Integrating Palliative Care in the ICU: The Nurse in a Leading Role

Triggers of intensive care patients with palliative care needs from nurses' perspective: a mixed methods study

PURPOSE

Triggers have been developed internationally to identify intensive care patients with palliative care needs. Due to their work, nurses are close to the patient and their perspective should therefore be included. In this study, potential triggers were first identified and then a questionnaire was developed to analyse their acceptance among German intensive care nurses.

METHODS

For the qualitative part of this mixed methods study, focus groups were conducted with intensive care nurses from different disciplines (surgery, neurosurgery, internal medicine), which were selected by convenience. Data were analysed using the "content-structuring content analysis" according to Kuckartz. For the quantitative study part, the thus identified triggers formed the basis for questionnaire items. The questionnaire was tested for comprehensibility in cognitive pretests and for feasibility in a pilot survey.

RESULTS

In the qualitative part six focus groups were conducted at four university hospitals. From the data four main categories (prognosis, interprofessional cooperation, relatives, patients) with three to 15 subcategories each could be identified. The nurses described situations requiring palliative care consults that related to the severity of the disease, the therapeutic course, communication within the team and between team and patient/relatives, and typical characteristics of patients and relatives. In addition, a professional conflict between nurses and physicians emerged. The questionnaire, which was developed after six cognitive interviews, consists of 32 items plus one open question. The pilot had a response rate of 76.7% (23/30), whereby 30 triggers were accepted with an agreement of ≥ 50%.

CONCLUSION

Intensive care nurses see various triggers, with interprofessional collaboration and the patient's prognosis playing a major role. The questionnaire can be used for further surveys, e.g. interprofessional triggers could be developed.

Palliative Care Utilization in Patients Requiring Extracorporeal Membrane Oxygenation: An Observational Study

Palliative care (PC) is a model of care centered around improving the quality of life for individuals with life-limiting illnesses. Few studies have examined its impact in patients on extracorporeal membrane oxygenation (ECMO). We aimed to describe demographics, clinical characteristics, and complications associated with PC consultation in adult patients requiring ECMO support. We analyzed data from an ECMO registry, including patients aged 18 years and older who have received either venoarterial (VA)- or venovenous (VV)-ECMO support between July 2016 and September 2021. We used analysis of variance and Fisher exact tests to identify factors associated with PC consultation. Of 256, 177 patients (69.1%) received VA-ECMO support and 79 (30.9%) received VV-ECMO support. Overall, 115 patients (44.9%) received PC consultation while on ECMO. Patients receiving PC consultation were more likely to be non-white (47% vs. 53%, p = 0.016), have an attending physician from a medical versus surgical specialty (65.3% vs. 39.6%), have VV-ECMO (77.2% vs. 30.5%, p < 0.001), and have longer ECMO duration (6.2 vs. 23.0, p < 0.001). Patients were seen by the PC team on an average of 7.6 times (range, 1-35), with those who died having significantly more visits (11.2 vs. 5.6, p < 0.001) despite the shorter hospital stay. The average time from cannulation to the first PC visit was 5.3 ± 5 days. Congestive heart failure in VA-ECMO, coronavirus disease 2019 infection in VV-ECMO, and non-white race and longer ECMO duration for all patients were associated with PC consultation. We found that despite the benefits of PC, it is underused in this population.

Confidence in carrying out palliative care among intensive care nurses

BACKGROUND

Nurses in intensive care units (ICUs) play a crucial role in providing palliative care. Effective provision of palliative care in the ICU requires nurses' active engagement, yet little is known about the confidence for palliative care that ICU nurses hold in China.

AIM

To explore confidence in performing palliative care among ICU nurses in China and factors related to nurses' level of confidence.

STUDY DESIGN

A cross-sectional design was implemented.

METHODS

This study utilized convenience sampling to recruit ICU nurses from nine hospitals in Wuhan, China. Data were collected via an online survey. Multiple regression was conducted to identify the predictors of the ICU nurses' confidence in performing palliative care.

RESULTS

A total of 231 ICU nurses participated in the study, resulting in a response rate of 78% (231/296). Participants reported a relatively low level of confidence for carrying out palliative care (mean score = 2.60 ± 0.53; range = 1-4). Nurses who had more positive attitudes toward palliative care communication (P < .001), higher levels of formal training on palliative care (P < .001), more years of working as an ICU nurse (P < .05) and those working in integrated ICU (P < .001) showed a higher level of confidence in carrying out palliative care.

CONCLUSION

Participants' lack of confidence in performing palliative care makes for increased challenges, particularly in uncertainty about family assessments, palliative care discussions and lack of palliative care training. Strengthening palliative care curricula in nursing education and professional training is imperative to enhance ICU nurses' confidence.

RELEVANCE TO CLINICAL PRACTICE

Strengthening palliative care education and training, particularly in relation to palliative care communication, is critical. Implementing and tailoring culturally relevant palliative care call for attention to practice and for policy changes in palliative care delivery in China.

Relationship between End-of-Life Care Stress, Death Anxiety, and Self-Efficacy of Clinical Nurses in South Korea

In South Korea, the number of cancer patients continues to rise, indicating that nurses have greater access to end-of-life care in clinical settings. This study examined the relationship between the end-of-life care stress, death anxiety, and self-efficacy of clinical nurses in South Korea. A cross-sectional descriptive design was used. Participants were 124 nurses working in university hospitals. Data included the general characteristics of study participants, end-of-life care stress, death anxiety, and self-efficacy. Data were collected from February to March 2021. This study shows that the degrees of end-of-life care stress and death anxiety of clinical nurses in South Korea were higher than the median values. Married nurses had higher self-efficacy than unmarried, and there was a difference between bedside and administrative nurses’ self-efficacy. Nurses with no experience of end-of-life care nursing education had higher death anxiety than nurses with experience. The higher the end-of-life care stress of nurses, the higher the death anxiety. The study suggests that therapeutic and detailed educational programs to reduce end-of-life care stress and death anxiety of clinical nurses are needed, and experimental research to verify this. The results can contribute to countries as an additional and enriching reference.

I've Got the Power: Nurses' Moral Distress and Perceptions of Empowerment

BACKGROUND

Nurses experience moral distress when they feel disempowered or impeded in taking the ethically right course of action. Research suggests an inverse relationship between moral distress and empowerment. In the intensive care unit, providing palliative care services may reduce moral distress because palliative care is often provided in situations that give rise to moral distress.

OBJECTIVE

To evaluate the effect of nurses' use of a palliative care screening tool on their moral distress and perceptions of empowerment.

METHODS

A pretest-posttest pilot study was conducted involving day-shift medical intensive care unit nurses. The nurses administered a palliative care screening tool to their assigned patients daily for 8 weeks and communicated the results to an attending physician or fellow. Demographic information was collected, along with data on nurses' moral distress and perceptions of structural and workplace empowerment before and after the intervention. Moral distress was evaluated using the Moral Distress Scale-Revised. Perceptions of structural and workplace empowerment were quantified using the Conditions for Work Effectiveness Questionnaire-II and the Global Empowerment Scale, respectively.

RESULTS

Preintervention and postintervention surveys were completed by 17 nurses. Paired-sample t tests revealed a significant decrease in the frequency of moral distress (t16 = -2.22, P = .04) and a significant increase in workplace empowerment (t16 = -2.75, P = .01). No significant changes in moral distress intensity or structural empowerment were found.

CONCLUSION

Nurses' sense of empowerment and the frequency of moral distress are favorably affected by active participation in assessing and communicating patients' palliative care needs.

Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach

BACKGROUND

The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations.

AIM

Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative.

DESIGN

A qualitative thematic analysis of semi-structured interviews.

SETTING/PARTICIPANTS

Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers.

RESULTS

Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers.

CONCLUSIONS

Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.

Assessment of Palliative Care Needs in a Kenyan Intensive Care Unit Using a Trigger-Based Model

CONTEXT

Palliative care triggers have been used in the intensive care unit (ICU) setting, usually in high-income countries, to identify patients who may benefit from palliative care consults. The utility and benefits of palliative care triggers in the ICU have not been previously studied in sub-Saharan Africa.

OBJECTIVES

Our objectives were to determine the prevalence of ICU admissions in those who met at least one palliative care trigger and whether a palliative care consult influenced the length of ICU stay and time to change of goals order.

METHODS

We conducted a prospective observational cohort study within our ICU at the Aga Khan University Hospital, Nairobi, between December 2019 and August 2020. Data including initiation of a palliative care consult, length of ICU stay, mortality, and time to change of goals order were collected.

RESULTS

During our study period, 72 of 159 (45.9%) patients met at least one palliative care trigger point. Of the patients who met the palliative care triggers, only 29.2% received a palliative care consult. Patients who received palliative care consults had higher rates of change of goals orders signed (52.3%) vs. those who did not (P = 0.009). There was no statistically significant difference between the consult and nonconsult groups in regard to length of ICU stay, time to change of goals order, and mortality.

CONCLUSION

A trigger-based model, geared to the needs of the specific ICU, may be one way of improving integration of palliative care into the ICU, especially in sub-Saharan Africa.

Selecting Patients for Palliative Procedures in Oncology

Surgical palliation in oncology can be defined as "procedures employed with non-curative intent with the primary goal of improving symptoms caused by an advanced malignancy," and is an important aspect of the end-of-life care of patients with incurable malignancies. Palliative interventions may provide great benefit, but they also carry high risk for morbidity and mortality, which may be minimized with careful patient selection. This can be done by consideration of the patient and his or her indication for the given intervention via open communication, as well as prediction of benefits and risks to define the therapeutic index of the operation or procedure.

Training needs assessment of intensive care nurses in Zabol University of Medical Sciences' Hospitals

BACKGROUND

The improvement of the knowledge, skill, and attitude of nurses working at the intensive care unit (ICU) through implementing training need assessment and holding continuous in-service training courses are of main requisites for providing better health services to the community. Based on this, in the present work, we are looking for the identification and prioritization of the training need of intensive care nurses in the Zabol University of Medical Sciences' hospitals.

MATERIALS AND METHODS

As a cross-sectional, descriptive study, including two phases of identification and prioritization of training needs of ICU nurses, it was conducted by a close-ended researcher-made questionnaire for collecting the data on training needs from the viewpoint nursing officials, supervisors, and head nurses of the ICU wards in the first phase and a multiple-choice scientific test plus a checklist for measuring the knowledge and skill of the nurses in the ICU in the second phase. In both phases, census method was used for collecting the data. The validity and reliability of data-gathering tools, mentioned above, were tested and verified before gathering data. Data were analyzed with the descriptive statistics.

RESULTS

The results indicated that ventilator setting according to arterial blood gas sampling and interpretation (77.81), cardiac monitoring, detecting dysrhythmia and taking immediate intervention (73.04), ventilator setting according to patient's respiratory status (68.61), airway management, oxygenation and intubation (64.39), and adults cardiopulmonary resuscitation (61.77) were the high-priority training needs of the nurses successively.

CONCLUSION

To improve the quality of training programs and upgrading the knowledge, skill, and attitude of nurses working at ICU, the significance and the weight of each training titles should be determined according to the standards and the continuous in-service training plan along with nurses' training needs and duties.

Palliative Care Referrals in Cardiac Disease

OBJECTIVES

With evidence of benefits of pediatric palliative care (PPC) integration, we sought to characterize subspecialty PPC referral patterns and end of life (EOL) care in pediatric advanced heart disease (AHD).

METHODS

In this retrospective cohort study, we compared inpatient pediatric (<21 years) deaths due to AHD in 2 separate 3-year epochs: 2007-2009 (early) and 2015-2018 (late). Demographics, disease burden, medical interventions, mode of death, and hospital charges were evaluated for temporal changes and PPC influence.

RESULTS

Of 3409 early-epoch admissions, there were 110 deaths; the late epoch had 99 deaths in 4032 admissions. In the early epoch, 45 patients (1.3% admissions, 17% deaths) were referred for PPC, compared with 146 late-epoch patients (3.6% admissions, 58% deaths). Most deaths (186 [89%]) occurred in the cardiac ICU after discontinuation of life-sustaining therapy (138 [66%]). Medical therapies included ventilation (189 [90%]), inotropes (184 [88%]), cardiopulmonary resuscitation (68 [33%]), or mechanical circulatory support (67 [32%]), with no temporal difference observed. PPC involvement was associated with decreased mechanical circulatory support, ventilation, inotropes, or cardiopulmonary resuscitation at EOL, and children were more likely to be awake and be receiving enteral feeds. PPC involvement increased advance care planning, with lower hospital charges on day of death and 7 days before (respective differences $5058 [P = .02] and $25 634 [P = .02]).

CONCLUSIONS

Pediatric AHD deaths are associated with high medical intensity; however, children with PPC consultation experienced substantially less invasive interventions at EOL. Further study is warranted to explore these findings and how palliative care principles can be better integrated into care.

Palliative care in adult intensive care units: A nationwide survey

BACKGROUND

There are no data on the provision of palliative nursing care in Egyptian adult intensive care units (ICUs). The Palliative and End-Of-Life (PEOL) Care Index is reliable and content valid; however, its construct and criterion validities have not been examined.

AIMS AND OBJECTIVES

First, to assess palliative care education, practice, and perceived competence among adult ICU nurses in Egypt. Second, to explore factors related to palliative care nursing practice and perceived competence. Third, to assess the construct and criterion validities of the PEOL Care Index.

DESIGN

A cross-sectional survey.

METHODS

Nurse managers and staff nurses in 33 adult ICUs completed self-administered questionnaires. The questionnaires assessed nurses' palliative care practice and perceived competence. A multilevel regression analysis was used to determine the best predictors of palliative care practice and perceived competence. Theory evidence construct validity and predictive criterion validity of the PEOL Care Index were examined.

RESULTS

Thirty-three nurse managers and 403 staff nurses participated in the study-response rate = 100% and 72.5%, respectively. On a 0-100 scale, the mean scores of undergraduate education, practice, and perceived competence were 54.0 ± 18.7, 49.7 ± 18.1, and 54.5 ± 17.0, respectively. Palliative care practice was significantly related to receiving in-service training on palliative care or end-of-life care (regression coefficients: 3.39), higher job satisfaction (0.97), and higher organizational support (1.85). Palliative care perceived competence was significantly related to older nurses' age (0.20), higher job satisfaction (0.97), and higher palliative care undergraduate education (0.63).

CONCLUSIONS

Palliative care education, practice, and perceived competence among adult ICU nurses in Egypt are inadequate, especially in terms of spiritual and cultural care. The PEOL Care Index is construct and criterion valid.

RELEVANCE TO CLINICAL PRACTICE

Palliative care education should begin in nursing schools and extend through clinical in-services. Guidelines should be developed to maximize staff collaboration and the utilization of chaplains in ICUs.

Psychometric properties of the Chinese version of the End-of-Life Decision-Making and Staff Stress Questionnaire

Background/objective

The goal of this study is to establish a Chinese version of the End-of-Life Decision Making and Associated Staff Stress Questionnaire to assess its reliability and validity.

Method

A sample of 119 Intensive Care Unit physicians and 485 nurses in China completed the questionnaire, along with questionnaires assessing motional exhaustion subscale, Stress Overload Scale, and other variables associated with end-of-life decision.

Results

Seven factors obtained via exploratory factor analysis could explain 70.61% of the total variance. Confirmatory factor analysis demonstrated an acceptable model fit with Root Mean Square Error of Approximation (RMSEA) being .078 and Standardized Root Mean Square Residual (SRMR) being .066. Validity evidence based on relationships with other variables was provided by positive or negative correlations between the questionnaire subscales and emotional exhaustion, stress overload, and other variables associated with end-of-life decision. The average content validity index was .96. The Cronbach’s α and test–retest reliability was outstanding.

Conclusions

The Chinese version of the End-of-Life Decision Making and Associated Staff Stress Questionnaire is a reliable and valid instrument for measuring the facilitators and hinders to facilitate the end-of-life decision-making, communication and the associated pressure perceived by relevant Intensive Care Unit medical staff among the Chinese population.

Interactions Between Intensive Care and Palliative Care Are Influenced by Training, Professionals' Perceptions and Institutional Barriers

BACKGROUND

There is growing interest in the use of a Palliative care approach in Intensive care. However, it tends to remain inconsistent, infrequent or non-existent, as does its acceptance by intensive care physicians. This study sought to explore the perceptions, level of knowledge, perceived barriers, and practices of physicians regarding palliative care practices (PC) in Intensive Care Units (ICU).

METHODS

Descriptive-correlational study. Participating physicians working in ICU in Colombia (n = 101) completed an ad hoc questionnaire that included subscales of perceptions, knowledge, perceived barriers, and PC practices in ICU. A Structural Equation Model (PLS-SEM) was used to examine the reciprocal relationships between the measured variables and those that could predict interaction practices between the 2 specialties.

RESULTS

First, results from the measurement model to examine the validity and reliability of the latent variables found (PC training, favorable perceptions about PC, institutional barriers, and ICU-PC interaction practices) and their indicators were obtained. Second, the structural model found that, a greater number of hours of PC training, a favorable perception of PC and a lower perception of institutional barriers are related to greater interaction between PC and ICU, particularly when emotional or family problems are detected.

CONCLUSIONS

PC-ICU interactions are influenced by training, a positive perception of PC and less perceived institutional barriers. An integrated ICU-PC model that strengthens the PC training of those who work in ICU and provides clearer guidelines for interaction practices, may help overcome perceived barriers and improve the perception of the potential impact of PC.

Feasibility and Acceptability of a Palliative Approach Screening Tool in the Intensive Care Unit

BACKGROUND

Identifying critically ill patients who have unmet needs for palliative care is the first step in integrating the palliative approach for patients and their families into intensive care units.

OBJECTIVE

To explore how palliative care is addressed in an intensive care unit and to develop and test a screening tool for unmet needs that may be met through the palliative approach.

METHODS

A mixed-methods study was conducted in the intensive care unit of a tertiary care hospital to explore the palliative approach. Focus groups and a survey were used to identify items for the screening tool. After pilot testing of the tool, interviews were conducted to refine the content.

RESULTS

The first focus group (14 participants) revealed participants' frustration with unclear communication and a desire for better collaboration among health care team members regarding patients with serious life-limiting illnesses and their families. The survey (response rate: 20%; 30 of 150) showed clinicians' preference for items that identify specific needs rather than diagnoses. The second focus group (8 participants) yielded strategies to operationalize the tool for all patients in the intensive care unit. After 2 separate pilot testing cycles, bedside nurses noted that use of the screening tool prompted earlier discussions and broader assessments of what is meaningful to patients and their families.

CONCLUSION

Development of a screening tool for unmet palliative care needs among intensive care unit patients is feasible and acceptable and may help to systematically integrate the palliative approach into routine care for critically ill patients.

Grave new world: The conspiracy of silence surrounding non-voluntary euthanasia

The scholarship of euthanasia indicates that in most cases, to date, non-voluntary euthanasia has been studied where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that non-voluntary euthanasia is pervasive in these countries. The research is aimed at answering two questions: (1) What are the common death hastening methods? (2) Is the acceptance of active non-voluntary euthanasia related to the legal status of euthanasia? A qualitative study was conducted in ICUs with 15 nurses. All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause death. Therefore, doctors who conducted NVE did it by themselves. The present study provides evidence of the phenomenon of illegal non-voluntary euthanasia as a routine practice by physicians in palliative care units in Israel. Interviews with 15 nurses employed in these units shed light on the means and methods used by these doctors to hasten terminal patients' death. We conclude that Nurses in various end-of-life care units persist in preserving their professional integrity and refuse to obey doctors' instructions for non-voluntary euthanasia. The slippery slope argument has been refuted in this context.

Integration of Pediatric Palliative Care Into Cardiac Intensive Care: A Champion-Based Model

Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and (3) developing and implementing quality improvement initiatives and CICU-specific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.

Palliative Care Planner: A Pilot Study to Evaluate Acceptability and Usability of an Electronic Health Records System-integrated, Needs-targeted App Platform

RATIONALE

The quality and patient-centeredness of intensive care unit (ICU)-based palliative care delivery is highly variable.

OBJECTIVE

To develop and pilot an app platform for clinicians and ICU patients and their family members that enhances the delivery of needs-targeted palliative care.

METHODS

In the development phase of the study, we developed an electronic health record (EHR) system-integrated mobile web app system prototype, PCplanner (Palliative Care Planner). PCplanner screens the EHR for ICU patients meeting any of five prompts (triggers) for palliative care consultation, allows families to report their unmet palliative care needs, and alerts clinicians to these needs. The evaluation phase included a prospective before/after study conducted at a large academic medical center. Two control populations were enrolled in the before period to serve as context for the intervention. First, 25 ICU patients who received palliative care consults served as patient-level controls. Second, 49 family members of ICU patients who received mechanical ventilation for at least 48 hours served as family-level controls. Afterward, 14 patients, 18 family members, and 10 clinicians participated in the intervention evaluation period. Family member outcomes measured at baseline and 4 days later included acceptability (Client Satisfaction Questionnaire [CSQ]), usability (Systems Usability Scale [SUS]), and palliative care needs, assessed with the adapted needs of social nature, existential concerns, symptoms, and therapeutic interaction (NEST) scale; the Patient-Centeredness of Care Scale (PCCS); and the Perceived Stress Scale (PSS). Patient outcomes included frequency of goal concordant treatment, hospital length of stay, and discharge disposition.

RESULTS

Family members reported high PCplanner acceptability (mean CSQ, 14.1 [SD, 1.4]) and usability (mean SUS, 21.1 [SD, 1.7]). PCplanner family member recipients experienced a 12.7-unit reduction in NEST score compared with a 3.4-unit increase among controls (P = 0.002), as well as improved mean scores on the PCCS (6.6 [SD, 5.8]) and the PSS (-0.8 [SD, 1.9]). The frequency of goal-concordant treatment increased over the course of the intervention (n = 14 [SD, 79%] vs. n = 18 [SD, 100%]). Compared with palliative care controls, intervention patients received palliative care consultation sooner (3.9 [SD, 2.7] vs. 6.9 [SD, 7.1] mean days), had a shorter mean hospital length of stay (20.5 [SD, 9.1] vs. 22.3 [SD, 16.0] patient number), and received hospice care more frequently (5 [36%] vs. 5 [20%]), although these differences were not statistically significant.

CONCLUSIONS

PCplanner represents an acceptable, usable, and clinically promising systems-based approach to delivering EHR-triggered, needs-targeted ICU-based palliative care within a standard clinical workflow. A clinical trial in a larger population is needed to evaluate its efficacy.

Nurse-Family Communication During and After Family Meetings in the Intensive Care Unit

PURPOSE

To explore nurse-family communication during and after family meetings.

DESIGN

A cross-sectional study in which 36 family meetings were audio-recorded in two intensive care units in an urban, community hospital.

METHODS

Data were analyzed using conversation analysis, a qualitative method.

FINDINGS

Nurses spoke during 10 (28%) of the family meetings. During the family meetings, nurses mostly self-selected to take a turn by interrupting a physician or family member, finishing their sentences, responding to questions, and, in one instance, asking a question. Nurses were mostly selected as the next speaker to address logistical issues, but were also asked questions. Most of nurses' turns were short and simple, and aimed to provide clarification, reassurance, and information regarding the patient's status. Immediately after the family meetings, nurses offered to provide family members clarification or gestures of empathy, but these offers were met with resistance from family members.

CONCLUSIONS

Despite calls for nurses to take a more active role in surrogate decision making, nurses minimally participated during family meetings. Empowering nurses to share their expertise is one solution for nurses to contribute during family meetings. Further research is needed to explore nurse-family bedside interactions to improve our understanding of the nurse's role in the surrogate decision-making process.

CLINICAL RELEVANCE

Findings from this exploration of nurse communication during and after family meetings can inform how nurses may best assist families during surrogate decision making in the intensive care unit.

Integrating Palliative Care Into the ICU: From Core Competency to Consultative Expertise

OBJECTIVES

To propose a model describing levels of integration of palliative care into the care of ICU patients.

DATA SOURCES

Literature review and author opinion.

CONCLUSIONS

All critical care team members should demonstrate and foster their core competencies in caring for patients with complex illness and uncertain prognosis, including at the end of life. We describe these core competencies of the ICU team member as "primary" palliative care skills. Some ICU team members will have special expertise in end-of-life care or symptom management and decision-making support and will serve as local experts within the ICU team as a resource to other team members. We call this skillset "secondary" palliative care. Some patients will benefit from the full range of expertise provided by a separate consulting team, with additional training, focused on caring for patients with palliative care needs across the full spectrum of patient locations within a health system. We term the skillset provided by such outside consultants "tertiary" palliative care. Solutions for meeting patients' palliative care needs will be unique within each system and individual institution, depending on available resources, history, and structures in place. Providers from multiple professions will usually contribute to meeting patient needs.

New concepts in palliative care in the intensive care unit

Some patients admitted to an intensive care unit may face a terminal illness situation, which usually leads to death. Knowledge of palliative care is strongly recommended for the health care providers who are taking care of these patients. In many situations, the patients should be evaluated daily as the introduction of further treatments may not be beneficial to them. The discussions among health team members that are related to prognosis and the goals of care should be carefully evaluated in collaboration with the patients and their families. The adoption of protocols related to end-of-life patients in the intensive care unit is fundamental. A multidisciplinary team is important for determining whether the withdrawal or withholding of advanced care is required. In addition, patients and families should be informed that palliative care involves the best possible care for that specific situation, as well as respect for their wishes and the consideration of social and spiritual backgrounds. Thus, the aim of this review is to present palliative care as a reasonable option to support the intensive care unit team in assisting terminally ill patients. Updates regarding diet, mechanical ventilation, and dialysis in these patients will be presented. Additionally, the hospice-model philosophy as an alternative to the intensive care unit/hospital environment will be discussed.

Ethical decision making in pain management: a conceptual framework

Introduction

The practice and study of pain management pose myriad ethical challenges. There is a consensual opinion that adequate management of pain is a medical obligation rooted in classical Greek practice. However, there is evidence that patients often suffer from uncontrolled and unnecessary pain. This is inconsistent with the leges artis, and its practical implications merit a bioethical analysis. Several factors have been identified as causes of uncontrolled and unnecessary pain, which deprive patients from receiving appropriate treatments that theoretically they have the right to access. Important factors include (with considerable regional, financial, and cultural differences) the following: 1) failure to identify pain as a priority in patient care; 2) failure to establish an adequate physician-patient relationship; 3) insufficient knowledge regarding adequate prescription of analgesics; 4) conflicting notions associated with drug-induced risk of tolerance and fear of addiction; 5) concerns regarding "last-ditch" treatments of severe pain; and 6) failure to be accountable and equitable.

Objective

The aim of this article was to establish that bioethics can serve as a framework for addressing these challenging issues and, from theoretical to practical approaches, bioethical reflection can contextualize the problem of unrelieved pain.

Methods

This article is organized into three parts. First, we illustrate that pain management and its undertreatment are indeed ethical issues. The second part describes possible ethical frameworks that can be combined and integrated to better define the ethical issues in pain management. Finally, we discuss possible directions forward to improve ethical decision making in pain management.

Discussion

We argue that 1) the treatment of pain is an ethical obligation, 2) health science schools, especially medical training institutions, have the duty to teach pain management in a comprehensive fashion, and 3) regulatory measures, which prevent patients from access to opioid treatment as indicated in their cases, are unethical and should be reconsidered.

Conclusion

Developing an ethical framework for pain management will result in enhanced quality of care, linking the epistemic domains of pain management to their anthropological foundations, thereby making them ethically sound.

Palliative and End-of-Life Care Education Needs of Nurses Across Inpatient Care Settings

BACKGROUND

Educating nurses about palliative and end-of-life (EOL) care is a high priority in health care settings. The purpose of this study was to assess nurses' perceived competency regarding the provision of palliative and EOL care to hospitalized patients.

METHOD

This study surveyed nurses from 25 pediatric and adult acute and intensive care units (ICU; N = 583) Quantitative data analysis was descriptive and correlational. Qualitative data analysis identified themes of participant concerns.

RESULTS

Data analysis revealed that perceived competency in palliative and EOL care is significantly higher in the ICU nurses (p <.0001). Mean scores were significantly higher when nurses had more than 10 years of experience (p <.0001). Open-ended responses indicated concerns regarding improved communication behaviors, decision making, and facilitation of continuity of care.

CONCLUSION

The results provide guidance for development of palliative and EOL care nursing education programs tailored to address specific unit needs according to staff characteristics, patient population focus of care, and acuity level of care. J Contin Educ Nurs. 2017;48(7):329-336.

End-of-Life Decision Support in the ICU: Where Are We Now?

Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.

Medical Record Quality Assessments of Palliative Care for Intensive Care Unit Patients. Do They Match the Perspectives of Nurses and Families?

RATIONALE

To understand how well palliative care is provided in the intensive care unit (ICU) and to direct improvements, measurement of the quality of care delivered is requisite.

OBJECTIVES

To measure the quality of palliative care delivered in the ICU, using chart review-derived process quality measures of palliative care in critically ill patients, and to compare these measures with family and nursing perspectives on the quality of care provided.

METHODS

We developed and operationalized a comprehensive quality evaluation measure set from previously endorsed palliative care measure statements, using a rigorous multidisciplinary Delphi process focused on optimizing the validity and feasibility of chart review-derived metrics. Fourteen process measures assessed the quality of care delivered across established domains of palliative care for the ICU. We assessed the quality of care for ICU patients with ICU length of stay exceeding 2 days from three perspectives: medical record reviews, family satisfaction reports, and nurse ratings from those providing care in the ICU.

MEASUREMENTS AND MAIN RESULTS

We evaluated the care over a 7-month period of 150 patients (mean age, 63.9 yr [SD 13.4], average ICU length of stay, 7.5 d [SD 7.2]). Overall, ICU patients received 53.1% of recommended palliative care. The Family Satisfaction with Care in the Intensive Care Unit total scores from 136 family members (response rate, 91%) were high, 85.7 (SE 2.0) and 86.0 (SE 1.6), at the two sites but not correlated to measured quality delivered. Nurses rated the quality of care higher than medical record review (mean, 77.3% [SD 13.4]; n = 135) and similarly correlation with chart based process measures was poor.

CONCLUSIONS

Delivering high-quality palliative care in the ICU requires assessing key patient-centered domains. However, assessments from different perspectives do not always agree with technical quality of care as measured through chart-based metrics. We found deficits across seven domains of technical quality that were not correlated with either nurse or family ratings. Despite care gaps, families were generally satisfied with the care delivered. We conclude that each measurement perspective provides an independent view that can guide quality improvement and innovation work as well as subsequent research.

Palliative Care Communication in the ICU: Implications for an Oncology-Critical Care Nursing Partnership

OBJECTIVES

To describe the development, launch, implementation, and outcomes of a unique multisite collaborative (ie, IMPACT-ICU [Integrating Multidisciplinary Palliative Care into the ICU]) to teach ICU nurses communication skills specific to palliative care. To identify options for collaboration between oncology and critical care nurses when integrating palliation into nursing care planning.

DATA SOURCES

Published literature and collective experiences of the authors in the provision of onco-critical-palliative care.

CONCLUSION

While critical care nurses were the initial focus of education, oncology, telemetry, step-down, and medical-surgical nurses within five university medical centers subsequently participated in this learning collaborative. Participants reported enhanced confidence in communicating with patients, families, and physicians, offering emotional support and involvement in family meetings.

IMPLICATIONS FOR NURSING PRACTICE

Communication education is a vital yet missing element of undergraduate nursing education. Programs should be offered in the work setting to address this gap in needed nurse competency, particularly within the context of onco-critical-palliative care.

Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs

OBJECTIVE

Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment.

DESIGN

Mixed-methods study.

SETTING

Medical and surgical ICUs at three large academic hospitals.

PARTICIPANTS

Three hundred three nurses, intensivists, and advanced practice providers.

MEASUREMENTS AND MAIN RESULTS

Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships.

CONCLUSIONS

Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.

Nurses' Interest in Independently Initiating End-of-Life Conversations and Palliative Care Consultations in a Suburban, Community Hospital

BACKGROUND

Patients who receive early palliative care consults have clinical courses and outcomes more consistent with their goals. Nurses have been shown to be advocates for early palliative care involvement and are able to lead advanced care planning discussions.

OBJECTIVE

The purpose of this study was to assess whether after a brief educational session, nurses at a suburban, community hospital could demonstrate knowledge of palliative care principles, would want to independently initiate end-of-life conversations with patients and families, and would want to place specialty palliative care consults.

DESIGN

Four 1 hour presentations were made at 4 nursing leadership council meetings from November through December 2015. Anonymous pre- and post-presentation surveys were distributed and collected in person. Setting/Participant: Nonprofit, suburban, community hospital in Maryland. Participants were full-time or part-time hospital employees participating in a nursing leadership council who attended the presentation.

MEASUREMENTS

We compared responses from pre- and post-presentation surveys.

RESULTS

Fifty nurses (19 departments) completed pre-presentation surveys (100% response rate) and 49 nurses completed post-presentation surveys (98% response rate). The average score on 7 index questions increased from 71% to 90%. After the presentations, 86% strongly agreed or agreed that nurses should be able to independently order a palliative care consult and 88% strongly agreed or agreed with feeling comfortable initiating an end-of-life conversation.

CONCLUSION

Brief educational sessions can teach palliative care principles to nurses. Most participants of the study would want to be able to directly consult palliative care and would feel comfortable initiating end-of-life conversations after this educational session.

Clinical Nurse Participation at Family Conferences in the Pediatric Intensive Care Unit

BACKGROUND

Clinical nurses attend family conferences in the intensive care unit, but their role during these meetings is not yet fully understood.

OBJECTIVES

To assess perceived and observed contributions of the clinical nurse during family conferences.

METHODS

Prospective cross-sectional survey and review of 40 audio-recorded family conferences conducted in the 44-bed pediatric intensive care unit of an urban pediatric hospital.

RESULTS

Survey responses from 47 nurses were examined. Most nurses thought it important to attend family conferences, but identified workload as a barrier to attendance. They perceived their roles as gaining firsthand knowledge of the discussion and providing a unique perspective regarding patient care, emotional support, and advocacy. Audio recordings revealed that bedside nurses attended 20 (50%) of 40 family conferences and spoke in 5 (25%) of the 20. Nurses verbally contributed 4.6% to the overall speech at the family conference, mostly providing information on patient care.

CONCLUSIONS

The clinical nurse is often absent or silent during family conferences in the intensive care unit, despite the important roles they want to play in these settings. Strategies to improve both the physical and verbal participation of clinical nurses during the family conference are suggested, especially in the context of previous research demonstrating the need for more attention in family conferences to social-emotional support and patient advocacy.

Patterns of palliative care service consultation in a sample of critically ill ICU patients at high risk of dying

OBJECTIVE

Describe patterns of palliative care service consultation among a sample of ICU patients at high risk of dying.

BACKGROUND

Patients receiving mechanical ventilation (MV) face threats to comfort, social connectedness and dignity due to pain, heavy sedation and physical restraint. Palliative care consultation services may mitigate poor outcomes.

METHODS

From a dataset of 1440 ICU patients with ≥2 days of MV and ≥12 h of sustained wakefulness, we identified those at high risk of dying and/or who died and assessed patterns of sub-specialty palliative care consultation.

RESULTS

About half (773/1440 [54%]) were at high risk of dying or died, 73 (9.4%) of whom received palliative care consultation. On average, referral occurred after 62% of the ICU stay had elapsed. Primary reason for consult was clarification of goals of care (52/73 [72.2%]).

CONCLUSIONS

Among MV ICU patients at high risk of dying, palliative care service consultation occurs late and infrequently, suggesting a role for earlier palliative care.

Advancing palliative and end-of-life science in cardiorespiratory populations: The contributions of nursing science

Nursing science has a critical role to inform practice, promote health, and improve the lives of individuals across the lifespan who face the challenges of advanced cardiorespiratory disease. Since 1997, the National Institute of Nursing Research (NINR) has focused attention on the importance of palliative and end-of-life care for advanced heart failure and advanced pulmonary disease through the publication of multiple funding opportunity announcements and by supporting a cadre of nurse scientists that will continue to address new priorities and future directions for advancing palliative and end-of-life science in cardiorespiratory populations.

Mismatch between physicians and family members views on communications about patients with chronic incurable diseases receiving care in critical and intensive care settings in Georgia: a quantitative observational survey

BACKGROUND

Physicians working in critical and intensive care settings encounter death of chronic incurable patients on a daily basis; however they have scant skills on how to communicate with the patients and their family members. The aim of the present survey is to examine communication of critical and intensive care physicians with patients' family members receiving treatment due to chronic incurable diseases/conditions and to compare the views of families with physicians working in critical and intensive care settings.

METHODS

The survey was conducted in four cities of Georgia (Tbilisi, Kutaisi, Batumi and Telavi) in 2014. Physicians working in critical and intensive care settings and family members were asked to fill in separate questionnaires, covering various aspects of communication including patients' prognosis, ways of death occurrence, treatment plans and religion. Participants ranked their responses on a scale ranging from "0" to "10", where "0" represented "never" and "10"-"always". After data collection, responses were recoded into three categories: 0-3 = never/rarely, 4-7 = somewhat and 8-10 = often/always. Differences were tested using Pearson's chi-square or Fisher's exact test as appropriate. P value of < 0.05 was considered as significant.

RESULTS

Sixty-five physicians and 59 patients' family members participated in this cross-sectional study. Majority of their responses was statistically significantly different. Only one quarter (23.7 %) of family members of patients receiving medical aid in critical and intensive care settings were satisfied with the communication level. In contrast, 78.5 % of physicians considered their communication with families as positive (p < 0.0001).

CONCLUSIONS

The survey revealed the mismatch between the views on communication of critical and intensive care settings physicians and family members of the patients with chronic incurable diseases receiving care in critical and intensive care settings. In order to provide the best care for chronic incurable patients and their family members, physicians working in critical and intensive care settings must have relevant clinical knowledge and ability to provide effective communication. Present results reflect important potential targets for educational interventions including critical and intensive care physicians training through online modules.

ICU Bedside Nurses' Involvement in Palliative Care Communication: A Multicenter Survey

CONTEXT

Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses.

OBJECTIVES

To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication.

METHODS

A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S.

RESULTS

The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%).

CONCLUSION

ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions.

A multicenter study of key stakeholders' perspectives on communicating with surrogates about prognosis in intensive care units

RATIONALE

Surrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit (ICU) clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.

OBJECTIVE

To determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.

METHODS

This was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.

MEASUREMENTS AND MAIN RESULTS

There was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: (1) In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. (2) Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. (3) Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. (4) Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.

CONCLUSIONS

Family members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs.

Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care

OBJECTIVES

To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill.

DATA SOURCES

A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury."

DATA EXTRACTION AND SYNTHESIS

We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting.

CONCLUSIONS

Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

End-of-life decisions in intensive care medicine-shared decision-making and intensive care unit length of stay

BACKGROUND

Most deaths on the intensive care unit (ICU) occur after end-of-life decisions (EOLD) have been made. During the decision-making process, responsibility is often shared within the caregiver team and with the patients' surrogates. The intensive care unit length of stay (ICU-LOS) of surgical ICU-patients depends on the primary illness as well as on the past medical history. Whether an increasing ICU-LOS affects the process of EOLD making is unknown.

METHODS

A retrospective analysis was conducted on all deceased patients (n = 303) in a 22-bed surgical ICU of a German university medical center. Patient characteristics were compared between surgical patients with an ICU-LOS up to 1 week and those with an ICU-LOS of more than 7 days.

RESULTS

Deceased patients with a long ICU-LOS received more often an EOLD (83.2% vs. 63.6%, p = 0.001). Groups did not differ in urgency of admission. Attending intensivists participated in every EOLD. Participation of surgeons was significantly higher in patients with a short ICU-LOS (24.1%, p = 0.003), whereas nurses and the patients' surrogates were involved more frequently in patients with a long ICU-LOS (18.8%, p = 0.021 and 18.9%, p = 0.018, respectively).

CONCLUSION

EOLDs of surgical ICU-patients are associated with the ICU-LOS. Reversal of the primary illness leads the early ICU course, while in prolonged ICU-LOS, the patients' predicted will and the expected post-ICU-quality of life gain interest. Nurses and the patients' surrogates participate more frequently in EOLDs with prolonged ICU-LOS. To improve EOLD making on surgical ICUs, the ICU-LOS associated participation of the different decision makers needs further prospective analysis.

Destination to nowhere: a new look at aggressive treatment for heart failure--a case study

Approximately 5.7 million people in the United States experience heart failure, and about 670 000 new cases are diagnosed annually. Patients who are ineligible for heart transplant may benefit from a left ventricular assist device. These devices have provided patients with an increased life span, but eventually patients die of the underlying heart disease. This case study illustrates the appropriate use of palliative care teams to address preparedness planning and help decrease moral distress among nursing staff. (Critical Care Nurse. 2014; 34[2]:47-56).

Nurses' perspectives: hospitalized older patients and end-of-life decision-making

AIMS

To explore pressing issues identified by nurses caring for older patients in US NICHE (Nurses Improving Care for the Healthsystem Elders) hospitals, regarding palliative care and end-of-life (EOL) decision-making. Objectives are to (1) identify the most pressing palliative care and EOL decision-making issues and strategies to address them and (2) identify the association of nursing demographics (age, gender, race, education and experience), institutional/unit characteristics and these issues.

BACKGROUND

Critical care nurses have an integral role in supporting older patients and families faced with palliative care and EOL decision-making issues. Despite national imperatives to improve the quality of palliative care, patients continue to experience uncontrolled pain, inadequate communication, disregard of their wishes and life prolonging interventions. These contribute to increased hospitalizations and costs. Understanding the prevalent issues is needed to address patient needs at the end-of-life.

DESIGN

It is a mixed method study.

METHODS

A secondary analysis of the NICHE Geriatric Institutional Assessment Profile (GIAP) database (collected 1/08-9/13) was conducted using the sample of Critical Care RNs who provided comments regarding palliative care and EOL decision-making. Qualitative data were analyzed using Dedoose software. Data clusters and patterns of co-occurring codes were explored through an iterative analysis process. Themes were examined across nurse demographics, institutional and unit characteristics.

RESULTS

Comments specifically addressing issues regarding EOL decision-making were provided by 393 critical care nurses from 156 hospitals (x‾ age = 42·3 years, 51% BSN degree). Overarching theme was discordance in goals of care (prolonging life versus quality of life), ineffective physician-patient-family communication, lack of time and unrealistic expectations.

CONCLUSIONS

Nurses' descriptions highlight the need for increased communication, staff education and availability of palliative care services.

RELEVANCE TO PRACTICE

Palliative care and EOL decision-making will remain a nursing priority as people age and require increased care.

Nursing practice of palliative care with critically ill older adults

Palliative care is emerging as an alternative care paradigm for critically ill older patients in the critical care setting. Critical care nurses are well positioned to take on a leadership role in reconceptualizing care in the critical care unit, and creating the space and opportunity for palliative care. This article provides information on the practice of palliative care with critically ill older adults along with evidence-based content and resources, allowing critical care nurses to advocate for palliative care in their own work environments accompanied by the necessary resources that will support efficient implementation.

End-of-life care in the intensive care unit: a patient-based questionnaire of intensive care unit staff perception and relatives' psychological response

BACKGROUND

Communication is a hallmark of end-of-life care in the intensive care unit. It may influence the impact of end-of-life care on patients' relatives. We aimed to assess end-of-life care and communication from the perspective of intensive care unit staff and relate it to relatives' psychological symptoms.

DESIGN

Prospective observational study based on consecutive patients with severe sepsis receiving end-of-life care; trial registration NCT01247792.

SETTING/PARTICIPANTS

Four interdisciplinary intensive care units of a German University hospital. Responsible health personnel (attendings, residents and nurses) were questioned on the day of the first end-of-life decision (to withdraw or withhold life-supporting therapies) and after patients had died or were discharged. Relatives were interviewed by phone after 90 days.

RESULTS

Overall, 145 patients, 610 caregiver responses (92% response) and 84 relative interviews (70% response) were analysed. Most (86%) end-of-life decisions were initiated by attendings and only 2% by nurses; 41% of nurses did not know enough about end-of-life decisions to communicate with relatives. Discomfort with end-of-life decisions was low. Relatives reported high satisfaction with decision-making and care, 87% thought their degree of involvement had been just right. However, 51%, 48% or 33% of relatives had symptoms of post-traumatic stress disorder, anxiety or depression, respectively. Predictors for depression and post-traumatic stress disorder were patient age and relatives' gender. Relatives' satisfaction with medical care and communication predicted less anxiety (p = 0.025).

CONCLUSION

Communication should be improved within the intensive care unit caregiver team to strengthen the involvement of nurses in end-of-life care. Improved communication between caregivers and the family might lessen relatives' long-term anxiety.

Improving End-of-Life Care Prognostic Discussions

Research has validated the desire of patients and families for ongoing prognostic information; however, few conversations occur before patients reach the advanced stages of their disease trajectory. Physician hesitance and delay in discussing unfavorable prognoses deny patients and families optimal time to prepare for critical decision making. Advanced practice registered nurses can play a crucial, complementary role with the critical care interdisciplinary team to implement strategies to improve communication about prognosis and end of life with patients and families. Clinicians should discuss deterioration in disease-specific characteristics and changes (decline) in functional status. Functional status can serve as an accurate guide for forecasting prognosis, particularly in patients with heart failure, stroke, chronic lung disease, and end-stage renal disease. This article provides an overview of effective intensive care unit prognostic systems and discusses barriers and opportunities for nurses to use evidence-based knowledge related to disease trajectory and prognosis to improve communication and the quality of palliative and end-of-life care for patients.

Palliative care in the intensive care unit

Most patients who receive terminal care in the intensive care setting die after withdrawing or limiting of life-sustaining measures provided in the intensive care setting. The integration of palliative care into the intensive care unit (ICU) provides care, comfort, and planning for patients, families, and the medical staff to help decrease the emotional, spiritual, and psychological stress of a patient's death. Quality measures for palliative care in the ICU are discussed along with case studies to demonstrate how this integration is beneficial for a patient and family. Integrating palliative care into the ICU is also examined in regards to the complex adaptive system.

The changing role of palliative care in the ICU

OBJECTIVES

Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.

DATA SOURCES

We searched the MEDLINE database from inception through January 2014. We also searched the Reference Library of The Improving Palliative Care in the ICU Project website sponsored by the National Institutes of Health and the Center to Advance Palliative Care, which is updated monthly. We hand-searched reference lists and author files.

STUDY SELECTION

Selected studies included all English-language articles concerning adult patients using the search terms 'intensive care' or 'critical care' with 'palliative care,' 'supportive care,' 'end-of-life care,' or 'ethics.'

DATA EXTRACTION

: After examination of peer-reviewed original scientific articles, consensus statements, guidelines, and reviews resulting from our literature search, we made final selections based on author consensus.

DATA SYNTHESIS

Existing evidence is organized to address: 1) opportunities to alleviate physical and emotional symptoms, improve communication, and provide support for patients and families; 2) models and specific interventions for improving ICU palliative care; 3) available resources for ICU palliative care improvement; and 4) ongoing challenges and targets for future research. Key domains of ICU palliative care have been defined and operationalized as measures of quality. There is increasing recognition that effective integration of palliative care during acute and chronic critical illness may help patients and families face challenges after discharge from intensive care.

CONCLUSIONS

Palliative care is increasingly accepted as an essential component of comprehensive care for critically ill patients, regardless of diagnosis or prognosis. A variety of strategies to improve ICU palliative care appear to be effective, and resources including technical assistance and tools are available to support improvement efforts. As the longer-term impact of intensive care on those surviving acute critical illness is increasingly documented, palliative care can help prepare and support patients and families for challenges after ICU discharge. Further research is needed to inform efforts to integrate palliative care with intensive care more effectively and efficiently in and after the ICU and to document improvement using valid and responsive outcome measures.

Prerequisites for sustainable care improvement using the reflective team as a work model

Several work models for care improvement have been developed in order to meet the requirement for evidence-based care. This study examines a work model for reflection, entitled the reflective team (RT). The main idea behind RTs is that caring skills exist among those who work closest to the patients. The team leader (RTL) encourages sustainable care improvement, rooted in research and proven experience, by using a lifeworld perspective to stimulate further reflection and a developmental process leading to research-based caring actions within the team. In order to maintain focus, it is important that the RTL has a clear idea of what sustainable care improvement means, and what the prerequisites are for such improvement. The aim of the present study is, therefore, to explore the prerequisites for improving sustainable care, seeking to answer how RTLs perceive these and use RTs for concrete planning. Nine RTLs were interviewed, and their statements were phenomenographically analysed. The analysis revealed three separate qualitative categories, which describe personal, interpersonal, and structural aspects of the prerequisites. In the discussion, these categories are compared with previous research on reflection, and the conclusion is reached that the optimal conditions for RTs to work, when focussed on sustainable care improvement, occur when the various aspects of the prerequisites are intertwined and become a natural part of the reflective work.