Intensive Care Unit death and factors influencing family satisfaction of Intensive Care Unit care

Assessing palliative care practices in intensive care units and interpreting them using the lens of appropriate care concepts. An umbrella review

PURPOSE

Intensive care units (ICUs) have significant palliative care needs but lack a reliable care framework. This umbrella review addresses them by synthesising palliative care practices provided at end-of-life to critically ill patients and their families before, during, and after ICU admission.

METHODS

Seven databases were systematically searched for systematic reviews, and the umbrella review was conducted according to the guidelines laid out by the Joanna Briggs Institute (JBI).

RESULTS

Out of 3122 initial records identified, 40 systematic reviews were included in the synthesis. Six key themes were generated that reflect the palliative and end-of-life care practices in the ICUs and their outcomes. Effective communication and accurate prognostications enabled families to make informed decisions, cope with uncertainty, ease distress, and shorten ICU stays. Inter-team discussions and agreement on a plan are essential before discussing care goals. Recording care preferences prevents unnecessary end-of-life treatments. Exceptional end-of-life care should include symptom management, family support, hydration and nutrition optimisation, avoidance of unhelpful treatments, and bereavement support. Evaluating end-of-life care quality is critical and can be accomplished by seeking family feedback or conducting a survey.

CONCLUSION

This umbrella review encapsulates current palliative care practices in ICUs, influencing patient and family outcomes and providing insights into developing an appropriate care framework for critically ill patients needing end-of-life care and their families.

Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study

Background and aim

While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored.

Methods

There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes.

Results

About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC.

Conclusion

Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians.

How to cite this article

Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Family Satisfaction with Care Provided in Intensive Care Unit; a Multi-Center, Cross-Sectional Study

Background

Healthcare provided in medical facilities should prioritize the needs of families, as it enhances the quality of care for the patients. Family satisfaction gauges how effectively healthcare professionals address the perceived needs and expectations of family members. Numerous factors, including information dissemination, communication, family dynamics, patient characteristics, hospital facilities, and the caregiving process, serve as predictors of family satisfaction. Thus, this study seeks to evaluate the satisfaction of families with the care received by patients admitted to the intensive care unit.

Methods

A hospital-based cross-sectional study involving 400 participants was conducted across multiple centers from March to June 2023. Multicollinearity was assessed by examining variance inflation factors (VIF), while the goodness-of-fit was evaluated using the Hosmer and Lemeshow test. Both bivariable and multivariable logistic regression analyses were utilized to identify factors correlated with family satisfaction. Variables with a p-value below 0.2 in the bivariable logistic regression were included in the multivariable logistic regression analysis. Adjusted Odds Ratios (AORs) with 95% Confidence Intervals were computed to indicate the strength of association. In the multivariable analysis, variables with a p-value less than 0.05 were deemed statistically significant.

Results

The overall family satisfaction with the care provided in the intensive care unit was 58.6%, with a 95% confidence interval ranging from 55.882% to 61.241%. Families expressed higher satisfaction levels with patient care (64.8%) and professional care (67.4%). However, they reported lower satisfaction levels regarding care provided for families (52.2%), the ICU environment (56.8%), and involvement of families in decision-making (55.8%). Lack of formal education (AOR: 1.949, 95% CI: 1.005, 4.169), completion of primary education (AOR: 2.581, 95% CI: 1.327, 5.021), and completion of grades 9-12 (AOR: 2.644, 95% CI: 1.411, 4.952) were found to be significantly associated with overall family satisfaction.

Conclusion and recommendation

The overall level of satisfaction is satisfactory. To enhance service quality and family satisfaction, healthcare providers should prioritize effective and regular communication with family members. Keeping them well informed about the patient's condition and treatment plan is essential.

Nurses' perceptions of barriers and supportive behaviors in end-of-life care in the intensive care unit: a cross-sectional study

BACKGROUND AND AIM

Patient deaths are common in the intensive care unit, and a nurse's perception of barriers to and supportive behaviors in end-of-life care varies widely depending upon their cultural background. The aim of this study was to describe the perceptions of intensive care nurses regarding barriers to and supportive behaviors in providing end-of-life care in a Chinese cultural context.

METHODS

A cross-sectional survey was conducted among intensive care nurses in 20 intensive care units in 11 general hospitals in central and eastern China. Instruments used in this study were general survey and Beckstrand's questionnaire. Data were collected via online survey platform. Descriptive analysis was used to describe general characteristics of participants and mean and standard deviations of the barriers and supportive behaviors. The mean and standard deviation were used to describe the intensity and frequency of each barrier or supportive behavior following Beckstrand's method to calculate the score of barriers and supportive behaviors. Content analysis was used to analyze the responses to open-ended questions.

RESULTS

The response rate was 53% (n = 368/700). Five of the top six barriers related to families and the other was the nurse's lack of time. Supportive behaviors included three related to families and three related to healthcare providers. Nurses in the intensive care unit felt that families should be present at the bedside of a dying patient, there is a need to provide a quiet, independent environment and psychological support should be provided to the patient and family. Nurses believe that if possible, families can be given flexibility to visit dying patients, such as increasing the number of visits, rather than limiting visiting hours altogether. Families need to be given enough time to perform the final rites on the dying patient. Moreover, it is remarkable that nurses' supportive behaviors almost all concern care after death.

CONCLUSIONS

According to ICU-nurses family-related factors, such as accompany of the dying patients and acceptence of patient's imminent death, were found the major factors affecting the quality of end-of-life care. These findings identify the most prominent current barriers and supportive behaviors, which may provide a basis for addressing these issues in the future to improve the quality of end-of-life care.

Practicing Neighbor Love: Empathy, Religion, and Clinical Ethics

The role of religion in clinical ethics consultations is contested. The religion of the ethics consultant can be an important part of the consultation process and improve the quality of a consultation. Practicing neighbor love leads to empathy, which not only can improve the quality of ethics consultations but also creates a space for religion to be part of, but not imposed on, the consultation. The practice of empathy will build trust, rapport, and an intersubjective connection that improves the quality of the consultation. (The views expressed are the author's and not representative of any institution or employer).

The effect of structured virtual patient visits (sVPVs) on COVID-19 patients and relatives' anxiety levels in intensive care unit

AIM AND OBJECTIVES

To determine the effect of structured Virtual Patient Visits (sVPVs) on the anxiety, satisfaction, hospital anxiety and depression levels of intensive care unit (ICU) COVID-19 patients and their relatives.

BACKGROUND

There is no evidence regarding the direct effect of virtual patient visits in the ICU.

DESIGN

The STROBE statement guided this study. This investigator-initiated, prospective and single-centre study included COVID-19 patients and their relatives in an adult ICU between July and December 2020. We implemented daily sVPVs between all patients and their relatives. The study's primary outcome was the daily anxiety levels of patients and relatives immediately before and after sVPVs. The secondary outcomes were as follows: 1) hospital anxiety (HADS-A) and depression (HADS-D) levels during admission to and after discharge from the ICU and 2) satisfaction levels regarding the ICU and sVPVs of patients' relatives.

RESULTS

A total number of 301 daily sVPVs were conducted between 50 patients and their relatives. There was a significant difference between daily anxiety levels before and after sVPVs in both patients (2.97 vs. 1.49) and their relatives (5.70 vs. 3.53; p > .05). Whereas the anxiety levels of patients with basic face or high flow nasal cannula and non-invasive mechanical ventilation decreased statistically significantly more than those with IMV after a sVPV (p < .001), there was not a significant difference in decreased anxiety levels of patients' relatives according to the type of respiratory support provided to the patient (p > .05). HADS-A levels of relatives decreased statistically significantly after discharge/death. There was no statistically significant difference in HADS-A and HADS-D levels after discharge/death between the relatives of patients who died or did not die (p > .05). Furthermore, the overall ICU satisfaction rates were statistically significantly lower in relatives of patients who died than those who did not die (p < .05).

CONCLUSION

Regardless of whether the patients were intubated, sVPVs reduced the anxiety levels of all patients and relatives. The sVPV programme offered emotional support to patients and family members, with high levels of satisfaction, as well as provided regular informative updates and the opportunity for daily visits or final goodbyes.

RELEVANCE FOR CLINICAL PRACTICE

The sVPV programme is essential for all ICUs during the COVID-19 pandemic.

What Does Coma Mean? Implications for Shared Decision Making in Acute Brain Injury

BACKGROUND

Insufficient attention has been devoted to shared decision-making (SDM) in the setting of acute brain injury (ABI). Communication occupies a central role that has been highlighted in recent research on SDM with brain injured patients, with respect to "the impact of specific clinician words and expressions". In this investigation, we seek to understand lay public understandings of the term "coma."

METHODS

Qualitative analysis of lay interpretations of the term "cComa" using modified open coding of a free-text response question at the end of a survey exploring public attitudes in the context of hypothetical ABI. Respondents (n = 511) were drawn from a convenience sample using Amazon Mechanical Turk. This analysis focuses on respondents' free-text responses to the question: "When doctors say a patient is in a coma, what does that mean?"

RESULTS

We analyzed 206 unique responses in order to derive emergent lay conceptualizations of coma. The following 4 themes emerged in how respondents understood coma: (1) State descriptive. (2) Marker of injury severity. (3) As in distinction (or lack thereof) from brain death or sleep. (4) Covert consciousness. For each concept, we discuss its salient elements and offer representative quotes.

CONCLUSIONS

This study provides preliminary qualitative evidence of lay public understandings of the neurologic term "coma". These findings can have implications for surrogate/family-clinician communications. While a physician may intend "coma" to convey a technical description, a family member or surrogate may interpret it as a very different activity (e.g., prognostication, emotional signaling), setting the stage for miscommunication.

Family Experience during Patient Assistance Process in General Intensive Care Unit: A Phenomenology Study

BACKGROUND: Intensive care unit (ICU) treatment can lead to fear, anxiety, depression, panic, and tension in the family. Place of the family as active presence, guardian, facilitator, historian, and coaching of the family cannot be separated from the recovery process. During the assistance of ICU patients, the family is faced with a strange environment, strict rules, emotional stress, and everyday life changes that have caused them to encounter psychological and physiological concerns. AIM: This study aims to describe and interpret of the family’s experience during assistance patient in the ICU. METHODS: A phenomenological methodology is used to explore experience of family. In-depth interviews were conducted on nine participants who were selected using purposive sampling. Data were analyzed by Colaizzi techniques, began with read transcripts, look for phenomenon, formulated data, organized, and verified to the participants. RESULTS: The result is presented in three themes; physically and psychologically tired; good language is a medicine, strengthens each other’s companion. CONCLUSION: The support of the patient in the ICU helps the family face a number of stressful circumstances. Adaptive coping and psychosocial help from health care workers and friends build a supportive family to cope with the difficulties when supporting patients in the ICU.

Israeli Nurses' Palliative Care Knowledge, Attitudes, Behaviors, and Practices

OBJECTIVES

To describe and compare self-perceived end-of-life (EOL) knowledge, attitudes, behaviors, and practices of intensive care unit (ICU) nurses compared to oncology nurses.

SAMPLE & SETTING

126 Israeli nurses (79 oncology nurses and 47 ICU nurses) who were members of the Israel Association of Cardiology and Critical Care Nurses and the Israeli Oncology Nurses Organization.

METHODS & VARIABLES

This cross-sectional study used an online survey to gather demographic information, clinical setting, and study measures (EOL knowledge, attitudes, behaviors, and practices).

RESULTS

Oncology nurses and ICU nurses showed moderate levels of self-perceived knowledge and attitudes toward palliative care; however, their self-reported behaviors were low. Oncology nurses scored slightly higher than ICU nurses on knowledge and attitudes but not behaviors, although the difference was not statistically significant.

IMPLICATIONS FOR NURSING

Contrary to the current authors' expectations, oncology nurses and ICU nurses have similar levels of knowledge, attitudes, and behaviors regarding palliative care. Nurses in both settings need to be better trained and empowered to provide such care.

Family Bereavement Adaptation After Death of a Loved One in an Intensive Care Unit: Impact of Race/Ethnicity

Limited longitudinal studies have hindered the understanding of family adaptation after loss of a loved one in an intensive care unit (ICU). Based on the Double ABCX Model, this study examined changes in adaptation to bereavement for family members in the first year after the ICU death, with special attention to the effects of race/ethnicity. A repeated-measures design was used to conduct the investigation using 3 time points (1-3, 6, and 12 months) after the ICU death. Data were analyzed using linear mixed modeling. Family members (n = 30) consisted of 60% non-Hispanic Whites and 40% African Americans (AAs). During the first 1 to 3 months, moderate to severe symptoms of posttraumatic stress disorder, depression, anxiety, and stress were found (60%, 40%, 30%, and 26.7%, respectively). Initially, non-Hispanic Whites had higher depression scores than African Americans. The change in depression and posttraumatic stress disorder symptoms over 1 year differed by race/ethnicity. Many family members tended to be at risk of psychological sequelae in the early months after a patient's death in an ICU. Racial/ethnic differences in bereavement process need further exploration to understand the broader context within family members grieve and effectively offer support over the course of the first year.

Surrogate Satisfaction with Decision Making After Intracerebral Hemorrhage

BACKGROUND/OBJECTIVE

Surrogate decision makers for patients with intracerebral hemorrhage (ICH) are frequently asked to make difficult decisions on use of life-sustaining treatments. We explored ICH surrogate satisfaction with decision making and experience of decision regret using validated measures in a prospective multicenter study.

METHODS

Cases of non-traumatic ICH were enrolled from three hospitals (September 2015-December 2016), and surrogate decision makers were invited to complete a self-administered survey. The primary outcome was the 10-item decision-making subscale of the Family Satisfaction in the Intensive Care Unit scale (FSICU-DM, range 0-100, higher is greater satisfaction), and the secondary outcome was the decision regret scale (range 0-100, higher is greater regret). Linear regression models were used to assess the association between satisfaction with decision making and pre-specified covariates using manual backward selection.

RESULTS

A total of 73 surrogates were approached for participation (in person or mail), with 48 surrogates returning a completed survey (median surrogate age 60.5 years, 63% female, 77% white). Patients had a median age of 72.5, 54% were female, with a median admission Glasgow coma scale of 10, in-hospital mortality of 31%, and 56% with an in-hospital DNR order. Physicians commonly made treatment recommendation (> 50%) regarding brain surgery or transitions to comfort measures, but rarely made recommendations (< 20%) regarding DNR orders. Surrogate satisfaction with decision making was generally high (median FSICU-DM 85, IQR 57.5-95). Factors associated with higher satisfaction on multivariable analysis included greater use of shared decision making (P < 0.0001), younger patient age (p = 0.02), ICH score of 3 or higher (p = 0.03), and surrogate relationship (spouse vs. other, p = 0.02). Timing of DNR orders was not associated with satisfaction (P > 0.25). Decision regret scores were generally low (median 12.5, IQR 0-31.3).

CONCLUSIONS

Considering the severity and abruptness of ICH, it is reassuring that surrogate satisfaction with decision making was generally high and regret was generally low. However, more work is needed to define the appropriate outcome measures and optimal methods of recruitment for studies of surrogate decision makers of ICH patients.

Going beyond "bad news": A surgical case report and systematic review of the literature surrounding futile care

•

There is a paucity of literature surrounding futile care.

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There is no consensus definition of “futile care”.

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A conversation is needed to discuss training of surgeons to manage cases of futile care.

Introduction

Surgeons frequently deliver “bad news” to patients, but do they know how to address situations where further surgery is considered futile? Is there a clear definition of futile care in the literature? This paper explores these questions and seeks to start a conversation about how we can train future surgeons to deliver news of futile care.

Presentation of case

This paper describes how one surgical team handled a difficult case of futile care and provides an interview from the perspective of a surgical resident.

Discussion

The case report gives one example of how the news of futile care was delivered and how appropriate steps were taken to provide continued management of the patient and support to the family. A systematic review of the literature surrounding futile care reveals no consensus on how to define futile care within the medical community.

Conclusion

There is a paucity of information surrounding how surgeons should manage cases of futile care. The literature focuses on the physician-patient relationship and includes methods for delivering bad news, yet it fails to identify a consensus definition of futile care and does not provide guidelines that future surgeons can follow when they encounter these cases. With this paper we seek to open a discussion about how to define futile care and how to teach future surgeons best practices when managing these cases.

Family members´ experiences of the end-of-life care environments in acute care settings - a photo-elicitation study

PURPOSE

This article explores experiences of the acute-care environment as a setting for end-of-life (EoL) care from the perspective of family members of a dying person.

METHOD

We used participant-produced photographs in conjunction with follow-up interviews with nine family members to persons at the EoL, cared for in two acute-care settings.

RESULTS

The interpretive description analysis process resulted in three constructed themes-Aesthetic and un-aesthetic impressions, Space for privacy and social relationships, and Need for guidance in crucial times. Aspects of importance in the physical setting related to aesthetics, particularly in regard to sensory experience, and to a need for enough privacy to facilitate the maintenance of social relationships. Interactions between the world of family members and that of professionals were described as intrinsically related to guidance about both the material and immaterial environment at crucial times.

CONCLUSION

The care environment, already recognized to have an impact in relation to patients, is concluded to also affect the participating family members in this study in a variety of ways.

Spiritual and Religious Coping of Medical Decision Makers for Hospitalized Older Adult Patients

BACKGROUND

Critically ill adult patients who face medical decisions often delegate others to make important decisions. Those who are authorized to make such decisions are typically family members, friends, or legally authorized representatives, often referred to as surrogates. Making medical decisions on behalf of others produces emotional distress. Spirituality and/or religion provide significant assistance to cope with this distress. We designed this study to assess the role of surrogates' spirituality and religion (S/R) coping resources during and after making medical decisions on behalf of critically ill patients. The study's aim was to understand the role that S/R resources play in coping with the lived experiences and challenges of being a surrogate.

METHODS

Semistructured interviews were conducted with 46 surrogates by trained interviewers. These were audio-recorded and transcribed by research staff. Three investigators conducted a thematic analysis of the transcribed interviews. The codes from inter-rater findings were analyzed, and comparisons were made to ensure consistency.

RESULTS

The majority (67%) of surrogates endorsed belief in God and a personal practice of religion. Five themes emerged in this study. Personal prayer was demonstrated as the most important coping resource among surrogates who were religious. Trusting in God to be in charge or to provide guidance was also commonly expressed. Supportive relationships from family, friends, and coworkers emerged as a coping resource for all surrogates. Religious and nonreligious surrogates endorsed coping strategies such as painting, coloring, silent reflection, music, recreation, and reading. Some surrogates also shared personal experiences that were transformative as they cared for their ill patients.

CONCLUSION

We conclude that surrogates use several S/R and other resources to cope with stress when making decisions for critically ill adult patients. The coping resources identified in this study may guide professional chaplains and other care providers to design a patient-based and outcome-oriented intervention to reduce surrogate stress, improve communication, increase patient and surrogate satisfaction, and increase surrogate integration in patient care. We recommend ensuring that surrogates have S/R resources actively engaged in making medical decisions. Chaplains should be involved before, during, and after medical decision making to assess and address surrogate stress. An interventional research-design project to assess the effect of spiritual care on surrogate coping before, during, and after medical decision making is also recommended.

Clinicians’ moral distress and family satisfaction in the intensive care unit

This study explored the relationship between clinicians’ moral distress and family satisfaction with care in five intensive care units in Italy. A total of 122 clinicians (45 physicians and 77 nurses) and 59 family members completed the Italian Moral Distress Scale-Revised and the Family Satisfaction in the ICU questionnaire, respectively. Clinicians’ moral distress inversely correlated with family satisfaction related to the inclusion in the decision-making process. Specifically, physicians’ moral distress inversely correlated with satisfaction regarding the respect shown toward the patient. Nurses’ moral distress inversely correlated with satisfaction regarding breathlessness and agitation management, provision of emotional support, understanding of information, and inclusion in the decision-making process.

Self-Perceived End-of-Life Care Competencies of Health-Care Providers at a Large Academic Medical Center

Background:

In the United States, most deaths occur in hospitals, with approximately 25% of hospitalized patients having palliative care needs. Therefore, the provision of good end-of-life (EOL) care to these patients is a priority. However, research assessing staff preparedness for the provision of EOL care to hospitalized patients is lacking.

Objective:

To assess health-care professionals’ self-perceived competencies regarding the provision of EOL care in hospitalized patients.

Methods:

Descriptive study of self-perceived EOL care competencies among health-care professionals. The study instrument (End-of-Life Questionnaire) contains 28 questions assessing knowledge, attitudes, and behaviors related to the provision of EOL care. Health-care professionals (nursing, medicine, social work, psychology, physical, occupational and respiratory therapist, and spiritual care) at a large academic medical center participated in the study. Means were calculated for each item, and comparisons of mean scores were conducted via t tests. Analysis of variance was used to identify differences among groups.

Results:

A total of 1197 questionnaires was completed. The greatest self-perceived competency was in providing emotional support for patients/families, and the least self-perceived competency was in providing continuity of care. When compared to nurses, physicians had higher scores on EOL care attitudes, behaviors, and communication. Physicians and nurses had higher scores on most subscales than other health-care providers.

Conclusions:

Differences in self-perceived EOL care competencies were identified among disciplines, particularly between physicians and nurses. The results provide evidence for assessing health-care providers to identify their specific training needs before implementing educational programs on EOL care.

Post-traumatic Stress Disorder and Complicated Grief are Common in Caregivers of Neuro-ICU Patients

BACKGROUND

To explore the effect of end of life and other palliative decision making scenarios on the mental health of family members of patients in the neuro-intensive care unit.

METHODS

Decision makers of patients in the neuro-ICU at a large, urban, academic medical center meeting palliative care triggers were identified from November 10, 2014, to August 27, 2015. Interviews were conducted at 1 and 6 months post-enrollment. At 1 month, the Inventory of Complicated Grief-Revised (ICG-R), Impact of Events Scale-Revised (IES-R), and the Family Satisfaction-ICU (FS-ICU) were performed along with basic demographic questionnaires. At 6 months, only the ICG-R and IES-R were repeated.

RESULTS

At 1 month, 9 (35%) subjects had significant symptoms in at least one of the three domains of traumatic response. Two (7.7%) subjects met full criteria for PTSD (IES-R ≥ 1.5). At 6 months, 5 (22%) subjects met criteria for PTSD and 5 (22%) for Complicated Grief (ICG-R ≥ 36). Fifteen (50%) had at least one domain of PTSD symptoms identified in follow-up. Time spent at bedside and lower household income were associated with PTSD at 1 and 6 months, respectively. In all, clinically significant psychological outcomes were identified in 9 (30%) of subjects.

CONCLUSIONS

Clinically significant grief and stress reactions were identified in 30% of decision makers for severely ill neuro-ICU patients. Though factors including time at bedside during hospitalization and total household income may have some predictive value for these disorders, further evaluation is required to help identify family members at risk of psychopathology following neuro-ICU admissions.