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An Interhospital, Interdisciplinary Needs Assessment of Palliative Care in a Community Critical Care
Abstract
Aim:
There is a paucity of data on the provision of palliative care in the critical care settings of smaller community hospitals. This study aimed to identify the gaps that affect the provision of palliative care in a community critical care setting.
Setting:
The study was set in a 10-bed, open intensive care unit and emergency department at a community hospital.
Methods:
Mixed methods were used. Quantitative data included those drawn from databases and surveys; qualitative data included those collected from interviews, focus groups, and onsite walk-throughs and were analyzed with inductive coding techniques.
Results:
Gaps were identified in palliative care, goals of care and end-of-life discussions, and resources. Community hospital healthcare professionals did not fully appreciate their essential contribution to the provision of palliative care in the intensive care unit. In addition, there was a lack of expertise, and a lack of interest in gaining expertise, in palliative/end-of-life care.
Conclusion:
Interrelated needs in a complex interprofessional, interhospital context were captured. Further studies are required to obtain data on palliative practice in the care of critically ill patients in various community hospital contexts.
... Next is detailed the distribution of studies by country. Most of the studies included were conducted in the UK [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35], the USA [36][37][38][39][40][41][42][43][44], Australia [45][46][47][48][49][50][51][52][53], Canada [54][55][56][57][58][59][60], and Germany [61][62][63][64][65][66]. Some studies were performed in two or more countries: Belgium, Netherlands, UK, Germany, Hungary [67]: North America, Australia [68], UK, Ireland, USA [69], USA, UK, Australia, Canada, Belgium, Germany, Hong Kong, Japan, Malaysia, Singapore [70], USA, UK, Sweden, Netherlands, Spain, Canada, Ireland, Australia, New Zealand [71], South Africa, Kenya, South Korea, United States, Canada, UK, Belgium, Finland, Poland [72], Australia, New Zealand, UK [73], Canada, USA, UK [74]. ...
... Studies included were undertaken in different health care settings: inpatient care (52.7%) [16][17][18]21,22,24,26,27,[29][30][31][32]34,37,38,40,[42][43][44][47][48][49]54,57,59,60,62,67,68,72,74,77,78,80,82,83,85,[91][92][93] outpatient care (18.5%) [28,33,35,36,39,45,46,52,53,64,68,73,86,87], and combined inpatient and outpatient care (21.2%) [20,25,41,50,56,61,63,65,66,[69][70][71]76,81,89,90]. In addition, five studies (6.7%) did not specify the care setting [19,23,58,75,94]. ...
... (a) Referral to PC Often, multimorbid patients are referred to PC units in the terminal stages of their disease; thus, professionals consider it necessary to initiate these referrals earlier to promote continuous care [78,85], especially with older patients [61], patients with Chronic Heart Failure (CHF) and COPD [75,76], and patients with conditions other than cancer [25]. Moreover, professionals do not always know who has the responsibility to care for CCC patients in need of PC, and often the roles are not defined, which causes fear of starting conversations about palliative care with the family or the patient [26,60,66,90]. ...
Although numerous studies have been conducted previously on the needs of cancer patients at the end of their life, there is a lack of studies focused on older patients with non-oncological complex chronic multipathologies. Examining these needs would help to gain a greater understanding of the profile of this specific population within the palliative care (PC) pathway and how the health and care systems can address them. The aim of this review was to identify the needs influencing PC among older patients with multimorbidities, their relatives or informal caregivers, and the health professionals who provide care for these patients. A scoping literature review guided by the Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was carried out with literature searched in the Medline, Embase, CINAHL, WoS, Cochrane Library, PsycINFO, and Scopus databases from 2009 to 2022. Eighty-one studies were included, demonstrating a great variety of unaddressed needs for PC among chronic older patients and the complexity in detecting those needs and how to refer them to PC pathways. This review also suggested a scarcity of tools and limited pathways for professionals to satisfy their needs for these patients and their families, who often felt ignored by the system. Substantial changes will be needed in health and care systems at the institutional level, providing more specialized PC environments and systematizing PC processes.
... A mixed method design was employed to identify intra-hospital needs, as well as inter-hospital needs between the community hospital and a referral hospital where patients could be transferred. A further publication by Sarti et al. (2015) based on the critical care needs assessment in the community hospital revealed gaps in the provision of palliative care. Factors that influenced the provision of palliative care included physician availability, frequent transfers to other facilities, and the priority of caring for critically ill patients. ...
... Factors that influenced the provision of palliative care included physician availability, frequent transfers to other facilities, and the priority of caring for critically ill patients. Sarti et al. (2015) described how physicians and nurses held differing perceptions in regards to the timing, as well as roles and responsibilities associated with initiating and/or leading goals of care discussions with patients and families. Because of these differing perceptions, discussions and decision-making about shifting goals of care to EOLC occurred inconsistently. ...
... Because of these differing perceptions, discussions and decision-making about shifting goals of care to EOLC occurred inconsistently. The findings from the study by Sarti et al. (2015), in part, suggest that physicians and nurses in the community ICU context may view EOLC differently (both philosophically and practically), as compared to their counterparts in ICUs of teaching hospitals. ...
Written from the perspective of a critical care nurse, this commentary examines how the author envisions knowledge translation becoming more effective in the year 2020. The coronavirus pandemic, social media dissemination, and digital innovations are contended as central to such improvements in knowledge translation. Future direction for knowledge translation within the nursing profession are also discussed.
Background
The intensive care unit (ICU) is a care context that is sometimes described as being unconducive to the values and ideals of a good death in end-of-life care. Such assumptions render the ICU emblematic of a troubling discourse about end-of-life care in this clinical context.
Aim
To stimulate a reflective examination of intensive care nursing practice with respect to end-of-life care.
Methods
The work of contemporary nursing scholar Laurie Gottlieb is used to perform a strengths-based relational ethical examination of previously published literature that describes critical care nurses' experiences of providing end-of-life care in the ICU.
Findings
This literature suggests that the relational ethical value of authentic engagement, which is fundamental to the disciplinary ethos of expert palliative care nursing, is reflected in the everyday practice of intensive care nurses whose patients die while under their care.
Conclusion
A strengths-based approach can make visible the relational ethical practice of critical care nurses who care for dying patients and their families in the ICU.
Abstract Most physicians believe that to provide the best possible care to their patients, they must commit to continuous learning. For the most part, it appears the learning activities currently available to physicians do not provide opportunities for meaningful continuous ...
Aim:
To investigate critical care nurses' perceptions of barriers and supportive behaviors in providing end of life (EOL) care to dying patients and their families.
Methods:
The study involved a convenient sample of 70 nurses who were involved in caring for critically ill patients. Data were collected using a structured interview sheet.
Results:
Barriers to providing EOL care were related to intensive care environment, family members, nurses' knowledge and skills, physicians' attitudes and treatment policy. Possible help to providing EOL care involved nurses' support to each other, patient and family-centered care, and families' support.
Conclusions:
There is a need to allow the family unlimited access to the dying patient, involve them in patient care and provide them with a private place for grieving.
Most physicians believe that to provide the best possible care to their patients, they must commit to continuous learning. For the most part, it appears the learning activities currently available to physicians do not provide opportunities for meaningful continuous learning. At the same time there have been increasing concerns about the quality of health care, and a variety of groups within organized medicine have proposed approaches to address issues of physician competence and performance. The authors question whether CME will be accepted as a full partner in these new approaches if providers continue to use current approaches to planning and assessing CME. A conceptual model is proposed for planning and assessing continuous learning for physicians that the authors believe will help CME planners address issues of physician competence, physician performance, and patient health status.
The aim of this study was to explore nurses' experiences and perceptions of caring for dying patients in an intensive care unit (ICU) with focus on unaccompanied patients, the proximity of family members and environmental aspects.
Interviews were conducted with nine experienced ICU nurses. A qualitative descriptive approach was employed. The analysis was performed by means of conventional content analysis [Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277-88] following the steps described by e.g. Elo and Kyngas [Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs 2008;62:107-15].
The analysis resulted in a main category; Doing one's utmost, described by four generic categories and 15 sub-categories, comprising a common vision of the patients' last hours and dying process. This description was dominated by the nurses' endeavour to provide dignified end-of-life care (EOLC) and, when relatives were present, to give them an enduring memory of their loved one's death as a calm and dignified event despite his/her previous suffering and death in a high-technological environment.
This study contributes new knowledge about what ICU nurses focus on when providing EOLC to unaccompanied patients but also to those whose relatives were present. Nurses' EOLC was mainly described as their relationship and interaction with the dying patient's relatives, while patients who died alone were considered tragic but left a lesser impression in the nurses' memory.
Theories such as interactionism, phenomenology, and critical theory can be used to help design a research question, guide the selection of relevant data, interpret the data, and propose explanations of causes or influences Previous articles in this series have addressed several methodologies used in qualitative research. Qualitative researchers also rely heavily on theories drawn from the social sciences and humanities to guide their research process and illuminate their findings. This article discusses the role and use of three theoretical approaches commonly used by qualitative researchers in health domains: interactionism, phenomenology, and critical theory. It also explains why such theories are important for clinicians, for health policy, and for patient care.
This integrative study investigated the generalization of the transtheoretical model across 12 problem behaviors. The cross-sectional comparisons involved relationships between two key constructs of the model, the stages of change and decisional balance. The behaviors studied were smoking cessation, quitting cocaine, weight control, high-fat diets, adolescent delinquent behaviors, safer sex, condom use, sunscreen use, radon gas exposure, exercise acquisition, mammography screening, and physicians' preventive practices with smokers. Clear commonalities were observed across the 12 areas, including both the internal structure of the measures and the pattern of changes in decisional balance across stages.
In this article the results of research undertaken to explore and describe the experience of Registered Nurses regarding the withdrawal of treatment from the critically ill patient in an Intensive Care Unit (ICU), are discussed. Withdrawal of treatment from a critically ill patient in an Intensive Care Unit (ICU) is a very traumatic experience for all those involved. The Registered Nurse has the most contact with all those who are involved throughout the process. This raises questions regarding how the nurse experiences the withdrawal of treatment, and about guidelines that can be developed to accompany the nurse during the process of treatment withdrawal.
The study was qualitative, descriptive, exploratory, descriptive and contextual in nature. Data was gathered by means of phenomenological interviews conducted by the researcher. Trustworthiness was ensured through the implementation of Guba’s model (in Krefting 1991: 214). The following themes were identified:
1. The relationships the nurse develops with individuals involved in the process of treatment withdrawal.
2. The inner moral conflict experienced by the nurse relating to the ethical aspects of withdrawal of treatment.
The focus of this article is on the discussion of these experiences of the registered nurses. Based on the identified themes, guidelines were developed to accompany the nurse during the process of withdrawal of treatment.
Acute and chronic pulmonary and cardiac diseases often have a high mortality rate, and can be a source of significant suffering. Palliative care, as described by the Institute of Medicine, "seeks to prevent, relieve, reduce or soothe the symptoms of disease or disorder without effecting a cure... Palliative care in this broad sense is not restricted to those who are dying or those enrolled in hospice programs." The American College of Chest Physicians strongly supports the position that such palliative and end-of-life care of the patient with an acute devastating or chronically progressive pulmonary or cardiac disease and his/her family should be an integral part of cardiopulmonary medicine. This care is best provided through an interdisciplinary effort by competent and experienced professionals under the leadership of a knowledgeable and compassionate physician. To that end, it is hoped that this statement will serve as a framework within which physicians may develop their own approach to the management of patients requiring palliative care.
Understanding patients' and family members' perspectives on the relative importance of elements of end-of-life (EOL) care and their satisfaction with those elements will help prioritize quality improvement initiatives. We administered a face-to-face questionnaire containing a selection of 28 elements of care to eligible inpatients with advanced lung, heart, or liver disease, or metastatic cancer, and available family caregivers (FCGs) in five tertiary care hospitals across Canada. 440 of 569 (78%) eligible patients and 160 of 176 (91%) FCGs participated. No respondent reported complete satisfaction with all elements of care. The average satisfaction score was 4.6 on a 26 point scale. Medical patients reported lower levels of satisfaction than cancer patients. Elements rated as "extremely important" and anything other than "completely satisfied" most frequently by respondents related to discharge planning, availability of home health services, symptom relief, not being a burden, physician trust, and communication. In conclusion, most patients and their family members in our survey were not completely satisfied with EOL care. Improvement initiatives to target key elements identified by patients and FCGs have the potential to improve satisfaction with EOL care across care settings.
Palliative care aims to prevent and relieve suffering by controlling symptoms and to provide other support to patients and families in order to maintain and improve their quality of living. Although originally conceived and practiced as end-of-life care, palliative care may be applied to all stages of illness, whether terminal or not. Because its members commonly care for children and adults and their families in need of palliative care due to chronic respiratory diseases or critical illnesses, the American Thoracic Society (ATS) approved formation of an ad hoc End-of-Life Care Task Force whose purpose was to develop this statement that focuses on how to better integrate palliative care into standard clinical management (curative and/or restorative care). The statement's goals are both educational and prescriptive. The task force took a principle- and values-based approach in meeting this goal. It first identified the core values and principles of the ATS, as a professional society, related to palliative care (Table 1). It then applied those principles and values to clinical practice for both children and adults with chronic and advanced pulmonary disorders as well as those with critical illnesses. The task force derived its positions and recommendations based on those values and principles, on expert opinions and experience of members and consultants of the task force, and on a focused literature review. The statement strongly endorses the concept that palliative care should be available to patients at all stages of illness and should be individualized based on the needs and preferences of the patient and the patient's family (Figures 1 and 2). It also recommends that clinicians who care for patients with chronic or advanced respiratory diseases and/or critical illnesses should be trained in, and capable of, providing a set of recommended basic competencies in palliative care (Table 2). Finally, it recommends that these clinicians should consult with palliative care specialists as appropriate for managing palliative care situations beyond the clinician's level of competence. The statement also provides clinicians a set of practical recommendations for providing palliative care to adult and pediatric patients with advanced respiratory diseases and critical illnesses. These relate to common symptoms of those terminally ill with advanced respiratory disorders, including management of dyspnea (Table 3) and pain (Table 4) and other physical complications. In addition, the statement discusses the psychological challenges related to suffering and dying as an adult or as a child and approaches to meeting those challenges. The statement endorses hospice care as an appropriate multidisciplinary system to provide palliative care to the patients and their families. It also presents current criteria for enrollment into hospice in the United States (Table 5). The statement reviews current recommendations related to discussions and decisions when the goals of care in the intensive care unit (ICU) change from primarily curative/restorative care to primarily or entirely palliative care (Figure 2). It also discusses a number of "do's" and "don'ts" relevant to withholding and withdrawing life support for adults and children. One section discusses the concept of the principle of double effect as applied to palliative care of ICU patients or those with advanced respiratory diseases. This includes a description of the clinical practice of "palliative sedation" (formerly referred to as "terminal sedation") and a discussion of its ethical and medical complexities. Bereavement care both before and after the patient's death is recognized as an essential component of palliative care (Figures 1 and 2). In addition, the statement recommends measures to "care for the caregivers" - both family and friend caregivers and professional caregivers. In conclusion, the statement describes current barriers to patients and families receiving comprehensive and individualized palliative care. It calls on the ATS to work with other professional organizations of health care professionals to support palliative care in terms of enhanced public and professional education and to encourage the funding of further research in palliative care to provide best practices and an evidence-based approach to inform such practices.
This nursing research text features state-of-the-art research undertaken by Canadian nurse researchers, as well as additional Canadian content relating to the history of nursing research, ethical considerations, models of nursing, and models of research utilization. This thoroughly updated Third Edition has a greater focus on evidence-based practice and assists the reader in evaluating the adequacy of research findings. The text includes four new research reports, two with full written critiques. © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. All rights reserved.
Investigated the generalization of the transtheoretical model across 12 problem behaviors. The cross-sectional comparisons involved relationships between 2 key constructs of the model, the stages of change and decisional balance. The behaviors studied were smoking cessation, quitting cocaine, weight control, high-fat diets, adolescent delinquent behaviors, safer sex, condom use, sunscreen use, radon gas exposure, exercise acquisition, mammography screening, and physicians' preventive practices with smokers. Clear commonalities were observed across the 12 areas, including both the internal structure of the measures and the pattern of changes in decisional balance across stages.
Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.
(JAMA 1988;260:1743-1748)
To design and implement a needs assessment process that identifies gaps in caring for critically ill patients in a community hospital.
This mixed-method study was conducted between June 2011 and February 2012. A conceptual framework, centered on the critically ill patient, guided the design and selection of the data collection instruments. Different perspectives sampled included regional leaders, healthcare professionals at the community hospital and its referral hospital, as well as family members of patients who had received care at the community ICU. Data sources included interviews (n = 22), walk-throughs (n = 5), focus groups (n = 31), database searches, context questionnaires (n = 8), family surveys (n = 16), and simulations (n = 13).
None.
Nine needs were identified. At the community hospital, needs identified included lack of access to human resources, gaps in expertise, poor patient flow and ICU bed use, communication, lack of educational opportunities, and gaps in end-of-life care and interprofessional teamwork. Needs were also identified in the interhospital interaction between the community and referral hospitals, which included an inadequate hospital network and gaps in transfer and repatriation of patients. The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. Proposed solutions by the participants are presented including both organizational and educational/clinical solutions.
This study captured needs in a complex, interprofessional, interhospital context, which can be targeted with tailored interventions to improve patient outcomes in a community hospital. Furthermore, this study provides a preliminary framework and rigorous methodology to performing a needs assessment in this setting.
Board certification has evolved from a "point-in-time" event to a process of periodic learning and reevaluation of medical competence through maintenance of certification (MOC). To better understand MOC participation, the transtheoretical model (TTM) was used to describe physicians' perceptions of MOC as a sequence of attitudinal changes.
Data were from a survey of internal medicine (IM) physicians' attitudes toward periodic reevaluation through MOC. An overall importance or decisional balance score was computed for each physician by summing his or her ratings across the 10 quality measures. The decisional balance score was used to classify physicians according to their acceptance of MOC, aligned with the 3 early TTM stages-of-change groups-precontemplation (PC), contemplation (C), and preparation (P)-where PC was least accepting and P was most accepting. Effect sizes assessed whether differences in attitudes toward reevaluation via MOC were of sufficient magnitude to support the TTM principles.
The difference in degree of acceptance of MOC between the P group and the PC and C groups was significant (p < 0.001), but the effect size was lower than predicted by the "strong" principle. Resistance to MOC for the PC and C groups was significantly greater than the P group (p < 0.001) and supported the "weak" principle. Physicians' beliefs about how often they should demonstrate performance on quality measures aligned well with the American Board of Internal Medicine's MOC requirements, with the P group believing in more frequent assessments than the PC and C groups (p < 0.001).
Results show that physicians in the Preparation stage had overcome resistance to MOC as predicted by the "weak" principle of the TTM, but their attitude scores about the benefits of MOC were below what was expected by theory. This suggests that the structure of MOC may have made it easier for physicians to overcome barriers to MOC participation but may have lacked adequate resources to promote the benefits of participating in the process. More effort is needed to understand the specific benefits of MOC for reevaluating competencies, how to engage physicians and other stakeholders in the design of MOC, and how to communicate the rationale and evidence to those who are less accepting of MOC.
End-of-life care and planning is critically important to the next decades of health care in Canada. In our country, between 2005 and 2036, the number of seniors 65 years and older is projected to increase by up to 25%, and the number of deaths by 65%. The majority of patients are currently admitted to hospital and intensive care units at the end of life; however, up to 70% of elderly patients say they would prefer a less aggressive treatment plan focusing on providing comfort rather than a technologically supported, institutionalized death. Herein we provide a brief overview of the end-of-life care in the Canadian context, and highlight challenges and opportunities for health care system change in the coming decades.
The focus group is a method of needs assessment that continues to increase in popularity. The purpose of this article is to present the reader with examples of how focus groups have been used in the continuing health education field for needs assessment, examine some of the techniques involved in the method, and discuss implications for further research. © 1998 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education. All right reserved.
Barriers to providing quality end-of-life (EOL) care in the intensive care unit (ICU) are common, but little is known about how these barriers vary by level of training or discipline.
Medical residents and ICU fellows, attendings, and nurses at two teaching hospitals were surveyed about barriers to EOL care in the ICU. The survey consisted of questions about possible barriers in four domains: patient-family factors, clinician factors, institutional factors, and education-training factors.
There were significant differences in reported barriers to EOL care by level of training, discipline, and institution, particularly in the education-training domain. Insufficient resident training in EOL care was reported as a large or huge barrier by a smaller proportion of residents (20%) than attendings (62%), fellows (55%) or nurses (36%) (p=0.001). Nurses' perceptions of barriers to EOL care varied between institutions. Barriers that varied significantly between nurses included difficulty communicating due to language (p=0.008), and inadequate training in recognition of pain and anxiety (p=0.001).
We found that perceived barriers to EOL care differed significantly by level of training, discipline and institution, suggesting the interventions to improve EOL care may need to be locally targeted and specific to level of training and discipline.
High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality's National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance.
Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.
A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital.
Consecutive adult patients with length of intensive care unit stay ≥5 days.
None.
Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance.
Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers.
End-of-life care is a significant component of work in intensive care. Limited research has been undertaken on the provision of end-of-life care by nurses in the intensive care setting. The purpose of this study was to explore the end-of-life care beliefs and practices of intensive care nurses.
A descriptive exploratory qualitative research approach was used to invite a convenience sample of five intensive care nurses from one hospital to participate in a semi-structured interview. Interview transcripts were analysed using an inductive coding approach.
Three major categories emerged from analysis of the interviews: beliefs about end-of-life care, end-of-life care in the intensive care context and facilitating end-of-life care. The first two categories incorporated factors contributing to the end-of-life care experiences and practices of intensive care nurses. The third category captured the nurses' end-of-life care practices.
Despite the uncertainty and ambiguity surrounding end-of-life care in this practice context, the intensive care setting presents unique opportunities for nurses to facilitate positive end-of-life experiences and nurses valued their participation in the provision of end-of-life care. Care of the family was at the core of nurses' end-of-life care work and nurses play a pivotal role in supporting the patient and their family to have positive and meaningful experiences at the end-of-life. Variation in personal beliefs and organisational support may influence nurses' experiences and the care provided to patients and their families. Strategies to promote an organisational culture supportive of quality end-of-life care practices, and to mentor and support nurses in the provision of this care are needed.
The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement.
To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit. Design: Cross-sectional survey of 69 ICU physicians and 629 ICU nurses.
Single tertiary care academic medical institution.
A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level.
Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.
The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence.
This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research.
This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice.
This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.
Although the majority of hospital deaths occur in the intensive care unit and virtually all critically ill patients and their families have palliative needs, we know little about how patients and families, the most important "stakeholders," define high-quality intensive care unit palliative care. We conducted this study to obtain their views on important domains of this care.
Qualitative study using focus groups facilitated by a single physician.
A 20-bed general intensive care unit in a 382-bed community hospital in Oklahoma; 24-bed medical-surgical intensive care unit in a 377-bed tertiary, university hospital in urban California; and eight-bed medical intensive care unit in a 311-bed Veterans' Affairs hospital in a northeastern city.
Randomly-selected patients with intensive care unit length of stay >=5 days in 2007 to 2008 who survived the intensive care unit, families of survivors, and families of patients who died in the intensive care unit.
None.
Focus group facilitator used open-ended questions and scripted probes from a written guide. Three investigators independently coded meeting transcripts, achieving consensus on themes. From 48 subjects (15 patients, 33 family members) in nine focus groups across three sites, a shared definition of high-quality intensive care unit palliative care emerged: timely, clear, and compassionate communication by clinicians; clinical decision-making focused on patients' preferences, goals, and values; patient care maintaining comfort, dignity, and personhood; and family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Participants also endorsed specific processes to operationalize the care they considered important.
Efforts to improve intensive care unit palliative care quality should focus on domains and processes that are most valued by critically ill patients and their families, among whom we found broad agreement in a diverse sample. Measures of quality and effective interventions exist to improve care in domains that are important to intensive care unit patients and families.
Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.
The intensive care unit (ICU) represents a hospital setting in which death and discussion about end-of-life care are common, yet these conversations are often difficult. Such difficulties arise, in part, because a family may be facing an unexpected poor prognosis associated with an acute illness or exacerbation and, in part, because the ICU orientation is one of saving lives. Understanding and improving communication about end-of-life care between clinicians and families in the ICU is an important focus for improving the quality of care in the ICU. This communication often occurs in the "family conference" attended by several family members and members of the ICU team, including physicians, nurses, and social workers. In this article, we review the importance of communication about end-of-life care during the family conference and make specific recommendations for physicians and nurses interested in improving the quality of their communication about end-of-life care with family members. Because excellent end-of-life care is an important part of high-quality intensive care, ICU clinicians should approach the family conference with the same care and planning that they approach other ICU procedures. This article outlines specific steps that may facilitate good communication about end-of-life care in the ICU before, during, and after the conference. The article also provides direction for the future to improve physician-family and nurse-family communication about end-of-life care in the ICU and a research agenda to improve this communication. Research to examine and improve communication about end-of-life care in the ICU must proceed in conjunction with ongoing empiric efforts to improve the quality of care we provide to patients who die during or shortly after a stay in the ICU.
The primary goal of this study was to address the documented deficiencies in end-of-life care (EOLC) in intensive care unit settings by identifying key EOLC domains and related quality indicators for use in the intensive care unit through a consensus process. A second goal was to propose specific clinician and organizational behaviors and interventions that might be used to improve these EOLC quality indicators.
Participants were the 36 members of the Robert Wood Johnson Foundation (RWJF) Critical Care End-of-Life Peer Workgroup and 15 nurse-physician teams from 15 intensive care units affiliated with the work group members. Fourteen adult medical, surgical, and mixed intensive care units from 13 states and the District of Columbia in the United States and one mixed intensive care unit in Canada were represented.
An in-depth literature review was conducted to identify articles that assessed the domains of quality of EOLC in the intensive care unit and general health care. Consensus regarding the key EOLC domains in the intensive care unit and quality performance indicators within each domain was established based on the review of the literature and an iterative process involving the authors and members of the RWJF Critical Care End-of-Life Peer Workgroup. Specific clinician and organizational behaviors and interventions to address the proposed EOLC quality indicators within the domains were identified through a collaborative process with the nurse-physician teams in 15 intensive care units.
Seven EOLC domains were identified for use in the intensive care unit: a) patient- and family-centered decision making; b) communication; c) continuity of care; d) emotional and practical support; e) symptom management and comfort care; f) spiritual support; and g) emotional and organizational support for intensive care unit clinicians. Fifty-three EOLC quality indicators within the seven domains were proposed. More than 100 examples of clinician and organizational behaviors and interventions that could address the EOLC quality indicators in the intensive care unit setting were identified.
These EOLC domains and the associated quality indicators, developed through a consensus process, provide clinicians and researchers with a framework for understanding quality of EOLC in the intensive care unit. Once validated, these indicators might be used to improve the quality of EOLC by serving as the components of an internal or external audit evaluating EOLC continuous quality improvement efforts in intensive care unit settings.
Despite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospital discharge data from 1999 for six states and the National Death Index.
Retrospective analysis of administrative data to calculate age-specific rates of hospitalization with and without ICU use at the end of life, to generate national estimates of end-of-life hospital and ICU use, and to characterize age-specific case mix of ICU decedents.
All nonfederal hospitals in the states of Florida, Massachusetts, New Jersey, New York, Virginia, and Washington.
All inpatients in nonfederal hospitals in the six states in 1999.
None.
We found that there were 552,157 deaths in the six states in 1999, of which 38.3% occurred in hospital and 22.4% occurred after ICU admission. Using these data to project nationwide estimates, 540,000 people die after ICU admission each year. The age-specific rate of ICU use at the end of life was highest for infants (43%), ranged from 18% to 26% among older children and adults, and fell to 14% for those >85 yrs. Average length of stay and costs were 12.9 days and $24,541 for terminal ICU hospitalizations and 8.9 days and $8,548 for non-ICU terminal hospitalizations.
One in five Americans die using ICU services. The doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for dying patients in other settings.
To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.
Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.
118,199 adult admissions to ICUs.
The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7-96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.
Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.
One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care.
Self-administered mail survey.
Six hundred intensive care units.
A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States.
Mail survey.
We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available.
Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.
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.
Initiatives to improve end-of-life care in intensive care units face several important barriers. These include inflated expectations for critical care therapies, which are shared by many clinicians and many patients and families; preoccupation with an unattainable level of prognostic certainty, delaying attention to palliative needs; and fragmentation of the healthcare team into separate "silos" of disciplines and specialties. The article reviews these barriers and relevant empirical evidence. Specific strategies to improve intensive care unit palliative care, including consultation by palliative care specialists, and palliative care quality measurement are discussed.
The disciplines of critical care and palliative care may initially seem to be polar opposites, yet they share fundamental features. Both focus on the sickest patients in the healthcare system. Each discipline's primary goal-extending life for critical care and comfort and quality of life for palliative care-represents an important secondary goal for the other. A tremendous body of work in the last decade has laid the foundation for improving palliative care in intensive care units of the future. Pioneering projects have demonstrated the feasibility and acceptance of integrating palliative aspects of care within critical care settings and practice. This article introduces this special supplement of Critical Care Medicine, which describes the developments that have occurred moving us toward integration of palliative and critical care, and lays the foundation for the articles published in this supplement.
As most Canadians die in hospital, the final contact of family members with their loved ones is frequently in an unknown and uncomfortable environment. Family members are integral to the end-of-life decision-making process and are vital contributors to the comfort of dying patients. A quantitative study was conducted in three critical care areas where the stated goals were to provide not only quality care to patients, but also support to families. The researchers sought to determine levels of satisfaction with care, visitation, support, comfort and pain measures.
Three hundred surveys were mailed to next of kin who had a loved one die in the critical care areas of an urban tertiary care centre within the prior three years. Survey questions covered such issues as perceptions regarding the decision to stop life supports, access to the patient, access to physicians and nurses and information regarding the patient's status, support provided by the hospital, and organ donation attitudes.
Multiple regression analysis revealed that three factors predicted perceptions of overall quality of care: 1) being informed by nurses and physicians of any changes, 2) having the same group of nurses provide care, and 3) having one individual act as the family contact. Together these factors accounted for 52% of the variance in perceptions of care. Two factors accounted for 59% of the variance in dissatisfaction with the information received: 1) the perception that physicians did not spend enough time answering family questions, and 2) that the family was not present when the patient died.
Consistency in nursing care and provision of information to family members may be difficult in the fast pace of an ICU, but are reasonable program objectives considering the positive influence this has on perceptions of care. Further, flexible visitation policies which maximize access between family members and both their dying loved one and health care professionals appear to have a beneficial effect on satisfaction.
Background:
These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence.
Principal findings:
Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula.
Conclusions:
End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.
Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement
- Pa Selecky
- Eliasson
- Cah
- Ri Hall
An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses
- Pn Lanken
- Terry
- Pb
- Hm Delisser
Foundations of mixed methods research: Integrating quantitative and qualitative approaches in the social and behavioral sciences
- C Teddlie
- A Tashakkori
Canadian essentials of nursing research
- J Profetto-Mcgrath
- Polit
- Df
- Ct Beck
Knowledge translation in health care
- S Straus
- J Tetroe
- Id Graham
- Straus S
Meeting standards of high-quality intensive care unit palliative care: Clinical performance and predictors
- Jd Penrod
- Pronovost
- Pj
- Ee Livote