Ethical, legal, and communication challenges in managing goals-of-care discussions in chronically critically ill patients

More than "hematology": a qualitative study on the experience of hematologists treating people with blood cancer in Greece

PURPOSE

The present study aims to investigate the experiences of hematologists providing care to patients with hematological malignancies, whose care is pertinent to oncology.

METHODS

Semi-structured interviews with 30 hematologists across Greece were conducted. The interviews took place over the course of 6 months at 2020. Reflexive thematic analysis was employed for data analysis.

RESULTS

Three key themes (personal impact, organizational framework, and relating to patients) and eight subthemes were generated: (1) Hematologists were greatly affected on a personal level, as they had poor life-work balance and impacted social relationships. They experienced a great emotional toll, sometimes questioning the meaning of their work. They frequently struggled with loss, by witnessing people's passing. Nevertheless, they reported coping better over time. (2) On an organizational level, hematologists supported each other emotionally, but only rarely had formal support in managerial or administrative recourses. They were also hindered by structural restraints, both in terms of limited psychosocial training and supportive services. (3) Hematologists' relationship with their patients increased their job satisfaction. However, they strived to keep boundaries while balancing how close they got to their patients.

CONCLUSION

High job demands, organizational shortcomings, and emotional challenges negatively impact their well-being and pose the risk of developing compassion fatigue or burnout. At the same time, individual resources, teamwork, and strong personal relationships emerged as crucial coping elements, providing meaning and resilience. Psychosocial training and institutional support should be offered both personally and professionally to enhance hematologists' well-being and reduce potential turnover.

Workplace interpersonal relationships and turnover intentions among care workers working in older adult care facilities in Japan: a mediation analysis comparing direct and mediated effects via psychological distress

BACKGROUND

This study aimed to investigate the relationship between workplace interpersonal relationships, psychological distress, and turnover intentions among care workers working in older adult care facilities.

METHODS

An anonymous online survey among 811 care workers in Tottori Prefecture, Japan, was conducted between November and December 2023. The data were collected using the Workplace Interpersonal Problems Scale for care workers (WIPS), the K6 scale to assess psychological distress, the Turnover Intention Scale and basic attributes. Responses were obtained from 254 participants with a response rate of 31.3%. The low response rate suggests that selection bias may have affected the results of this study.

RESULTS

The results of the mediation analysis for the WIPS subscale which was adjusted for basic attributes show that the direct effects of insufficient communication and a sense of unfair workload were stronger than the mediating effects of psychological distress (Insufficient communication: direct effect: β = 0.319 [95% CI = 0.192, 0.459]; mediation effect: β = 0.194 [95% CI = 0.105, 0.285]), sense of unfair workload: direct effect: β = 0.314 [95% CI = 0.187, 0.443]; mediation effect: β = 0.190 [95% CI = 0.113, 0.268]). In these other four WIPS subscales, psychological distress was partially mediated (bullying: direct effect: β = 0.207 [95% CI = 0.091, 0.322]; mediation effect: β = 0.204 [95% CI = 0.135, 0.290], different attitudes to care work: direct effect: β = 0.278 [95% CI = 0.140, 0.401]; mediation effect: β = 0.204 [95% CI = 0.128, 0.293], difficulty in guidance for subordinates/new staff: direct effect: β = 0.207 [95% CI = 0.072, 0.329]; mediation effect: β = 0.219[95% CI = 0.141, 0.313], labeling: direct effect: β = 0.198 [95% CI = 0.073, 0.330]; mediation effect: β = 0.211 [95% CI = 0.143, 0.287]).

CONCLUSIONS

This study revealed that some workplace interpersonal problems have a stronger direct effect on turnover intentions, whereas others have a stronger mediating effect on turnover intentions through psychological distress. Workplace interpersonal problems are predictors of turnover intentions among care workers working in elderly care facilities, and different workplace interpersonal problems may be targeted for intervention to reduce turnover intentions.

Achieving Goals of Care Decisions in Chronic Critical Illness: A Multi-Institutional Qualitative Study

BACKGROUND

Physicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI), but little is currently known about this decision-making process.

RESEARCH QUESTION

How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process?

STUDY DESIGN AND METHODS

We conducted semistructured interviews with a purposeful sample of intensivists from the United States and Canada using a mental models approach adapted from decision science. We analyzed transcripts inductively using qualitative description.

RESULTS

We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members.

INTERPRETATION

Intensivists described a complex time- and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between physicians and decrease logistical and relational barriers to timely and consistent communication are key to improving GOC decision-making in CCI.

Pediatric Goals of Care Communication: A Socioecological Model to Guide Conversations

The purpose of this article is to explore factors that influence pediatric patients and their parents during provider-led goals-of-care conversations. Our framework can help providers enhance holistic communication by approaching difficult topics (ie, quality of life, end of life) with an understanding of the multilayered external influences that affect patient/parent decision making. A 5-layer model is presented that describes facilitators to conversations about quality goals of care and advance directives. Each year, complex health conditions (a) affect approximately 500 000 children in the United States, 8600 of whom meet current palliative care criteria, and (b) account for over 7 million child deaths globally. Nurses can use knowledge of the unique values and culture of families with children who have complex health conditions to support them by providing high quality, ongoing goals-of-care conversations, especially if their access to pediatric palliative care is limited.