Factors Associated With Quality of Death in Korean ICUs As Perceived by Medical Staff: A Multicenter Cross-Sectional Survey

Factors associated with good death for end-of-life patients in the intensive care unit based on nurses' perspectives: A systematic review

BACKGROUND

Ensuring a good death in the intensive care unit (ICU) is crucial due to high global mortality rates. Despite the central role of nurses in end-of-life care, existing reviews often focus on patients or families and overlook nurses' perspectives.

OBJECTIVES

This study aims to investigate the factors associated with a good death for end-of-life patients in the ICU based on nurses' perspectives by systematically summarizing current evidence.

METHODS

The researchers utilized a systematic review followed the PRISMA 2020 guidelines and was registered with PROSPERO. Databases searched included Scopus, ProQuest, PubMed, ScienceDirect, EBSCOhost, and Google Scholar. Inclusion criteria covered English-language quantitative studies published from the inception until February 20, 2024, that reported factors influencing a good death from the perspective of ICU nurses, and were available in full text. The exclusion criteria included studies with mixed participants if separate analyses for nurses were not provided. Risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for analytical cross-sectional studies, and a narrative synthesis was performed.

RESULTS

Five high-quality studies were included, involving 1,654 ICU nurses with an average age between 28.64 and 41.40 years, predominantly female (54.8 % to 91 %). Identified factors included nurses' personal factors, nurses' job characteristics, nurses' clinical competence in end-of-life care, and process of healthcare.

CONCLUSIONS

The review highlights the vital factor influencing a good death from ICU nurses' perspectives. Awareness of personal and job-related factors, along with enhanced clinical competence in end-of-life care, are essential for supporting patients to achieve a good death.

IMPLICATIONS FOR CLINICAL PRACTICE

ICU nurses can enhance their clinical competence in end-of-life care. Hospital managers should take into account nurses' work experience when assigning staff and consider implementing fixed shifts. Future research should explore these factors globally and develop interventions to support a good death in the ICU.

Gender differences in quality of dying and death among older adults: a cross-sectional study in China

Background

The aging of China is deepening year by year, and improving the quality of dying and death (QODD) is increasingly becoming an urgent and realistic need. This study explores the gender differences in the quality of dying and death and its influencing factors among Chinese older adults, aiming to provide assistance to the relevant authorities in formulating end-of-life care policies for the older adults, and to adapt to the needs of an aging society.

Methods

Based on the data of the Chinese Longitudinal Health Longevity Survey (CLHLS) during 2008-2018, a total of 7,341 respondents were included. Chi-square test and logistic regression analysis were used to analyze the quality of dying and death among Chinese older adults and its influencing factors. In addition, A Fairlie decomposition analysis (FDA) was conducted to ascertain the degree of influence exerted by various contributing factors.

Results

The proportion of high QODD among female older adults (63.80%) was significantly higher than male older adults (56.00%), which was statistically significant. Logistic regression showed that age, residence, home facilities score, place of death, medical costs, got timely treatment, number of chronic diseases and unconsciousness were the factors influencing QODD among male older adults. Meanwhile, residence, marital status, home facilities score, place of death, got timely treatment, bedridden, suffered from serious illness, unconsciousness and drinking were the factors influencing QODD among female older adults. FDA showed that 47.89% of the differences in QODD were caused by the observed variables, while 52.11% of the differences were caused by gender differences and unmeasured variables.

Conclusion

Chinese men have a poorer QODD compared to women. The main factors contributing to this difference were age, the number of chronic diseases, suffered from serious illness, unconsciousness, place of death, residence and home facilities scores. To ensure successful aging, the relevant departments should focus on these factors and work toward reducing the gender differences in QODD.

Effect of life-sustaining treatment decision law on pediatric in-hospital cardiopulmonary resuscitation rate: A Korean population-based study

AIM

The 2018 life-sustaining treatment (LST) decision law is expected to improve end-of-life quality in Korea. This study evaluated the national effect of the LST decision law on the cardiopulmonary resuscitation (CPR) rate among pediatric patients who died during hospital admission.

METHODS

This retrospective cohort study was based on the Korean National Health Insurance database. Pediatric admissions within 12 months before or after implementation of the LST decision law were compared, allowing a 1-month transition period (February 2018). The changes in mortality, CPR, and documentation of LST decision were evaluated.

RESULTS

The CPR rate of patients who died in hospital decreased after establishment of the LST decision law (49.6 vs 43.4 %, P = 0.04), without change of in-hospital mortality between pre/post-LST decision law activation (0.83 vs 0.81 per 1000 admissions, P = 0.67). In addition, in-hospital CPR (0.73 vs 0.67 per 1000 admissions, P = 0.15) and survival to discharge after in-hospital CPR (43.6 vs 47.2 %, P = 0.27) were slightly improved, although there was no statistical significance. Patients with LST decision documentation were less frequently mechanically ventilated (69.8 % vs 80.4 %, P < 0.01) and used fewer inotropes (76.5 % vs 90.1 %, P < 0.01) and more frequent opioids (67.1 % vs 57.4 %, P = 0.04).

CONCLUSIONS

The legally guided process of LST decision can decrease the CPR rate of children who die in hospitals. This result highlights the possibility of improving end-of-life quality by reducing non-beneficial in-hospital CPR.

Change in perception of the quality of death in the intensive care unit by healthcare workers associated with the implementation of the "well-dying law"

Purpose

The importance of dying with dignity in the intensive care unit (ICU) has been emphasized. The South Korean government implemented the “well-dying law” in 2018, which enables patients to refuse futile life-sustaining treatment (LST) after being determined as terminally ill. We aimed to study whether the well-dying law is associated with a significant change in the quality of death in the ICU.

Methods

The Quality of Dying and Death (QODD) questionnaires were prospectively collected from the doctors and nurses of deceased patients of four South Korean medical ICUs after the law was passed (January 2019 to May 2020). Results were compared with those of our previous study, which used the same metric before the law was passed (June 2016 to May 2017). We compared baseline characteristics of the deceased patients, enrolled staff, QODD scores, and staff opinions about withdrawing LST from before to after the law was passed.

Results

After the well-dying law was passed, deceased patients (N = 252) were slightly older (68.6 vs. 66.6, p = 0.03) and fewer patients were admitted to the ICU for post-resuscitation care (10.3% vs. 20%, p = 0.003). The mean total QODD score significantly increased after the law was passed (36.9 vs. 31.3, p = 0.001). The law had a positive independent association with the increased QODD score in a multiple regression analysis.

Conclusion

Our study is the first to show that implementing the well-dying law is associated with quality of death in the ICU, although the quality of death in South Korea remains relatively low and should be further improved.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06597-7.

Suffering and Symptoms At the End of Life in ICU Patients Undergoing Renal Replacement Therapy

BACKGROUND

We know little about the end-of-life suffering and symptoms of intensive care unit (ICU) decedents in general and those who undergo renal replacement therapy (RRT) in particular.

OBJECTIVES

To examine differences in end-of-life suffering and various symptoms' contribution to suffering between ICU decedents who did not undergo RRT, those who underwent RRT for end-stage kidney disease (ESKD), and those who underwent RRT for acute kidney injury (AKI).

METHODS

This is a cross-sectional study conducted at a quaternary-level referral hospital September 2015-March 2017. Nurses completed interviews about ICU patients' suffering and symptoms in their final week. We dichotomized overall suffering into elevated and non-elevated and each symptom as contributing or not to a patient's suffering.

RESULTS

Sixty-four nurses completed interviews on 165 patients. Median patient age was 67 years (interquartile range 57, 78); 41% were female. In a multivariable model, undergoing RRT for AKI (odds ratio [OR] 2.95, 95% confidence interval [CI] 1.34-6.49) was significantly associated with elevated suffering compared to no RRT; undergoing RRT for ESKD was not. Adjusting for length of stay, AKI-RRT patients were more likely than non-RRT patients to have fecal incontinence (OR 2.21, 95% CI 1.00-4.93), painful broken skin (OR 2.41, 95% CI 1.14-5.12), and rashes (OR 3.61, 95% CI 1.35-9.67) contributing to their suffering.

CONCLUSIONS

Undergoing RRT for AKI was associated with elevated suffering in the last week of life in ICU decedents. Painful broken skin, rashes, and fecal incontinence were more likely to contribute to suffering in AKI-RRT patients than in non-RRT patients. How to reduce suffering associated with AKI-RRT in ICU patients merits further study.

Factors Associated with Quality of Dying and Death in Korean Intensive Care Units: Perceptions of Nurses

The objective of this study was to investigate the factors affecting the quality of dying and death among terminally ill patients in an intensive care unit in Korea using a cross-sectional, online survey. A total of 300 nurses in the intensive care unit who had cared for a terminally ill patient for at least 48 h prior to death in the past six months were chosen to participate. The person-centered critical care nursing (PCCN) score and quality of dying and death (QODD) had a positive correlation. The QODD score increased when the consultation was conducted between the terminally ill patients and their doctors when CPR was not performed within 48 h of death, and when the PCCN score increased. The quality of death of patients is affected by whether they have sufficiently consulted with healthcare providers regarding their death and how much respect they receive. It is important for nurses to practice and improve patient-centered nursing care in order to ensure a good quality of death for terminally ill patients.