The Patient Dignity Inventory and Dignity-Related Distress among the Critically Ill

Factors Associated With Distress Related to Perceived Dignity in Patients With Rheumatic Diseases

BACKGROUND

The loss of perceived dignity is an existential source of human suffering, described in patients with cancer and chronic diseases and hospitalized patients but rarely explored among patients with rheumatic diseases (RMDs). We recently observed that distress related to perceived dignity (DPD) was present in 26.9% of Mexican patients with different RMDs. The study aimed to investigate the factors associated with DPD.

METHODS

This cross-sectional study was performed between February and September 2022. Consecutive patients with RMDs completed patient-reported outcomes (to assess mental health, disease activity/severity, disability, fatigue, quality of life [QoL], satisfaction with medical care, and family function) and had a rheumatic evaluation to assess disease activity status and comorbidity. Sociodemographic variables and disease-related and treatment-related variables were retrieved with standardized formats. DPD was defined based on the Patient Dignity Inventory score. Multivariate regression analysis was used.

RESULTS

Four hundred patients were included and were representative of outpatients with RMDs, while 7.5% each were inpatients and patients from the emergency care unit. There were 107 patients (26.8%) with DPD. Past mental health-related comorbidity (Odds Ratio [OR]: 4.680 [95% Confidence Interval [CI]: 1.906-11.491]), the number of immunosuppressive drugs/patient (OR: 1.683 [95% CI: 1.015-2.791]), the physical health dimension score of the World Health Organization Quality of Life-Brief questionnaire (WHOQOL-BREF) (OR: 0.937 [95% CI: 0.907-0.967]), and the emotional health dimension score of the WHOQOL-BREF (OR: 0.895 [95% CI: 0.863-0.928]) were associated with DPD.

CONCLUSIONS

DPD was present in a substantial proportion of patients with RMDs and was associated with mental health-related comorbidity, disease activity/severity-related variables, and the patient QoL.

Dignity-related distress and recall among alert, non-delirious critically ill patients

OBJECTIVES

Critical illness is associated with multiple undesired impacts, including residual psychological distress, frequently associated with recollections of critical illness. Dignity-related distress is highly prevalent among the one-fifth of critically ill patients who are alert. The distress may be associated with unpleasant recollections of care. We examined whether patients at risk for dignity-related distress had recall of their reported distress approximately 1 week after assessment and whether this recall differed from another high-risk group, specifically patients undergoing dialysis for end-stage renal disease.

METHODS

The prospective cohort study included patients with critical illness and patients with end-stage renal disease enrolled from intensive care units (ICUs) and dialysis units at 1 academic center. Distress was assessed using the Patient Dignity Inventory (PDI). Participants received in-patient or telephonic follow-up 7-10 days after the initial interaction. Follow-up encounters focused on recollection of key aspects of the interpersonal interaction as well as the content of the PDI.

RESULTS

A total of 32 critically ill patients participated in initial assessment and follow-up. In total, 26 dialysis patients participated in both phases. The groups' demographics differed. Fifty percent (n = 16) of critically ill patients and 58% (n = 15) of dialysis patients reported a mean score per item of >1.6, corresponding with severe distress on the PDI. Among the ICU patients, the 95% upper 2-sided confidence interval for the median level of recall was commensurate with the participant having had no recall of the initial interview beyond remembering that there was an interview. The end-stage renal disease group did not demonstrate significantly better recall.

SIGNIFICANCE OF RESULTS

Dignity-related distress is high in both critically ill patients and those with end-stage renal disease; however, recollection of assessment is poor in both groups. Any intervention designed to mitigate dignity-related distress will need either to be immediately deployable or not to be reliant upon recollection for impact.

Top Ten Tips Palliative Care Clinicians Should Know About Dignity-Conserving Practice

The acknowledgment and promotion of dignity is commonly viewed as the cornerstone of person-centered care. Although the preservation of dignity is often highlighted as a key tenet of palliative care provision, the concept of dignity and its implications for practice remain nebulous to many clinicians. Dignity in care encompasses a series of theories describing different forms of dignity, the factors that impact them, and strategies to encourage dignity-conserving care. Different modalities and validated instruments of dignity in care have been shown to lessen existential distress at the end of life and promote patient-clinician understanding. It is essential that palliative care clinicians be aware of the impacts of dignity-related distress, how it manifests, and common solutions that can easily be adapted, applied, and integrated into practice settings. Dignity-based constructs can be learned as a component of postgraduate or continuing education. Implemented as a routine component of palliative care, they can provide a means of enhancing patient-clinician relationships, reducing bias, and reinforcing patient agency across the span of serious illness. Palliative care clinicians-often engaging patients, families, and communities in times of serious illness and end of life-wield significant influence on whether dignity is intentionally integrated into the experience of health care delivery. Thus, dignity can be a tangible, actionable, and measurable palliative care goal and outcome. This article, written by a team of palliative care specialists and dignity researchers, offers 10 tips to facilitate the implementation of dignity-centered care in serious illness.

Humanizing the Intensive Care Unit: Perspectives of Patients and Families on the Get to Know Me Board

In this qualitative study, we explored perspectives of patients in the intensive care unit (ICU) and their families on the Get to Know Me board (GTKMB). Of the 46 patients approached, 38 consented to participate. Of the 66 family members approached, 60 consented to participate. Most patients (26, 89%) and family members (52, 99%) expressed that GTKMB was important in recognizing patient's humanity. Most patients (20, 68%) and families (39, 74%) said that it helped to build a better relationship with the provider team. 60% of patients and families commented that the GTKMB was used as a platform by providers to interact with them. Up to 45 (85%) of the family members supported specific contents of the GTKMB. In structured interviews (11 patients, 7 family members), participants additionally commented on ways providers used the GTKMB to communicate, support patient's personhood, and on caveats in interacting with GTKMB. Critically ill patients and families found the GTKMB helpful in preserving personhood of patient, fostering communication, and building relationships with clinicians.

Lack of Useful Predictors of Dignity-Related Distress Among the Critically Ill as Assessed With the Patient Dignity Inventory

BACKGROUND

Many intensive care unit patients are awake (ie, alert and engaging in conversation), actively experiencing many facets of their critical care. The Patient Dignity Inventory can be used to elicit sources of distress in these patients. We examined the administrative question as to which awake intensive care unit patients should be evaluated and potentially treated (eg, through palliative care consultation) for distress. Should the decision to screen for distress be based on patient demographics or treatment conditions?

METHODS

This was a retrospective cohort study of 155 adult patients from 5 intensive care units of one hospital from 2019 to 2020. Each patient had ≥48 hours without delirium, dementia, or sedation. The Patient Dignity Inventory has 25 items to which patients responded on a 1 (not a problem) to 5 (an overwhelming problem) scale. Multiple complete, stepwise forward, and stepwise backward logistic regression models were created among patient and treatment variables for predicting thresholds of the mean among the 25 items.

RESULTS

There were 50% (78/155; 95% confidence interval [CI], 42-58) of patients with significant dignity-related distress (mean score ≥1.60). There were 34% (52/155; CI, 26-42) of patients with severe dignity-related distress (mean score ≥1.92; previously associated with often feeling like wanting to die). Models including combinations of vasopressor medication (protective of distress), tracheostomy (greater risk of distress), and female gender (greater risk of distress) had some predictive value. However, all combinations of potential predictors had misclassification rates significantly >20%.

CONCLUSIONS

Identification of subsets of patients with little potential benefit to screening for dignity-related distress would have a reduced workload of palliative care team members (eg, nurses or social workers). Our results show that this is impractical. Given that approximately one-third of critical care patients who are alert and without delirium demonstrate severe dignity-related distress, all such patients with prolonged intensive care unit length of stay should probably be evaluated for distress.

Perceived dignity is an unrecognized source of emotional distress in patients with rheumatic diseases: Results from the validation of the Mexican version of the Patient Dignity Inventory

INTRODUCTION

Dignity has rarely been explored in patients with rheumatic diseases (RMDs), which contrasts with patients´ observations that dignity is a relevant area for research focus. The study's primary objective was to adapt and validate the Mexican version of the Patient Dignity Inventory (PDI-Mx) in patients with RMDs, and to estimate the proportion of patients with distress related to perceived dignity (DPD) assessed with the PDI-Mx.

METHODS

This cross-sectional study was developed in 2 phases. Phase 1 consisted of pilot testing and questionnaire feasibility (n = 50 patients), PDI-Mx content validity (experts' agreement), construct validity (exploratory factor analysis), discriminant validity (Heterotrait-Monotrait correlations' rate [HTMT]), criterion validity (Spearman correlations) and PDI-Mx reliability with internal consistency (Cronbach's alpha) and test-retest (intra-class correlation coefficients [ICC]) in 220 additional outpatients (among whom 30 underwent test-retest). Phase 2 consisted of quantifying DPD (PDI-Mx cut-off ≥54.4) in 290 outpatients with RMDs.

RESULTS

Overall, patients were representative of typical outpatients with RMDs from a National tertiary care level center. The 25-item PDI-Mx was found feasible, valid (experts' agreement ≥82%; a 4-factor structure accounted for 68.7% of the total variance; HTMT = 0.608; the strength of the correlations was moderate to high between the PDI-Mx, the Depression, Anxiety, and Stress scale dimensions scores, and the Health Assessment Questionnaire Disability Index score) and reliable (Cronbach's ɑ = 0.962, ICC = 0.939 [95%CI = 0.913-0.961]). DPD was present in 78 patients (26.9%).

CONCLUSIONS

The PDI-Mx questionnaire showed good psychometric properties for assessing DPD in our population. Perceived dignity in patients with RMDs might be an unrecognized source of emotional distress.

Forecasting Caseload of Critically Ill Patients Who Are Alert and Without Delirium for at Least Two Consecutive Days for the Assessment of Their Psychological Distress

INTRODUCTION

One-quarter of alert, non-delirious patients in critical care units report significant psychological distress. Treatment of this distress depends upon identifying these high-risk patients. Our aim was to characterize how many critical care patients remain alert and without delirium for at least two consecutive days and could thus predictably undergo evaluation for distress.

METHODS

This retrospective cohort study used data from a large teaching hospital in the United States of America, from October 2014 to March 2022. Patients were included if they were admitted to one of three intensive care units, and for >48 hours all delirium and sedation screenings were negative (Riker sedation-agitation scale four, calm and cooperative, and no delirium based on all Confusion Assessment Method for the Intensive Care Unit scores negative and all Delirium Observation Screening Scale less than three). Means and standard deviations of means for counts and percentages are reported among the most recent six quarters. Means and standard deviations of means for lengths of stay were calculated among all N=30 quarters. The Clopper-Pearson method was used to calculate the lower 99% confidence limit for the percentages of patients who would have had at most one assessment of dignity-related distress before intensive care unit discharge or change in mental status.

RESULTS

An average of 3.6 (standard deviation 0.2) new patients met the criteria daily. The percentages of all critical care patients (20%, standard deviation 2%) and hours (18%, standard deviation 2%) meeting criteria decreased slightly over the 7.5 years. Patients spent a mean of 3.8 (standard deviation 0.1) days awake in critical care before their condition or site changed. In the context of assessing distress and potentially treating it before the date of change of condition (e.g., transfer), 66% (6818/10314) of patients would have zero or one assessment, lower 99% confidence limit of 65%.

CONCLUSIONS

Approximately one-fifth of critically ill patients are alert and without delirium and thus could be evaluated for distress during their intensive care unit stay, mostly during a single visit. These estimates can be used to guide workforce planning.

Logistic Regression and Machine Learning Models for Predicting Whether Intensive Care Patients Who Are Alert and Without Delirium Remain As Such for at Least Two More Days

Background Some intensive care unit patients are alert and without delirium for at least two consecutive days. These patients, like other critically ill individuals, are at risk for dignity-related distress. An interval of at least two days would provide for a palliative care multidisciplinary team to be consulted in the late morning or afternoon of day one and visit the next day. An assessment would include the administration of the validated Patient Dignity Inventory in a reflective manner. To determine whether dignity-related distress can be identified and treated during patients' intensive care unit stay, we evaluated whether a substantive fraction of such patients (≥5%) have a substantial (>90%) probability of remaining alert and without delirium in the intensive care unit for at least four consecutive days. Methods The retrospective cohort study used data from one large teaching hospital in the United States of America, from 2012 to June 2022. The inclusion criteria were: a) adults, b) present in an intensive care unit at 12 PM one day and continually so for the next 48 hours, c) during those two days had every Riker sedation-agitation scale score "4, calm and cooperative," and d) during those two days had all Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scores negative (i.e., no delirium) and all Delirium Observation Screening Scale (DOS) scores less than three (i.e., no delirium). Results Among the 10,314 patients alert and without delirium in an intensive care unit over two-day periods that included three successive 12 PMs, 3,826 (37%) maintained this status for at least two successive 12 PMs. Six patient characteristics (e.g., hemodynamic infusion or ventilatory support) had value in predicting those 37% of patients. However, logistic regression and classification models each predicted a few (≈0.2%) patients with >90% probability of maintaining these criteria. Forecasts were inaccurate for nearly all patients remaining alert and without delirium in the intensive care unit (≈37%) because the models predicted no patient alert, without delirium, and in the intensive care unit for two days would remain so for at least four days. That ≈63% accuracy was improved upon by random forest machine learning, but only with ≈3% improvement. Conclusion Although many intensive care unit patients remain alert and without delirium for several consecutive days, each patient has a high daily probability of intensive care unit discharge or deterioration in medical condition. Therefore, the results of our prediction modeling show that care models for the assessment and treatment of patients with intensive care unit-associated dignity-related distress should not rely solely on the intensive care unit team but instead should be taken from the perspective of the entire hospitalization.

Self-report instruments for measuring patient dignity: A psychometric systematic review

AIMS

To synthesize and evaluate the psychometric properties of self-report instruments that measure patient dignity.

DESIGN

A psychometric systematic review.

DATA SOURCES

A comprehensive search of studies published from inception until February 17, 2022, was performed using PubMed, Embase, CINAHL, Web of Science, and Scopus.

REVIEW METHODS

The methodological quality of the psychometric studies was evaluated following the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

RESULTS

Eleven self-report instruments that evaluate dignity were identified. For most instruments, psychometric properties, including reliability, cross-cultural validity, responsiveness, and measurement error, had not been adequately examined. The Patient Dignity Inventory (PDI), the Jacelon's Attributed Dignity Scale (JADS), and the Inpatient Dignity Scale (IPDS) had acceptable content validity, structure validity, and internal consistency to measure dignity among adult patients under palliative care, community-dwelling older adults, and inpatients receiving daily care.

CONCLUSION

The PDI, the JADS, and the IPDS are recommended for future clinical practice and research to measure dignity among adult patients under palliative care, community-dwelling older adults, and inpatients receiving daily care. Early identification of patients' dignity-related problems in nursing care can prevent negative health outcomes and help develop a timely intervention to promote patients' health and recovery.

IMPACT

Given that the psychometric properties of the existing self-report dignity instruments have not been systematically assessed, the present review utilized comprehensive methods according to COSMIN to evaluate and determine the most appropriate measure for research and practice. The PDI, the JADS, and the IPDS demonstrated satisfactory psychometric properties and are, thus, recommended for clinical and research applications. Nursing professionals can employ these instruments to assess and promptly identify dignity issues among both young and older adults in hospitals and communities.

Frequency of Follow-Up Assessment for Post-Intensive Care Syndrome Among Alert and Non-Delirious Critically Ill Patients

INTRODUCTION

Many patients surviving critical illness develop post-intensive care syndrome, a constellation of psychological, physical, and cognitive symptoms which can have long-term consequences. Physicians and nurses at our large rural teaching hospital treat many of the critically ill patients in the state. Our focus has been the subset of these critically ill patients who were alert and not delirious for multiple consecutive days. The goal of our retrospective cohort study was to estimate the percentage of the patients with multiple intensive care unit days alert and not delirious who had follow-up assessments for post-intensive care syndrome within 15 months.

METHODS

The inclusion criteria for the case series of randomly selected patients were: adults defined as patients aged >17 years on the date of hospital admission between October 2014 and December 2020, present in a critical care unit at noon one day and continually so for another 48 hours, and for that interval, ≥≥48 hours had every Riker sedation-agitation scale "4, calm and cooperative," as well as either all Confusion Assessment Method for the Intensive Care Unit scores negative (i.e., no delirium) or Delirium Observation Screening Scale <3 (i.e., no delirium). Each patient was then categorized as having a full one-year follow-up if there was an encounter at our hospital between 12 and 15 months after the last date meeting study inclusion criteria. All follow-up appointments completed within 15 months of the index intensive care unit stay were screened for systematic assessment for psychological and cognitive sequelae of critical illness.

RESULTS

From a manual chart review of 366 records, 73 patients were found with follow-up ≥≥12 months. There were 21% (15/73) of the patients assessed for post-intensive care syndrome sequelae (99% confidence interval 10%-35%).

CONCLUSIONS

The fact that far fewer than half the patients had documented assessments suggests that retrospective studies should not be used to judge the incidence of post-intensive care syndrome at our hospital. Prospective observational studies would be needed to judge outcomes among critically ill patients with multiple consecutive days of alert and without delirium.