Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care

Improving Outcomes for ICU Family Members: The Role of Spiritual Care

Having a family member hospitalized in the intensive care unit (ICU) can be a stressful experience for family members, encompassing both psychological and spiritual distress. With over 5 million ICU admissions annually in the United States, it is imperative to enhance the experiences and coping mechanisms of ICU family members. In particularly challenging situations, some family members even face psychological effects known as post-intensive care syndrome-family, which includes anxiety, depression, and posttraumatic stress. The distress may be worsened when patients and families experience poor communication or medical care, which has been shown to be more common among minoritized populations including Black and Hispanic patients and families. Family members' emotional and spiritual distress also has an effect on the medical decisions they make for the patient. While research has delved into the impact of spiritual care for ICU family members, further investigation is still needed to determine the most effective approaches for delivering such care. This narrative review will describe a conceptual model aimed at guiding future research in this endeavor. The model proposes that chaplains provide emotional, spiritual, and information support to ICU family members. This affects both their ICU experience, decision making, and outcomes for the patient and family. This process is also affected by characteristics of the family such as race, ethnicity, and economic status. This model helps identify gaps in research, including the need for randomized trials of spiritual care that identify mechanisms underlying outcomes and demonstrate impact of spiritual care, and consider race, ethnicity, and other characteristics.

TIEC, Trauma Capacity, and the Moral Priority of Surrogate Decision Makers in Futility Disputes

AbstractIn the past 15 years, trauma-informed care (TIC) has evolved as a new paradigm in healthcare that recognizes the impact of past traumas on patients' and families' healthcare experience while seeking to avoid inducing new trauma during clinical care. A recent paper by Lanphier and Anani extends TIC principles to healthcare ethics consultation (HEC) in what they label "trauma-informed ethics consultation" (TIEC), which calls for the "addition of trauma informed awareness, training, and skill in clinical ethics consultation." While Lanphier and Anani claim that TIEC is "novel, but not radical" because it builds on the approach to HEC endorsed by the American Society for Bioethics and Humanities, I believe that TIEC has radical implications, particularly regarding ethical obligations to surrogate decision makers (SDMs). Given what I call the SDM's "trauma capacity," I argue that TIEC accords moral priority to SDMs over patients in certain types of end-of-life cases, particularly futility disputes, which is a radical departure from the conventional HEC approach to SDMs.

Facilitators and Barriers to Values Discussions Following LVAD Implantation: Perspectives from Diverse Patients and Family Caregivers

BACKGROUND

Delivering care that is responsive to who or what is most important to patients and family caregivers is a key aspect of quality care, yet it remains unclear how clinicians can best support individuals in expressing their personal values. We aimed to describe patient- and family caregiver-identified facilitators and barriers to engaging in values discussions with clinicians following implantation of a left ventricular assist device (LVAD).

METHODS AND RESULTS

Using a qualitative descriptive approach, patients with an LVAD and their caregivers participated in 1-on-1 semistructured interviews and self-reported sociodemographics (January 2023-July 2023). Qualitative data were analyzed using thematic analysis and descriptive statistics were computed for quantitative data.

RESULTS

Patients (n = 27; ages 30-76 years) were predominantly male (59%) and non-Hispanic Black (67%). Caregivers (n = 21; ages 27-76) were female (76%), non-Hispanic Black (67%), and a spouse/partner (62%). Facilitators (5 shared across patient/caregiver groups; 8 unique across patient/caregiver groups) included a perceived close relationship (patient/caregiver), values alignment (patient/caregiver), clinician discussion initiation (patient/caregiver), facing an impending decision (patient/caregiver), 1-on-1 dyadic interactions (patient/caregiver), being assertive (patient), positive dyadic communication (caregiver), and involvement of a third party (caregiver). Barriers (2 shared; 7 unique) included belief that their values are already known (patient/caregiver), sensitivity about values (patient/caregiver), uncertainty about timing (patient), poor clinical communication (patient), patient hopelessness (patient), perceived lack of clinician time (caregiver), and having a reserved personality (caregiver).

CONCLUSION

Findings offer insight into actionable facilitators and barriers to discussions promoting incorporation of patient and family values into LVAD maintenance and chronic disease management.

"They Did Not Know How to Talk to Us and It Seems That They Didn't Care:" Narratives from Bereaved Family Members of Black Veterans

Racial disparities in the quality of health care services, including end of life (EOL) care, are well-documented. While several explanations for these inequities have been proposed, few studies have examined the underlying mechanisms. This paper presents the results of the qualitative phase of a concurrent mixed-methods study (QUANT + QUAL) that sought to identify explanations for observed racial differences in quality of EOL care ratings using the Department of Veterans Affairs Bereaved Family Survey (BFS). The objective of the qualitative phase of the study was to understand the specific experiences that contributed to an unfavorable overall EOL quality rating on the BFS among family members of Black Veterans. We used inductive thematic analysis to code BFS open-ended items associated with 165 Black Veterans whose family member rated the overall quality of care received by the Veteran in the last month of life as "poor" or "fair." Four major themes emerged from the BFS narratives, including (1) Positive Aspects of Care, (2) Unmet Care Needs, (3) Lack of Empathy, Dignity, and Respect, and (4) Poor Communication. Additionally, some family members offered recommendations for care improvements. Our discussion includes integrated results from both our qualitative and previously reported quantitative findings that may serve as a foundation for future evidence-based interventions to improve the equitable delivery of high-quality EOL care.

Perioperative Care of the Patient with Directives Limiting Life-Sustaining Treatments

Like most complex aspects of procedural care, sound perioperative management of limits to life-sustaining medical therapy requires a multidisciplinary team-based approach bolstered by appropriate care management strategies. This article discusses the implications of care for the patient for whom limitations of life-sustaining care are in place and the roles and responsibilities of each provider in supporting quality procedural care compatible with patients' right to self-determination. The authors focus on the roles of the surgeon, preoperative clinic provider, anesthesiologist, and postoperative care consultants and discuss how the health care system and care pathways can support and improve adherence to best practices.

Tumor Is Not the Only Target: Ensuring Equitable Person-Centered Supportive Care in the Era of Precision Medicine

Communication in oncology has always been challenging. The new era of precision oncology creates prognostic uncertainty. Still, person-centered care requires attention to people and their care needs. Living with cancer portends an experience that is life-altering, no matter what the outcome. Supporting patients and families through this unique experience requires careful attention, honed skills, an understanding of process and balance measures of innovation, and recognizing that supportive care is a foundational element of cancer medicine, rather than an either-or approach, an and-with approach that emphasizes the regular integration of palliative care (PC), geriatric oncology, and skilled communication.

Inequities in access to palliative and end-of-life care in the black population in Canada: a scoping review

BACKGROUND

Improving equity and early access to palliative care for underserved populations in Canada is a priority. Little is known regarding access to palliative and end-of-life care in the Black population.

METHODS

We undertook a scoping review using the framework by Arksey and O'Malley to identify knowledge, access gaps, and experiences of palliative and end-of-life care among Blacks living with life-limiting illnesses in Canada. Primary studies, discussion papers, books, and reports were considered eligible. We followed a comprehensive search strategy developed by an information scientist. Searches were performed in the following bibliographic databases: Medline, EMBASE, PsycINFO via OVID, CINAHL via EBSCOhost, Scopus and Cochrane Library via Wiley. The search strategy was derived from three main concepts: (1) Black people; (2) Canada and Canadian provinces; (3) Palliative, hospice, or end-of-life care. No publication date or language limits were applied. Titles and abstracts were screened for eligibility by one reviewer and full text by two independent reviewers.

RESULTS

The search yielded 233 articles. Nineteen articles were selected for full-text review, and 7 articles met the inclusion criteria. These studies were published between 2010 and 2021, and conducted in the provinces of Ontario and Nova Scotia only. Studies used both quantitative and qualitative methods and included cancer decedents, next of kin, family caregivers and religious leaders. Sample sizes in various studies ranged from 6 - 2,606 participants. Included studies reported a general lack of understanding about palliative and end-of-life care, positive and negative experiences, and limited access to palliative and end-of-life care for Blacks, across all care settings.

CONCLUSION

Findings suggest limited knowledge of palliative care and inequities in access to palliative and end-of-life care for Blacks living with life-limiting illnesses in 2 Canadian provinces. There is an urgent need for research to inform tailored and culturally acceptable strategies to improve understanding and access to palliative care and end-of-life care among Blacks in Canada.