Family Behaviors as Unchanging Obstacles in End-of-Life Care: 16-Year Comparative Data

Palliative Care in the Intensive Care Unit: The Standard of Care

Intensive care unit-based palliative care has evolved over the past 30 years due to the efforts of clinicians, researchers, and advocates for patient-centered care. Although all critically ill patients inherently have palliative care needs, the path was not linear but rather filled with the challenges of blending the intensive care unit goals of aggressive treatment and cure with the palliative care goals of symptom management and quality of life. Today, palliative care is considered an essential component of high-quality critical care and a core competency of all critical care nurses, advanced practice nurses, and other intensive care unit clinicians. This article provides an overview of the current state of intensive care unit-based palliative care, examines how the barriers to such care have shifted, reviews primary and specialist palliative care, addresses the impact of COVID-19, and presents resources to help nurses and intensive care unit teams achieve optimal outcomes.

Communication strategies for expressing empathy during family-clinician conversations in the intensive care unit: A mixed methods study

OBJECTIVES

To explore communication strategies intensive care clinicians and patients' family members prefer for expressing empathy during family-clinician conversations.

RESEARCH METHODOLOGY/DESIGN

Mixed-methods survey study.

SETTING

Two medical ICUs of a German academic tertiary care hospital.

MAIN OUTCOME MEASURES

Using a self-developed online survey with closed and open-ended questions with free-text options, the participants' preferences of communication strategies for expressing empathy were investigated. Quantifiable similarities and differences were determined by statistical analysis. Qualitative themes were derived at by directed content analysis.

FINDINGS

The responses of 94 family members, 42 nurses, and 28 physicians were analysed (response rate: 45.3 %). Four communication strategies were deduced: (1) reassuring the families that the intensive care unit team will not abandon neither them nor the patient, (2) acknowledging emotions and offering support, (3) saying that the families are welcome and cared for in the intensive care unit, (4) providing understandable information. In comparison, the families considered an expression of nonabandonment as more empathic than the physicians did (p =.031,r = 0.240), and those expressions focussing solely on the family members' well-being (p =.012,r = 0.228) or comprising evaluative wording ("good", "normal") (p =.017,r = 0.242) as less empathic than the nurses did. Unanimously advocated nonverbal communication strategies included to listen attentively and to avoid interrupting as well as being approachable and honest.

CONCLUSION

The participants' preferences supported expert recommendations and highlighted that it is not only important what the clinicians say but also how they say it. Further research is needed to elucidate ways of successfully expressing empathy during family-clinician conversations in the intensive care unit.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care unit clinicians are encouraged to practice active listening and to express their caring and nonabandonment. It is further suggested to reflect on and adjust pertinent nonverbal behaviours and relational aspects of their communication, as applicable.

Critical Access Hospital Nurses' Perceptions of Obstacles to End-of-Life Care: A Qualitative Study

BACKGROUND

Critical care nurses working in urban settings have reported obstacles in caring for dying patients. However, the perceptions of such obstacles by nurses working in critical access hospitals (CAHs), which are located in rural areas, are unknown.

OBJECTIVE

To study stories and experiences related to obstacles in providing end-of-life care reported by CAH nurses.

METHODS

This exploratory, cross-sectional study presents the qualitative stories and experiences of nurses working in CAHs as reported on a questionnaire. Quantitative data have been previously reported.

RESULTS

Sixty-four CAH nurses provided 95 categorizable responses. Two major categories emerged: (1) family, physician, and ancillary staff issues and (2) nursing, environment, protocol, and miscellaneous issues. Issues with family behaviors were families' insistence on futile care, intrafamily disagreement about do-not-resuscitate and do-not-intubate orders, issues with out-of-town family members, and family members' desire to hasten the patient's death. Issues with physician behaviors were providing false hope, dishonest communication, continuation of futile treatments, and not ordering pain medications. Nursing-related issues were not having enough time to provide end-of-life care, already knowing the patient or family, and compassion for the dying patient and the family.

CONCLUSION

Family issues and physician behaviors are common obstacles in rural nurses' provision of end-of-life care. Education of family members on end-of-life care is challenging because it is most families' first experience with intensive care unit terminology and technology. Further research on end-of-life care in CAHs is needed.

Caring for Rural Patients at End of Life: Perceptions of Critical Access Hospital Nurses

BACKGROUND

Critical access hospitals were created to bring health care to rural populations. These hospitals lack equipment and resources, but the nurses who work there still provide end-of-life care to critically ill and dying patients.

OBJECTIVE

To determine how nurses in critical access hospitals perceive the size of obstacles and helpful behaviors for the provision of end-of-life care.

METHODS

Questionnaires were sent to a cross-sectional, nationally representative sample of nurses working in 39 critical access hospitals. The nurses were asked to score obstacle and helpful behavior items on a scale of from 0 (not an obstacle or not a help, respectively) to 5 (extremely large obstacle or extremely large help, respectively). The items were then ranked from highest to lowest according to their mean scores.

RESULTS

Seven of the top 10 obstacles were directly related to family behaviors and attitudes, such as families not understanding what lifesaving measures entail and internal family disagreements about life support. Helpful behaviors ranked in the top 10 included interventions that were controlled by nurses and items that affected the nurses' having adequate time to deliver end-of-life care. Obstacles and helpful behavior items unique to critical access hospitals, such as a lack of resources and the nurse knowing the patient or the patient's family, ranked below the top 10 items.

CONCLUSION

Obstacles and helpful behaviors for providing end-of-life care remain consistent. Nurses in critical access hospitals are accustomed to working without the typical resources found in urban hospitals and thus did not perceive resource deficits to be among the greatest obstacles to providing end-of-life care. Family behaviors and attitudes remain the most dominant obstacle noted by nurses.