Bereavement Services Offered in Adult Intensive Care Units in the United States

The impact of COVID-19 on the provision of bereavement support in Australian intensive care units: A national survey

BACKGROUND

Bereavement support is a vital part of caring for families when a patient dies in the intensive care unit (ICU). Previous research has demonstrated that while many ICUs provide some informal aspects of bereavement care, formalised follow-up programmes are uncommon. The impacts of COVID-19 on ICU-based bereavement support are currently unknown.

OBJECTIVES

The objectives of this study were to explore the current provision of bereavement support in Australian ICUs and identify the impacts of the COVID-19 pandemic on these services.

METHODS

A cross-sectional exploratory web-based survey was used. The survey was distributed to one senior nurse in each public and private adult, paediatric, and neonatal ICU in Australia between April and July 2022. Descriptive statistics and reflexive thematic analysis were used to analyse the data. Ethical approval was received from La Trobe University.

RESULTS

One hundred and four ICUs from 82 hospitals responded to the survey, with 36 units reporting a formal bereavement follow-up service. When compared to prepandemic levels, almost all of the common bereavement care practices explored in the survey were significantly reduced during the COVID-19 pandemic. Open-ended responses also demonstrated significant impacts of COVID-19 on bereavement care provision, particularly related to Restricted family togetherness, Logistical Challenges, and Impacts on Staff. Staff members reported adjusting care provision in response to these challenges by exploring Alternative family communications, Facilitation of family togetherness, and Increasing familysupports.

CONCLUSIONS

Many of the common elements of ICU-based bereavement care were significantly reduced during the COVID-19 pandemic. In addition, the number of formal bereavement follow-up services in Australian ICUs remains largely unchanged since 2015. Ongoing research is needed to explore the long-term effects of these changes on staff and family wellbeing and on ongoing provision of ICU-based bereavement support.

EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

CONTEXT

Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

OBJECTIVES

The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

METHODS

Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

RESULTS

Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

CONCLUSIONS

EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Connecting Families to Bereavement Resources: A Hospital-Based, Bereavement Follow-Up Pilot During First-Wave COVID-19

Background: Hospitals often lack bereavement programs. Bereaved families often navigate grief support on their own. This problem was complicated by the early COVID-19 pandemic. Objective: Describe a cost neutral pilot to support next of kin (NOK) of deceased patients from our communicable disease response unit (CDRU) and palliative care unit (PCU). Design: Ad hoc pilot leveraging chaplains and a social worker (SW) to call NOK for grief support using a templated guide, referring interested NOK to bereavement support agencies. Setting/Subjects: NOK of patients who died in the CDRU and PCU at a metropolitan, quaternary care, hospital over five months. Results: One hundred eighty-six patients died. Eighty-one NOK were called, 51 calls were considered complete. Fourteen NOK accepted a referral for bereavement support. Conclusions: This cost neutral pilot successfully connected 81 NOK with either a pilot chaplain or SW for bereavement support. Fourteen NOK accepted referral for a community bereavement resource.

Family members' experiences of bereavement in the emergency department: A meta-synthesis of qualitative studies

The emergency department (ED) is one of the places where patient deaths frequently occur. Understanding family members' experiences of bereavement would help provide individualized bereavement care. We conducted a meta-synthesis to synthesize family members' experiences of bereavement in the ED and assess the impact of bereavement on their lives. We searched seven international electronic databases. Five studies were selected and critically appraised. Thematic analysis was employed. Five themes (with 13 subthemes) were derived: suffering sudden changes and are severely impacted, multiple feelings and needs of waiting, final farewell, personal and family difficulties after leaving the ED, and journey through grief. Family members endured agonizing waits to see and learn more about their family members' condition. Family members reported the need for effective follow-up resources. Findings revealed that it would be helpful if the EDs could provide sensitive and respectful care to family members.

The Current Status of Bereavement Care in Chinese Emergency Departments: A Multicenter Cross-Sectional Study

Understanding the current status and challenges of bereavement care will help facilitate the development of bereavement care in the emergency department. However, little is known about the status of bereavement care in Chinese emergency departments and nurses' perceptions of bereavement care. We used a self-made questionnaire to survey 124 head nurses and 870 emergency nurses in 21 hospitals in Jiangsu Province in September 2023. Among 124 emergency departments, 78 (62.90%) emergency departments provided bereavement care strategies, and the most frequent strategy was a waiting room, relevant information on funeral arrangements and the establishment of a relatively secluded environment conducive to the solace of the patient's family, or the provision of a dedicated farewell chamber. Emergency nurses believed that bereavement care is important but difficult to implement, with support resources, environment and human resources being the main challenges. In the future, further attention should be paid to the development of bereavement care in the emergency department, and the implementation of bereavement care should be supported in terms of policies, funds, resources and personnel.

Nurses' perceptions about bereavement care in critical care units: A qualitative study

AIM

To explore critical care nurses' perceptions of bereavement nursing care in critical care settings at a tertiary hospital in Singapore.

BACKGROUND

Grief and bereavement are stressful life experiences associated with significant health problems. Critical care nurses play important roles in supporting bereaved family members, and their self-competence affects the quality of the care they deliver. Exploring critical care nurses' perceptions of bereavement nursing care is thus essential.

METHODS

An exploratory descriptive qualitative study design was adopted. A total of 16 nurses were recruited. One-on-one interviews were conducted using a semi-structured interview guide and were audio-recorded. The data collected were analysed using thematic analysis. This study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.

FINDINGS

Five themes surfaced in the study, namely, family responses, holistic care, psychological impact, self-competence and organisational dynamics.

CONCLUSION

This study highlighted the key roles of critical care nurses in providing bereavement care, how their self-competence impacts care delivery and the significant impacts of organisational policies on their capacity to provide care.

IMPLICATIONS FOR NURSING AND NURSING POLICY

Nursing administrators should provide enhanced organisational support to critical care nurses who provide bereavement nursing care, and implement training work plans to ensure nurses are adequately prepared to provide culturally appropriate care. Strategies should be introduced to reduce administrative burden, expand the role of critical care nurses in providing bereavement nursing care, and establish and enlist role models as drivers of bereavement nursing care.

An integrative literature review examining the key elements of bereavement follow-up interventions in critical care

PURPOSE OF REVIEW

The aim of this review is to examine bereavement follow-up intervention studies in critical care, with the purpose of integrating results on the timing, content, aims and outcomes of interventions. The impact of a death in critical care is well documented, and bereavement follow-up is recognised as an important topic, but there is limited research with little consensus on the content and structure of interventions.

RECENT FINDINGS

A total of 18 papers were selected; 11 are intervention studies, with only one randomised control trial. Six papers were from national surveys and are not the focus of this review. Bereavement follow-up mainly consisted of information giving, condolence interventions, telephone calls and meetings with families. The timing, content, aims and outcomes depended on the intervention and were influenced by the design of the study.

SUMMARY

Overall, bereavement follow-up is acceptable for relatives but outcomes are mixed. Calls for more research are valid, but how do we utilise the current research to better inform the critical care community? Researchers suggest that bereavement follow-up interventions need to be designed with specific aims and outcomes, in collaboration with bereaved families that are appropriate to the intervention.

In-Hospital Bereavement Services as an Act of Care and a Challenge: An Integrative Review

CONTEXT

Globally, people most often die within hospitals. As such, healthcare providers in hospitals are frequently confronted with dying persons and their bereaved relatives.

OBJECTIVES

To provide an overview of the current role hospitals take in providing bereavement care. Furthermore, we want to present an operational definition of bereavement care, the way it is currently implemented, relatives' satisfaction of receiving these services, and finally barriers and facilitators regarding the provision of bereavement care.

METHODS

An integrative review was conducted by searching four electronic databases, from January 2011 to December 2020, resulting in 47 studies. Different study designs were included and results were reported in accordance with the theoretical framework of Whittemore and Knafl (2005).

RESULTS

Only four articles defined bereavement care: two as services offered solely post loss and the other two as services offered pre and post loss. Although different bereavement services were delivered the time surrounding the death, the follow-up of bereaved relatives was less routinely offered. Relatives appreciated all bereavement services, which were rather informally and ad-hoc provided to them. Healthcare providers perceived bereavement care as important, but the provision was challenged by numerous factors (such as insufficient education and time).

CONCLUSION

Current in-hospital bereavement care can be seen as an act of care that is provided ad-hoc, resulting from the good-will of individual staff members. A tiered or stepped approach based on needs is preferred, as it allocates funds towards individuals-at-risk. Effective partnerships between hospitals and the community can be a useful, sustainable and cost-effective strategy.

Availability and Quality of Grief and Bereavement Care in Pediatric Intensive Care Units Around the World, Opportunities for Improvement

Pediatric Intensive Care Units (PICUs) provide multidisciplinary care to critically ill children and their families. Grief is present throughout the trajectory of illness and can peak around the time of death or non-death losses. The objective of this study was to assess how PICUs around the world implement grief and bereavement care (GBC) as part of an integrated model of care. This is a multicenter cross-sectional, prospective survey study. Questionnaires with multiple-choice and open-ended questions focusing on unit infrastructure, personnel, policies, limited patient data, and practices related to GBC for families and health care professionals (HCPs) were completed by on-site researchers, who were HCPs on the direct care of patients. PICU fulfillment of GBC goals was evaluated using a custom scoring based on indicators developed by the Initiative for Pediatric Palliative Care (IPPC). We compared average total and individual items fulfillment scores according to the respective country's World Bank income. Patient characteristics and details of unit infrastructure were also evaluated as potential predictors of total GBC fulfillment scores. Statistical analysis included multilevel generalized linear models (GLM) with a Gaussian distribution adjusted by child age/gender and clustering by center, using high income countries (HICs) as the comparative reference. Additionally, we applied principals of content analysis to analyze and summarize open-ended answers to contextualize qualitative data. The study included 34 PICUs from 18 countries: high-income countries (HICs): 32.4%, upper middle-income countries (UMICs): 44.1%, low middle-income and low-income countries (LMI/LICs): 23.5%. All groups reported some compliance with GBC goals; no group reported perfect fulfillment. We found statistically significant differences in GBC fulfillment scores between HICs and UMICs (specifically, HCP grief support), and between HICs and LMICs (specifically, family grief support and HCP grief support). PICUs world-wide provide some GBC, independent of income, but barriers include lack of financial support, time, and training, overall unit culture, presence of a palliative care consultation service, and varying cultural perceptions of child death. Disparities in GBC for families and HCPs exist and were related to the native countries' income level. Identifying barriers to support families and HCPs, can lead to opportunities of improving GBC in PICUs world-wide.

Primary palliative care integrated model in paediatric ICU: an international cross-sectional study

OBJECTIVES

Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC.

METHODS

International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models.

RESULTS

High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores.

CONCLUSIONS

All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN12556149.

Healthcare professionals' knowledge, skills, and role in offering and facilitating memory making during end-of-life care in the adult intensive care unit

BACKGROUND

An activity to provide a tangible keepsake following the death of a loved one is termed 'memory making'. However, limited evidence is available related to professionals' education and support to provide memory making opportunities in the adult intensive care unit (ICU). Having a greater understanding of healthcare professionals' experiences can inform future patient/family care and support for professionals in end-of-life care.

OBJECTIVE

The objective of this study was to describe what participants perceive memory making to be, if they have facilitated memory making activities as part of their practice, if they perceive it as part of their role, and if they have the necessary skills to do so.

METHODS

Seventy-five registered nurses (75% response rate), 19 medical doctors (76% response rate), and two social workers (66.7% response rate) completed a survey at a single tertiary referral centre in an adult ICU.

RESULTS

Participants reported memory making to include the creation of tangible keepsakes as well as nontangible activities. Overall, participants reported high agreement scores that the responsibility for initiating memory making predominately belonged to the nurse. Participants reported skills most needed involved the ability to interact with the family, being open to the concept, and integrating memory making into their standard of care. Having developed a rapport with families was considered an enabler, whereas lack of knowledge and clinical workload were reported as inhibitors to offering memory making.

CONCLUSIONS

Overall, participants in this study reported positive experiences with offering memory making to families during end-of-life care in the adult ICU. Nurses are more likely to perceive professional responsibility for offering memory making, likely due to their increased time at the bedside and higher prominence and leadership in other end-of-life practices. To support professionals, education should include conceptual knowledge, procedural knowledge of keepsake creations, communication techniques using reflective practices, and organisational support to facilitate time requirements.

Emotional and cognitive barriers of bereavement care among clinical staff in hospice palliative care

OBJECTIVE

Bereavement care is one of the major components of hospice palliative care. Previous studies revealed the barriers to the success of the system, including lack of time or support from mental health professionals. Few studies have explored the intrapersonal barriers to bereavement care by clinical staff. The aims of the study were to explore (1) the emotional and cognitive barriers of bereavement care by hospice palliative care staff and (2) the demographic and work characteristics related to these emotional and cognitive barriers.

METHOD

The participants were clinical staff (n = 301) who were working in hospice palliative care units, including hospice wards, home care, and hospital-based palliative care teams. Their professional backgrounds included physicians (n = 12), nurses (n = 172), social workers (n = 59), psychologists (n = 34), spiritual care specialists (n = 15), and others (n = 9). A cross-sectional design was used and a standardized questionnaire including emotional and cognitive barriers was developed. Information on demographic and work characteristics was also collected. Content validity index, an exploratory factor analysis, and multiple regression analysis were conducted.

RESULTS

One emotional barrier, "negative emotional reactions" (13 items, Cronbach's α = 0.92), and three cognitive barriers, "lack of ability" (7 items, Cronbach's α = 0.85), "belief in avoidance" (5 items, Cronbach's α = 0.86), and "outcome expectancy" (4 items, Cronbach's α = 0.85) were identified. Clinical staff who had higher working stress, lower self-rated ability for bereavement care, and higher negative impact from major life loss tended to have higher emotional and cognitive barriers.

SIGNIFICANCE OF RESULTS

Clinical staff should be aware of intrapersonal barriers to bereavement care. Educational programs should be developed to improve the ability to engage in bereavement care.

Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients

OBJECTIVE

The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes.

METHOD

Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.

RESULTS

Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30).

SIGNIFICANCE OF RESULTS

Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Collaboration between the intensive care unit and organ donation agency to achieve routine consideration of organ donation and comprehensive bereavement follow-up: an improvement project in a quaternary Australian hospital

Objective Routine family follow-up after bereavement in the intensive care unit (ICU) and routine consideration of organ and tissue donation at end of life are both integral to good health care delivery, yet neither is widely achieved. This study evaluated an initiative to efficiently deliver these outcomes in an Australian setting through a novel collaboration between DonateLife South Australia (DLSA) and the ICU of the Royal Adelaide Hospital. Methods A Plan-Do-Study-Act method of quality improvement was used in the Royal Adelaide Hospital ICU between February 2018 and February 2019. The ICU clinical team identified adult patients and family members at medical consensus of end of life to donation specialist nursing coordinators, who assessed potential for donation and enrolled patients and family members into a bereavement follow-up program. After death, family members received bereavement information and details of a structured telephone follow-up conversation that took place 6-8 weeks later. Results Of 241 deaths, 216 were enrolled in the project. Follow-up telephone calls were completed with 124 of 201 (62%) family members, with 77 (38%) family members not contactable. Follow-up telephone interviews yielded practical suggestions to improve end-of-life care. Donation was considered in all patients enrolled in the project, and referral through DLSA increased from 24% to 90% of all ICU deaths. Associated with the collaborative initiative, consent to organ donation recorded a 63% increase on the 10-year average (from 19 to 31 donors). Corneal donation referral increased by 625%. The initiative required an additional 0.4 full-time equivalent registered nurse. Family members valued the opportunity to debrief their experience. Conclusions Collaboration between DLSA and the Royal Adelaide Hospital ICU achieved universal consideration of organ donation and high rates of structured bereavement follow-up. Follow-up calls were valued with areas for improvement identified. What is known about this topic? Death in the ICU is associated with significant psychopathology among bereaved family members, and bereavement follow-up is widely recommended. Opportunities to consider organ and tissue donation are commonly missed due to lack of consideration at end of life. What does this paper add? Collaboratively exploring donation and performing bereavement follow-up is feasible with a minimal added resource. Such comprehensive approach to good end-of-life care helps identify aspects of care that could be improved and is associated with an increase in organ and tissue donation rates. What are the implications for practitioners? Collaboration between the ICU and DonateLife achieved mutually beneficial outcomes of understanding the end-of-life experience for family members and timely consideration of organ and tissue donation. This timely consideration potentially identified some missed organ donors and then allowed family members to give feedback on their experience.

Practice Recommendations for End-of-Life Care in the Intensive Care Unit

TOPIC

A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices.

CLINICAL RELEVANCE

Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members.

PURPOSE OF PAPER

To provide recommendations for high-quality end-of-life care for patients and family members.

CONTENT COVERED

This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.

Intensive Care Unit Nursing Priorities in the United States

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.

Physician and Nurse Research in Multidisciplinary Intensive Care Units

BACKGROUND

Although clinical care is multidisciplinary, intensive care unit research commonly focuses on single-discipline themes. We sought to characterize intensive care unit research conducted by physicians and nurses.

METHODS

One hundred randomly selected reports of clinical studies published in critical care medical and nursing journals were reviewed.

RESULTS

Of the 100 articles reviewed, 50 were published in medical journals and 50 were published in nursing journals. Only 1 medical study (2%) used qualitative methods, compared with 9 nursing studies (18%) (P = .02). The distribution of quantitative study designs differed between medical and nursing journals (P < .001), with medical journals having a predominance of cohort studies (29 articles [58%]). Compared with medical journal articles, nursing journal articles had significantly fewer authors (median [interquartile range], 5 [3-6] vs 8 [6-10]; P < .001) and study participants (94 [51-237] vs 375 [86-4183]; P < .001) and a significantly lower proportion of male study participants (55% [26%-65%] vs 60% [51%-65%]; P = .02). Studies published in medical journals were much more likely than those published in nursing journals to exclusively involve patients as participants (47 [94%] vs 25 [50%]; P < .001). Coauthorship between physicians and nurses was evident in 14 articles (14%), with infrequent inclusion of authors from other health care disciplines.

CONCLUSIONS

Physician research and nurse research differ in several important aspects and tend to occur within silos. Increased interprofessional collaboration is possible and worthwhile.

Family and Clinician Experiences of Sympathy Cards in the 3 Wishes Project

BACKGROUND

A recent randomized trial of bereaved family members of patients who died in an intensive care unit identified symptoms of depression and posttraumatic stress in recipients of semistructured condolence letters.

OBJECTIVES

To explore family member and clinician experiences with receiving or sending handwritten sympathy cards upon the death of patients involved in a personalized end-of-life intervention, the 3 Wishes Project.

METHODS

Interviews and focus groups were held with 171 family members and 222 clinicians at 4 centers to discuss their experiences with the 3 Wishes Project. Interview transcripts were searched to identify participants who discussed sympathy cards. Data related to sympathy cards were independently coded by 2 investigators through conventional content analysis.

RESULTS

Sympathy cards were discussed during 32 interviews (by 25 family members of 21 patients and by 11 clinicians) and 2 focus groups (8 other clinicians). Family members reported that personalized sympathy cards were a welcome surprise; they experienced them as a heartfelt act of compassion. Clinicians viewed cards as an opportunity to express shared humanity with families, reminding them that they and their loved one were not forgotten. Signing cards allowed clinicians to reminisce individually and collectively with colleagues. Family members and clinicians experienced sympathy cards as a meaningful continuation of care after a patient's death.

CONCLUSIONS

Inviting clinicians who cared for deceased patients to offer personalized, handwritten condolences to bereaved family members may cultivate sincere and individualized expressions of sympathy that bereaved families appreciate after the death of patients involved in the 3 Wishes Project.

Self-Care in the Bereavement Process

Critical care nurses frequently provide end-of-life and bereavement care. This type of care is rewarding, but can put nurses at risk for moral distress, compassion fatigue, and burnout. By incorporating self-care into their routine, critical care nurses minimize this risk and maintain their own health and well-being. This article provides suggestions for promoting physical, emotional, and spiritual self-care for nurses caring for dying intensive care unit patients and their families. A case scenario illustrates the importance of this concept. Practical examples of self-care are highlighted along with discussion on how leadership can support self-care and maintain a healthy work environment.

A qualitative study of bereaved family members with complicated grief following a death in the intensive care unit

PURPOSE

Grief is a normal reaction, and most family members (FMs) experience grief following a death. Typically, grief subsides without any major psychological or medical impairment. Nevertheless, some FMs may experience complicated grief (CG) reactions, with symptoms lasting months or years, and CG is particularly prominent among FMs of those who die in the intensive care unit (ICU). The purpose of this study was to examine how FMs experience grief, particularly CG, to inform future early screening and support programs in the ICU.

METHODS

This was a multicentre qualitative study focusing on semi-structured interviews with FMs who displayed symptoms of CG. Family members of patients who died in the ICU and who had a six-month inventory of CG score > 25 were included. Semi-structured interviews were conducted with FMs post-loss, with follow-up interviews three months after the initial interviews.

RESULTS

Major themes identified following thematic analysis from eight participants with CG included 1) ante-mortem experience: the impact of the ICU experience prior to death of a loved on subsequent grief; 2) post-mortem experience: unpredictable post death reactions; 3) coping strategies: techniques used to reduce the severity of grief reactions; 4) sources of support: focusing on resources that the FM draws from for emotional support; and 5) perspectives on future ICU bereavement screening and support programs: advice that FM participants provided for future bereavement support.

CONCLUSION

Bereaved FMs with CG described their experiences with grief, how ICU events influenced their bereavement, their coping strategies and sources of support, and their advice for future bereavement support programs for FMs of deceased ICU patients.

The current status of bereavement follow-up in Japanese emergency departments: A cross-sectional nationwide survey

INTRODUCTION

The aim of this study was to investigate the current status of bereavement follow-up in Japanese emergency departments.

METHODS

This study employed a cross-sectional design and conducted a nationwide survey of all emergency departments in Japan. Self-reported questionnaires were sent to the nurse leaders of each emergency department.

RESULTS

Of 289 nurse leaders approached, 145 (50.2%) responded. Only 17.9% emergency departments provided bereavement follow-up strategies, and the most frequent strategy was referral to a specialist for psychological treatment. Most nurse leaders perceived that bereavement follow-up is necessary, and the greatest need of the bereaved as perceived by the nurse leaders was explanation of the patient's death. However, 60% of the nurse leaders perceived bereavement follow-up to be necessary but difficult, and the major challenges in bereavement follow-up were lack of time, knowledge, and skill.

CONCLUSION

In contemporary Japan, the prevalence of bereavement follow-up strategies offered by emergency departments was low, and although most nurse leaders perceived follow-up as necessary, it could not be provided because of limitations in human resources and staff training.

Elements of intensive care bereavement follow-up services: A European survey

BACKGROUND

Despite technological innovations and continuous improvement in evidence-based treatments, mortality in the intensive care unit (ICU) remains high. Consequently, a large group of family members may be in need of, and could benefit from, bereavement follow-up support.

AIMS AND OBJECTIVES

To explore the elements, organization, and evaluation of ICU bereavement services in European countries. Specific objectives were to investigate: (a) the model of bereavement follow-up services (elements of support), (b) the workforce model (organization of staff), and (c) the evaluation model (evaluation strategies).

DESIGN

This was a cross-sectional survey of conference delegates.

METHODS

A paper-and-pen questionnaire, including a cover letter assuring the respondents of anonymity and confidentiality, was distributed to 250 delegates during the opening ceremony of the 2017 European federation of Critical Care Nurses associations Congress in Belfast. The questionnaire was developed from a previously validated tool describing bereavement care practices in ICUs, including questions about the content and organization of bereavement follow-up services. Frequencies were calculated using yes/no questions, and content analysis was applied in additional free-text comments.

RESULTS

We received 85 responses from publicly employed nurses, mainly in mixed adult ICUs. Respondents were 48 (56.5%) bedside nurses, and the remaining respondents represented clinical nurse specialists, researchers, managers, or academic nurses. Bereavement follow up had existed for about 1 to 15 years. Important follow-up elements were: viewing the deceased in the unit, 77 (90.6%); providing follow-up information, 67 (79.8%); sending a letter of sympathy, 17 (20%); and calling the family to arrange a meeting, 27 (31%).

CONCLUSIONS

Bereavement follow up is common but variable in European ICUs. We recommend the development, implementation, and evaluation of evidence-based, but culture-specific, bereavement follow-up guidelines for European ICUs.

RELEVANCE TO CLINICAL PRACTICE

More critical care nurses are realizing the need for bereavement follow-up guidelines. This paper provides an overview of common elements that might be considered. WHAT IS KNOWN ABOUT THIS TOPIC Many families experience the death of a loved one in intensive care unit (ICU). Bereavement services are offered at some ICUs. WHAT THIS PAPER ADDS Bereavement services are not systematically offered in European ICUs. Culture-specific guidelines are needed for bereavement follow up in ICUs. Common elements of bereavement services have been identified, for example, viewing the deceased in the unit, providing follow-up information, sending a letter of sympathy, and calling the family to arrange a meeting. Consequences of bereavement in ICU have been discussed, for example, prolonged or complicated grief and lack of closure in the bereaved.

Dying in the Intensive Care Unit: A Candle Vigil Using Illustrations

With death and dying in intensive care units, there should be bereavement support for families. We propose placing an illustration of a candle on the door of an unresponsive dying patient, with additional illustrations of votive candles at the nurses’ station opposite to the door as a neutral way of identifying these rooms with patients who transitioned to comfort care or who have died. The candle illustrations encourage staff members to modify their words, silence themselves, and reflect. After a 1-year tryout in the neurointensive care unit with a strong positive experience for staff and families, it can be perceived as a symbol of tranquility.

Pilot Study Assessing the Impact of Bereavement Support on Families of Deceased Intensive Care Unit Patients

BACKGROUND

Family members of patients who die in an intensive care unit (ICU) may experience negative outcomes. However, few studies have assessed the effectiveness of bereavement care for families.

OBJECTIVE

To evaluate the effectiveness of bereavement follow-up on family members' anxiety, depression, posttraumatic stress, prolonged grief, and satisfaction with care.

METHODS

A cross-sectional, prospective pilot study of 40 family members of patients who died in 2 tertiary care ICUs. Those in the medical-surgical ICU received bereavement follow-up (bereavement group); those in the cardiac ICU received standard care (nonbereavement group). Both groups completed surveys 13 months after the death. Surveys included the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, Family Satisfaction With Care in the Intensive Care Unit, Prolonged Grief Disorder, and a bereavement survey.

RESULTS

Of 30 family members in the bereavement group and 10 in the nonbereavement group, most were female and spouses, with a mean (SD) age of 60.1 (13.3) years. Significantly more participants in the nonbereavement group than in the bereavement group had prolonged grief. Posttraumatic stress, anxiety, depression, and satisfaction with care were not significantly different in the 2 groups. However, overall posttraumatic stress scores were higher in the nonbereavement group than the bereavement group, indicating a higher risk of posttraumatic stress disorder.

CONCLUSIONS

Bereavement follow-up after an ICU death reduced family members' prolonged grief and may also reduce their risk of posttraumatic stress disorder. This type of support did not have a measurable effect on depression or satisfaction with ICU care.

The provision of nurse-led follow-up at Norwegian intensive care units

AIMS AND OBJECTIVES

To describe the prevalence, content and administration of intensive care unit diaries and follow-up practices offered to patients and their families in Norway.

BACKGROUND

Intensive care treatment has been associated with risks for new or increased health impairments affecting both patients and their families. These impairments have the potential of continuing beyond the acute phase of treatment. In parallel, preventive actions have gradually become an integrated part of critical care nursing, and in Norway, national recommendations for the use of intensive care unit diaries have been established.

DESIGN AND METHODS

A survey was conducted in Norwegian intensive care units offering care for adult patients, using a questionnaire asking about the frequency, administration and content of the follow-up offered to patients, their relatives, as well as bereaved family members.

RESULTS

Thirty-nine of 66 (59.1%) invited intensive care units answered the questionnaire. The majority (n = 33, 84.6%) of the responding units had follow-up routines. The provision of diaries was the most frequent follow-up activity (n = 24, 61.5%), and consultations postdischarge formed an integrated part of the diary practice. Consultations with bereaved were conducted in 21 (53.8%) of the intensive care units. About one quarter of the responding intensive care units had positions for follow-up nursing staff.

CONCLUSION

Nurse-led follow-up after critical care was a common activity in Norwegian intensive care units, comprising diaries and consultations offered to patients and family members. The follow-up was mainly driven by bottom-up processes conducted by dedicated nurses motivated by the patients' and their families' situation and feedback.

RELEVANCE TO CLINICAL PRACTICE

Adherence to recommendations, as well as the availability of defined positions for aftercare nurses or teams, may improve the implementation of follow-up practices and reduce suffering after discharge from Norwegian intensive care units.

Research in Review: Advancing Critical Care Practice

Research published in 2016 identified strategies to enhance acute and critical care, initiated discussions on professional roles and responsibilities, clarified complex care issues, and led to robust debate. Some of this important work addressed strategies to prevent delirium and pressure ulcers, considerations for pain management within the context of the opioid abuse crisis, strategies to guide fluid resuscitation in patients with sepsis and heart failure, and ways to enhance care for family members of intensive care patients. The new sepsis definitions highlight the importance of detecting and providing care to patients with sepsis outside of critical care areas. Chimeric antigen receptor T-cell therapy is an example of the advancement of research in genomics and personalized medicine and of the need to understand the care implications of these therapies. Other research topics include interprofessional collaboration and shared decision-making as well as nurses' role in family conferences. Resources such as policies related to medical futility and inappropriate care and the American Association of Critical-Care Nurses' healthy work environment standards may inform conversations and provide strategies to address these complex issues.