may prove a useful quality indicator for the delivery of EOL care and a risk indicator for poor bereavement adjustment.

Learned helplessness among families and surrogate decision-makers of patients admitted to medical, surgical, and trauma ICUs

BACKGROUND

We sought to determine the prevalence of and clinical variables associated with learned helplessness, a psychologic state characterized by reduced motivation, difficulty in determining causality, and depression, in family members of patients admitted to ICUs.

METHODS

We conducted an observational survey study of a prospectively defined cohort of family members, spouses, and partners of patients admitted to surgical, medical, and trauma ICUs at a large academic medical center. Two validated instruments, the Learned Helplessness Scale and the Perceived Stress Scale, were used, and self-report of patient clinical characteristics and subject demographics were collected.

RESULTS

Four hundred ninety-nine family members were assessed. Of these, 238 of 460 (51.7%) had responses consistent with a significant degree of learned helplessness. Among surrogate decision-makers, this proportion was 50% (92 of 184). Characteristics associated with significant learned helplessness included grade or high school education (OR, 3.27; 95% CI, 1.29-8.27; P = .01) and Perceived Stress Scale score > 18 (OR, 4.15; 95% CI, 2.65-6.50; P < .001). The presence of a patient advance directive or do not resuscitate (DNR) order was associated with reduced odds of significant learned helplessness (OR, 0.56; 95% CI, 0.32-0.98; P = .05).

CONCLUSIONS

The majority of family members of patients in the ICU experience significant learned helplessness. Risk factors for learned helplessness include lower educational levels, absence of an advance directive or DNR order, and higher stress levels among family members. Significant learned helplessness in family members may have negative implications in the collaborative decision-making process.

Obstinação terapêutica em Unidade de Terapia Intensiva: perspectiva de médicos e enfermeiros

O tema obstinação terapêutica ainda é insuficientemente estudado no Brasil, sobretudo pela enfermagem. Este estudo objetivou compreender as representações sociais de médicos e enfermeiros sobre o investimento excessivo no paciente terminal em Unidade de Terapia Intensiva Adulto. Trata-se de uma pesquisa qualitativa, exploratório-descritiva, fundamentada na Teoria das Representações Sociais. Os dados foram coletados por meio de entrevista focalizada e observação participante e interpretados pela análise de conteúdo. A seleção de cinco enfermeiros e oito médicos para concederem as entrevistas ocorreu por conveniência, a partir das escalas de serviço. Concluiu-se que estes profissionais constroem suas representações sociais sobre obstinação terapêutica partindo dos pedidos obstinados da família do paciente terminal para instituir medidas fúteis; das dificuldades de tomadas de decisão e da ausência de critérios quanto aos investimentos; e do receio das repercussões ético-legais em relação às decisões tomadas.

Honoring patient care preferences: surrogates speak

A growing body of evidence has pointed to the stressful experience surrounding surrogate decision-making on behalf of incapacitated patients. This study (N = 59) asked surrogates to speak about their experiences immediately after having made a life-sustaining treatment decision. Grounded theory analysis revealed four themes: (1) the emotional impact of the decision-making process on the surrogate; (2) the difficulty of watching a loved one's health deteriorate; (3) the importance of having a Living Will (LW) or other written/verbal instructions; and (4) the reliance on spirituality as a means of coping with the surrogate experience. Findings of this study suggest that engaging surrogates at the time of patient admission may be essential in order to clarify patient preferences and strengthen communication between surrogates and the interdisciplinary healthcare team.

Intensive care nurses’ involvement in the end-of-life process – perspectives of relatives

In this article, we report findings from a qualitative study that explored how the relatives of intensive care unit patients experienced the nurses’ role and relationship with them in the end-of-life decision-making processes. In all, 27 relatives of 21 deceased patients were interviewed about their experiences in this challenging ethical issue. The findings reveal that despite bedside experiences of care, compassion and comfort, the nurses were perceived as vague and evasive in their communication, and the relatives missed a long-term perspective in the dialogue. Few experienced that nurses participated in meetings with doctors and relatives. The ethical consequences imply increased loneliness and uncertainty, and the experience that the relatives themselves have the responsibility of obtaining information and understanding their role in the decision-making process. The relatives therefore felt that the nurses could have been more involved in the process.

Family involvement in the end-of-life decisions of competent intensive care patients

In this article, we report the findings from a qualitative study that explored how relatives of terminally ill, alert and competent intensive care patients perceived their involvement in the end-of-life decision-making process. Eleven family members of six deceased patients were interviewed. Our findings reveal that relatives narrate about a strong intertwinement with the patient. They experienced the patients' personal individuality as a fragile achievement. Therefore, they viewed their presence as crucial with their primary role to support and protect the patient, thereby safeguarding his values and interests. However, their inclusion in decision making varied from active participation in the decision-making process to acceptance of the physicians' decision or just receiving information. We conclude that models of informed shared decision making should be utilised and optimised in intensive care, where nurses and physicians work with both the patient and his or her family and regard the family as partners in the process.

Life-sustaining treatment decisions in the ICU for patients with ESLD: a prospective investigation

We conducted a prospective study in the ICU of life-sustaining treatment and comfort care decisions over time in patients with end-stage liver disease (ESLD) from the perspectives of patients, family members, and healthcare professionals. Six patients with ESLD, 19 family members, and 122 professionals participated. The overarching theme describing the decision-making process was "on the train." Four sub-themes positioned patients and family members as passengers with limited control, unable to fully understand the decision-making process. Findings suggest that including patients and family members in non-immediate life-saving decisions and verifying early on their understanding may help to improve the decision-making process.

Family members' informal roles in end-of-life decision making in adult intensive care units

BACKGROUND

To support the process of effective family decision making, it is important to recognize and understand informal roles that various family members may play in the end-of-life decision-making process.

OBJECTIVE

To describe some informal roles consistently enacted by family members involved in the process of end-of-life decision making in intensive care units.

METHODS

Ethnographic study. Data were collected via participant observation with field notes and semistructured interviews on 4 intensive care units in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical, a surgical, a burn and trauma, and a cardiovascular intensive care unit.

PARTICIPANTS

Health care clinicians, patients, and family members.

RESULTS

Informal roles for family members consistently observed were primary caregiver, primary decision maker, family spokesperson, out-of-towner, patient's wishes expert, protector, vulnerable member, and health care expert. The identified informal roles were part of families' decision-making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision making within the family system and between the family and health care domains.

CONCLUSIONS

These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these informal roles of family members can help clinicians recognize and understand the functions of these roles in families' decision making at the end of life and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes.

Meaning and practice of palliative care for hospitalized older adults with life limiting illnesses

Objective. To illustrate distinctions and intersections of palliative care (PC) and end-of-life (EOL) services through examples from case-centered data of older adults cared for during a four-year ethnographic study of an acute care hospital palliative care consultation service. Methods. Qualitative narrative and thematic analysis. Results. Description of four practice paradigms (EOL transitions, prognostic uncertainty, discharge planning, and patient/family values and preferences) and identification of the underlying structure and communication patterns of PC consultation services common to them. Conclusions. Consistent with reports by other researchers, study data support the need to move beyond equating PC with hospice or EOL care and the notion that EOL is a well-demarcated period of time before death. If professional health care providers assume that PC services are limited to assisting with and helping patients and families prepare for dying, they miss opportunities to provide care considered important to older individuals confronting life-limiting illnesses.

Family-provider alliance program in intensive care units

This nonrandomized controlled study evaluated the effects of Family-Provider Alliance Program on nurses' perception of therapeutic alliance, job satisfaction, and quality of care. A total of 275 nurses were included in the study: 206 nurses in the ICUs participated in the Program and 69 in the control group did not. Mean postinterventional Kim Alliance Scale-Provider score was improved not only in the experimental group (+0.87; p = .01), but also in the control group (+1.37; p = .016). However, Empowerment subscale mean score was improved in the experimental group alone (+0.34; p = .006). Hierarchical multiple regression analyses indicated that family-nurse therapeutic alliance explained 7.2% and 11.4% of the variance in nurses' job satisfaction and perceived quality of care, respectively. The Program was marginally effective in improving nurses' perception of family empowerment. The quality of family-nurse therapeutic alliance predicted small to moderate fractions of the variance in nurses' job satisfaction and perceived quality of care.

Cross-cultural communication and use of the family meeting in palliative care

Terminally-ill patients and their families often report poor communication and limited understanding of the patient's diagnosis, prognosis, and treatment plan; these deficits can be exacerbated by cross-cultural issues. Although family meetings are frequently recommended to facilitate provider-family communication, a more structured, evidence-based approach to their use may improve outcomes. Drawing on research and guidelines from critical care, palliative care, and cross-cultural communication, we propose a framework for conducting family meetings with consideration for cross-cultural issues.

Knowledge and attitudes toward brain stem death among university undergraduates

BACKGROUND

Withdrawal of life support and organ procurement for transplantation are the main implications of a diagnosis of brain stem death (BSD). Various factors may impact this important decision-making process. The present study sought to investigate the knowledge and attitudes about BSD among university undergraduates as a "well-informed" subgroup of our local population.

METHODS

A cross-sectional questionnaire survey was administered to a sample of nonmedical university undergraduate students in Hong Kong.

RESULTS

The subjects' overall knowledge of BSD was unsatisfactory. Only 24% of subjects knew that BSD was the equivalent of legal death in Hong Kong. Among subjects who agreed to withdraw life support treatment from themselves upon the diagnosis of BSD, 30% and 24% refused to do so for their family members or a stranger, respectively. Subjects who agreed to withdraw life support showed significantly better knowledge about BSD than did those who did not agree. Concerns about doctors' inclination to diagnose BSD to save resources and extract organs for transplantation were not observed to negatively affect subjects' decisions about life support withdrawal.

CONCLUSION

The level of knowledge is an important factor affecting an individual's decision concerning withdrawal of life support therapy upon the diagnosis of BSD. Adequate explanation and counseling are important to facilitate family members in coping with this important end-of-life issue.

End-of-life decision making and emotional burden: placing family meetings in context

BACKGROUND

Helping families make end-of-life care decisions can be challenging for health care providers in an intensive care unit (ICU). Family meetings facilitated by palliative care consult services (PCCS) have been recommended and found effective for improving support for families in these difficult situations. These services can be improved with a deeper understanding of factors associated with emotional burden in the aftermath of end-of-life decision making.

OBJECTIVE

This qualitative study seeks to provide a better understanding of family experiences and emotional burden surrounding end-of-life decision making.

PARTICIPANTS AND METHODS

We conducted in-depth, semistructured interviews with 23 family members following the death of a loved one in the ICU. All participants had been involved in a PCCS-led family meeting concerning end-of-life decisions about their loved one. Methodology from grounded theory was used to analyze the content of transcripts and to build a theoretical model.

RESULTS

From the perspective of the family, decision making at the end of life is described within a theoretical model of salient experiences that are relevant to families' emotional burdens. Three temporal stages were evident: (1) the illness experience, (2) decision making in the family meeting, and (3) the dying process. However, emotional burden in the form of lingering questions and resentment was more common when families reported having negative experiences during the final hospital stay.

CONCLUSIONS

Supportive responsiveness from the PCCS for families who have experienced critical incidents or who have unanswered questions or resentment about treatment may be an important consideration to alleviate later emotional burden.

Life support decision making in critical care: Identifying and appraising the qualitative research evidence

OBJECTIVE

The objective of this study is to identify and appraise qualitative research evidence on the experience of making life-support decisions in critical care.

DATA SOURCES

In six databases and supplementary sources, we sought original research published from January 1990 through June 2008 reporting qualitative empirical studies of the experience of life-support decision making in critical care settings.

STUDY SELECTION

Fifty-three journal articles and monographs were included. Of these, 25 reported prospective studies and 28 reported retrospective studies.

DATA EXTRACTION

We abstracted methodologic characteristics relevant to the basic critical appraisal of qualitative research (prospective data collection, ethics approval, purposive sampling, iterative data collection and analysis, and any method to corroborate findings).

DATA SYNTHESIS

Qualitative research traditions represented include grounded theory (n = 15, 28%), ethnography or naturalistic methods (n = 15, 28%), phenomenology (n = 9, 17%), and other or unspecified approaches (n = 14, 26%). All 53 documents describe the research setting; 97% indicate purposive sampling of participants. Studies vary in their capture of multidisciplinary clinician and family perspectives. Thirty-one (58%) report research ethics board review. Only 49% report iterative data collection and analysis, and eight documents (15%) describe an analytically driven stopping point for data collection. Thirty-two documents (60%) indicated a method for corroborating findings.

CONCLUSIONS

Qualitative evidence often appears outside of clinical journals, with most research from the United States. Prospective, observation-based studies follow life-support decision making directly. These involve a variety of participants and yield important insights into interactions, communication, and dynamics. Retrospective, interview-based studies lack this direct engagement, but focus on the recollections of fewer types of participants (particularly patients and physicians), and typically address specific issues (communication and stress). Both designs can provide useful reflections for improving care. Given the diversity of qualitative research in critical care, room for improvement exists regarding both the quality and transparency of reported methodology.

Nurses' perceptions of end-of-life care after multiple interventions for improvement

BACKGROUND

Nurses working in intensive care units may lack knowledge and skills in end-of-life care, find caring for dying patients and the patients' families stressful, and lack support to provide this care.

OBJECTIVES

To describe nurses' perceptions of (1) knowledge and ability, (2) work environment, (3) support for staff, (4) support for patients and patients' families, and (5) stress related to specific work situations in the context of end-of-life care before (phase 1) and after (phase 2) implementation of approaches to improve end-of-life care. The approaches were a nurse-developed bereavement program for patients' families, use of a palliative medicine and comfort care team, preprinted orders for the withdrawal of life-sustaining treatment, hiring of a mental health clinical nurse specialist, and staff education in end-of-life care.

METHODS

Nurses in 4 intensive care units at a university medical center reported their perceptions of end-of-life care by using a 5-subscale tool consisting of 30 items scored on a 4-point Likert scale. The tool was completed by 91 nurses in phase 1 and 127 in phase 2.

RESULTS

Improvements in overall mean scores on the 5 sub-scales indicated that the approaches succeeded in improving nurses' perceptions. In phase 2, most of the subscale overall mean scores were higher than a desired criterion (<2.0, good). Analysis of variance indicated that some improvements occurred over time differently in the units; other improvements occurred uniformly.

CONCLUSIONS

Continued practice development is needed in end-of-life care issues.

Metasynthesis: withdrawing life-sustaining treatments: the experience of family decision-makers

AIM

The present study was undertaken to synthesise findings from qualitative investigations of family participation in decisions to withdraw and/or withhold life-sustaining treatment from a seriously ill family member.

BACKGROUND

As a consequence of increasing effectiveness and sophistication of available medical interventions, death is commonly preceded by a decision to withdraw or withhold potentially life-sustaining treatments. These decisions take place in a bioethical context characterised by the pre-eminence of self-determination, but patients are typically too ill to make their own decisions. Thus, family members are called upon to participate in these morally consequential decisions on the patient's behalf.

DESIGN

Metasynthesis.

METHOD

Metasynthesis is a form of inquiry that provides for integration of qualitative studies' findings to strengthen knowledge for practice and advance theoretical development. This metasynthesis was conducted using the constant comparative methods of grounded theory.

RESULTS

Family members engage in a process of participation in decision-making that is comprised of three major categories: reframing reality, relating and integrating. Surrogates used both cues and information as they reframed their understanding of the patient's status. Relationships with providers and with other family members powerfully influenced the decision-making process. Integrating was characterised by reconciling and going forward. This part of the process has both intrapersonal and interpersonal aspects and describes how family decision-makers find meaning in their experience and move forward in their lives.

CONCLUSIONS

This synthesis provides a more comprehensive and empirically supported understanding of family members' experiences as they participate in treatment decisions for dying family members. Relevance to clinical practice. This metasynthesis provides evidence to improve family care during treatment withdrawal/withholding decision-making and a theoretical model that can be used to guide creation of clinical practice guidelines. Through increased understanding of family members' experiences, clinicians can more effectively support family decision-making processes.

Empowering family members in end-of-life care decision making in the intensive care unit

Critical care nurses are often faced with working with families during the end-of-life care of a loved one. Often there is indecisiveness in family members of critically ill patients when faced with making these difficult decisions. The purpose of this manuscript is to describe origins of indecisiveness in family members of critically ill patients who are faced with end-of-life care decisions. Strategies to empower family members during this crucial time are also discussed.

In their own time: the family experience during the process of withdrawal of life-sustaining therapy

Withdrawal of life-sustaining therapy (LST) occurs commonly in critical care units, yet little is known about the family experience with this process. The purpose of this study was to understand the lived experience of families participating in the process of withdrawal of LST from a family member with an unexpected, life-threatening illness or injury. A hermeneutic phenomenological approach was used as nineteen families were interviewed and observed. Within and across family analyses were conducted. Methodological rigor was established and redundancy was achieved. The categories that evolved from the data included: this happens to other families, time to understand the severity of the illness or injury, time to see if health would be restored, riding a roller coaster, family readiness: willingness to consider withdrawal of LST as a possible option, one step at a time, family readiness: time to make a decision, the family will go on, and waiting for a miracle. The family experience participating in the process of withdrawal of LST happened for families "in their own time." The results of this study have important implications for clinical practice and future research.

Communication in the intensive care unit about the end of life

Communicating well in the intensive care unit is essential to providing quality critical care for the families of patients who are expected to die. There are many examples in the literature of how clinicians fall short of meeting these needs of families. There is also a developing body of literature describing approaches and tools that may have a positive impact on the perceived quality of end-of-life communication. The quality of clinician communication can be improved just as other skills that are important in the intensive care unit.

The process used by surrogate decision makers to withhold and withdraw life-sustaining measures in an intensive care environment

PURPOSE/OBJECTIVES

To understand the process used by surrogate decision makers who have chosen to withhold and withdraw life-sustaining measures in intensive care units (ICUs).

DESIGN

Grounded theory.

SETTING

Multihospital system in central Texas.

SAMPLE

17 surrogates who decided to withhold and withdraw life-sustaining measures from patients with a variety of diagnoses, including cancer.

METHODS

Surrogates were identified by review of charts of patients in ICUs. Interviews were recorded on audiotape and analyzed using the process of constant comparison. Saturation of data occurred when no new themes emerged.

MAIN RESEARCH VARIABLE

The surrogate decision-making process.

FINDINGS

Domains and their respective themes included: (a) the personal domain: rallying family support, evaluating the patient's past and present condition, and viewing past and future quality of life; (b) the ICU environment domain: chasing doctors, developing relationships with the healthcare team, and confirming probable medical outcomes; and (c) the decision domain: arriving at a new belief, getting alone to make the decision, and communicating the decision.

CONCLUSIONS

Surrogates use a definite process to make decisions regarding withholding and withdrawing life-sustaining measures for patients in ICUs.

IMPLICATIONS FOR NURSING

The results reveal opportunities for healthcare providers to improve education and change practice when supporting surrogates. Additional opportunities exist for further research to expand nursing knowledge related to end-of-life issues.

Communication Strategies and Cultural Issues in the Delivery of Bad News

Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.

Innovative solutions: a plurality of vision--integrating the chaplain into the critical care unit

Banner Good Samaritan Medical Center is a 650-bed quarternary care facility located in the Southwestern United States. It contains 12 intensive care units (ICUs) and experience a high patient acuity as a result of being a referral center for Arizona. The palliative care nurse practitioner and ICU clinical nurse specialist collaborated with the chaplain to entrance his visibility in the ICUs and to incorporate the philosophy of spiritual care assessments in the ICU.

Intensive care unit cultures and end-of-life decision making

PURPOSE

Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM.

MATERIALS AND METHODS

Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit.

RESULTS

The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM.

CONCLUSIONS

As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.

Family presence and surveillance during weaning from prolonged mechanical ventilation

OBJECTIVES

The research was designed to describe the care and communication processes during weaning from long-term mechanical ventilation (LTMV). A portion of those findings, specifically, how family members interact with the patient and respond to the ventilator and associated intensive care unit bedside equipment during LTMV weaning, are reported here.

METHODS

Ethnography was conducted in a medical intensive care unit (MICU) and step-down MICU following 30 adults who were being weaned from LTMV (>4 days). Data collection involved field observations conducted from November 2001 to July 2003; interviews with patients, family members, and MICU clinicians; and clinical record review.

RESULTS

Family members were present at the patients' bedside during 46% of weaning trials and interacted with patients through touch, talking, and surveillance. Families' bedside surveillance activities were interpretive of numeric monitor displays and laboratory values, protective of patient safety and comfort, and often focused exclusively on weaning. Interpretive language and surveillance were learned from and imitative of clinician behaviors. Clinicians characterized the family's presence as helpful, a hindrance, or having no effect on the weaning process. Quantitative analysis using random coefficient modeling examining the effect of family presence on length of weaning trials showed significantly longer daily weaning trials when families were present (P < .0001).

CONCLUSION

Critical care clinicians influence families' acquisition of interpretive surveillance skills at the bedside of patients who are being weaned from LTMV. This study provides a potentially useful conceptual framework of family behaviors with long-term critically ill patients that could enhance the dialogue about family-centered care and guide future research on family presence in the intensive care unit.

Measuring success of interventions to improve the quality of end-of-life care in the intensive care unit

Because of the severity of illness, the intensive care unit (ICU) is a setting where death is common. Although optimal palliative care should prevent many terminal ICU admissions, the ICU will always remain an important setting for end-of-life care because of the severity of illness of patients in the ICU and because many patients with chronic, life-limiting diseases and their families opt for a trial of intensive care. Therefore, improving the quality of end-of-life care in the ICU is an important endeavor. Furthermore, there are data to suggest that current quality of end-of-life care in the ICU is often poor and that this is an important target for quality improvement. However, as interventions are designed to improve the quality of end-of-life care in the ICU, researchers, clinicians, and quality improvement personnel will need reliable and valid measures to determine whether these interventions do improve the quality of care. In this article, we examine some of the data supporting potential process and outcome measures that could be used to evaluate the success of interventions designed to improve end-of-life care in the ICU.

Measuring Intensive Care Nurses’ Perspectives on Family-Centered End-of-Life Care: Evaluation of 3 Questionnaires

• Background Attempts to improve end-of-life care increasingly focus on family-centered care, but few validated assessment tools exist.

• Objectives To evaluate 3 new short questionnaires measuring nurses’ perspectives on family-centered end-of-life care in the intensive care unit and to show the usefulness of the questionnaires.

• Methods Principal components analysis of data from 141 critical care nurses evaluating care given to families of 218 patients was used to develop domain scores for number of nursing activities with each family, number of barriers experienced, and nurses’ satisfaction that the family’s needs were met. Random effects models were used to test associations between critical care processes and outcome.

• Results Nursing activities fell into 2 domains: general and culture-related communication/support. Barriers consisted of 2 domains: patient/family barriers and system/team barriers. Meeting the needs of patients’ families represented a single dimension. In a path model based on domain scores, general activities had significant associations with both nurse communication and meeting families’ needs; patient/family barriers, with nurse communication; and nurse and physician communication, with meeting families’ needs. In a path model based on total activities and barriers scores, total activities and total barriers had significant associations with nurse communication ratings and meeting families’ needs. Patients’ and nurses’ characteristics were not significant independent predictors of meeting the needs of patients’ families.

• Conclusions The 3 questionnaires provide a consistent, valid picture of nurses’ perspectives on family-centered critical care and may be useful in evaluating family care processes and outcomes and in targeting areas for improvement.

Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward

Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.

Families and withdrawal of life-sustaining therapy: state of the science

As the science progresses related to families participating in the process of withdrawal of life-sustaining therapy (LST), it is important to assess research accomplishments, identify gaps in the knowledge and ways to build on the science, and suggest new directions for future research. Research-based articles related to families participating in the process of withdrawal of LST were obtained by conducting computer-assisted searches and analyzing references lists. A grid was developed that included key variables from each of the studies. A second grid was developed and included the subthemes that evolved from the analysis. Eleven studies were reviewed and analyzed. Themes that evolved include illness context, family context, and family and health care provider interactions. Important information has been discovered about the family decision-making process and helpful health care provider interactions. Additional research focused on withdrawal of LST is needed to understand important concepts, develop instruments, and test interventions.