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Jensen HI, Halvorsen K, Jerpseth H, Fridh I, Lind R. Practice Recommendations for End-of-Life Care in the Intensive Care Unit. Crit Care Nurse 2021; 40:14-22. [PMID: 32476029 DOI: 10.4037/ccn2020834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices. CLINICAL RELEVANCE Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members. PURPOSE OF PAPER To provide recommendations for high-quality end-of-life care for patients and family members. CONTENT COVERED This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.
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Affiliation(s)
- Hanne Irene Jensen
- Hanne Irene Jensen is an associate professor at the Department of Anaesthesiology and Intensive Care, Vejle and Middelfart Hospitals, Vejle, Denmark, and the University of Southern Denmark, Odense, Denmark
| | - Kristin Halvorsen
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Heidi Jerpseth
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Isabell Fridh
- Isabell Fridh is an associate professor at the Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden
| | - Ranveig Lind
- Ranveig Lind is an associate professor at UiT, the Arctic University of Norway, and a research nurse in the intensive care unit at University Hospital of North Norway, Tromsø, Norway
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Kydonaki K, Kean S, Tocher J. Family INvolvement in inTensive care: A qualitative exploration of critically ill patients, their families and critical care nurses (INpuT study). J Clin Nurs 2020; 29:1115-1128. [PMID: 31889366 DOI: 10.1111/jocn.15175] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/03/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To understand the different factors that impact on the involvement of adult family members in the care of critically ill patients from the perspective of patients, families and nurses, with the aim to inform the enactment of a patient- and family-centred care intervention to support the patient-family-nurse partnership in care involvement. BACKGROUND Existing evidence lacks theoretical underpinning and clarity to support enactment of patient- and family-centred care and involvement of families in the care of the critically ill patient. DESIGN Qualitative exploratory design using thematic analysis. METHODS This study was conducted at two adult intensive care units in two tertiary university hospitals in the central belt of Scotland. Between 2013-2014, we conducted semi-structured interviews with critically ill survivors (n = 19) and adult family members (n = 21), and five focus groups with nurses (n = 15) across both settings. Data were digitally recorded, transcribed verbatim, and uploaded in NVivo 10. Data were analysed thematically using a constructivist epistemology. Ethical approval was obtained prior to data collection. Data are reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. RESULTS Family's situational awareness; the perceived self in care partnership; rapport and trust; and personal and family attributes were the main factors that affected family involvement in care. Two key themes were identified as principles to enact patient- and family-centred care in adult intensive care units: "Need for 'Doing family'" and "Negotiations in care involvement." CONCLUSIONS Negotiating involvement in care requires consideration of patients' and family members' values of doing family and the development of a constructive patient-family-nurses' partnership. RELEVANCE TO CLINICAL PRACTICE Future policy and research should consider patients' and family's needs to demonstrate family bonds within a negotiated process in care participation, when developing tools and frameworks to promote patient- and family-centred care in adult intensive care units.
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Affiliation(s)
- Kalliopi Kydonaki
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Susanne Kean
- School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Jennifer Tocher
- School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
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3
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Fridh I, Åkerman E. Family‐centred end‐of‐life care and bereavement services in Swedish intensive care units: A cross‐sectional study. Nurs Crit Care 2019; 25:291-298. [DOI: 10.1111/nicc.12480] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 09/19/2019] [Accepted: 09/24/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Isabell Fridh
- Faculty of Caring Science, Work Life and Social WelfareUniversity of Borås Borås Sweden
- Department of Anesthesiology and Intensive CareSahlgrenska University Hospital Gothenburg Sweden
| | - Eva Åkerman
- Intensive Care Unit, Department of Perioperative Medicine and Intensive CareKarolinska University Hospital Stockholm Sweden
- Division of Nursing, Department of Neurobiology, Care Sciences and SocietyKarolinska Institutet Stockholm Sweden
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4
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Andersson M, Fridh I, Lindahl B. Is it possible to feel at home in a patient room in an intensive care unit? Reflections on environmental aspects in technology‐dense environments. Nurs Inq 2019; 26:e12301. [DOI: 10.1111/nin.12301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 05/09/2019] [Accepted: 05/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Morgan Andersson
- Department of Architecture and Civil Engineering Chalmers University of Technology Gothenburg Sweden
| | - Isabell Fridh
- Faculty of Caring Science, Work Life and Social Welfare University of Borås Borås Sweden
| | - Berit Lindahl
- Faculty of Caring Science, Work Life and Social Welfare University of Borås Borås Sweden
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Zadeh RS, Eshelman P. Palliative Design Meets Palliative Medicine: A Strategic Approach to the Design, Construction, and Operation of Healthcare Facilities to Improve Quality of Life and Reduce Suffering for Patients, Families, and Caregivers. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2019; 12:179-186. [DOI: 10.1177/1937586718820663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A built environment designed to be appropriate for palliative care can make a profound difference for people with life-limiting illnesses. The built environment affects a patient’s quality of life, the management of physical and psychological symptoms, and the quality of social interactions with loved ones and caregivers. This article is informed by the emerging trends in the research and practice in the disciplines of architecture, design, medicine, and nursing. The article is intended to provide a definition of palliative design and invite discussion of its potential impact on patients, families, and caregivers. Our goal is to initiate conversation about palliative design, foster sharing of experiences and feedback among building professionals, and discuss future paths for formal adoption into practice.
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Affiliation(s)
- Rana Sagha Zadeh
- Department of Design and Environmental Analysis, Cornell University, Ithaca, NY, USA
| | - Paul Eshelman
- Department of Design and Environmental Analysis, Cornell University, Ithaca, NY, USA
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Timmins F, Parissopoulos S, Plakas S, Naughton MT, de Vries JMA, Fouka G. Privacy at end of life in ICU: A review of the literature. J Clin Nurs 2018; 27:2274-2284. [DOI: 10.1111/jocn.14279] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Fiona Timmins
- School of Nursing and Midwifery; Trinity College Dublin; Dublin Ireland
| | - Stelios Parissopoulos
- Department of Nursing; School of Health and Welfare Technological Educational Institution (TEI) of Athens; Athens Greece
| | - Sotirios Plakas
- Department of Nursing; School of Health and Welfare Technological Educational Institution (TEI) of Athens; Athens Greece
| | | | - Jan MA de Vries
- School of Nursing and Midwifery; Trinity College Dublin; Dublin Ireland
| | - Georgia Fouka
- Department of Nursing; School of Health and Welfare Technological Educational Institution (TEI) of Athens; Athens Greece
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7
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Listening to How Experienced Nurses Care for the Dying Husband and His Spouse. Dimens Crit Care Nurs 2018; 36:193-201. [PMID: 28375996 DOI: 10.1097/dcc.0000000000000246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Although most nurses in critical care settings provide nursing care for marital couples when 1 of the partners is dying, this is a relatively new area of research. OBJECTIVE The aim of this study is to describe the nature of nursing care provided for marital couples in the critical care unit when the husbands were dying. METHOD A qualitative interpretive description was used to construct this study. Data were collected by conducting semistructured individual interviews with 15 experienced critical care nurses in quiet conference rooms. The initial sample was recruited by invitation, and then followed by the snowball method. Institutional review board approval was obtained at the supporting institution. Interviews were recorded and transcribed to facilitate analysis. Data were analyzed line by line with constant comparison to formulate key ideas and then organized into themes. RESULTS Three themes were identified: (a) experienced nurses support the wife and husband, (b) experienced nurses connect spiritually with the wife and husband, and (c) experienced nurses provide skillful care for the wife and her husband who is dying. These themes form a description of the nature of nursing care needed by novice nurses. Emphasis for novice nurses includes focusing on the uniqueness of the marital couple as the patient, being less task oriented, and being more emotionally sensitive to the needs of the marital dyad. In this study, experienced nurses relay the importance of engaging self with these couples and being present at the end of life. DISCUSSION Future research directions are to explore innovative ways nurses may provide spiritual and emotional support to these marital couples and to measure what care activities the wife deems most beneficial for her and her husband at his end of life.
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Sagha Zadeh R, Eshelman P, Setla J, Kennedy L, Hon E, Basara A. Environmental Design for End-of-Life Care: An Integrative Review on Improving the Quality of Life and Managing Symptoms for Patients in Institutional Settings. J Pain Symptom Manage 2018; 55:1018-1034. [PMID: 28935129 PMCID: PMC5856462 DOI: 10.1016/j.jpainsymman.2017.09.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 12/22/2022]
Abstract
CONTEXT The environment in which end-of-life (EOL) care is delivered can support or detract from the physical, psychological, social, and spiritual needs of patients, their families, and their caretakers. OBJECTIVES This review aims to organize and analyze the existing evidence related to environmental design factors that improve the quality of life and total well-being of people involved in EOL care and to clarify directions for future research. METHODS This integrated literature review synthesized and summarized research evidence from the fields of medicine, environmental psychology, nursing, palliative care, architecture, interior design, and evidence-based design. RESULTS This synthesis analyzed 225 documents, including nine systematic literature reviews, 40 integrative reviews, three randomized controlled trials, 118 empirical research studies, and 55 anecdotal evidence. Of the documents, 192 were peer-reviewed, whereas 33 were not. The key environmental factors shown to affect EOL care were those that improved 1) social interaction, 2) positive distractions, 3) privacy, 4) personalization and creation of a home-like environment, and 5) the ambient environment. Possible design interventions relating to these topics are discussed. Examples include improvement of visibility and line of sight, view of nature, hidden medical equipment, and optimization of light and temperature. CONCLUSION Studies indicate several critical components of the physical environment that can reduce total suffering and improve quality of life for EOL patients, their families, and their caregivers. These factors should be considered when making design decisions for care facilities to improve physical, psychological, social, and spiritual needs at EOL.
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Affiliation(s)
- Rana Sagha Zadeh
- Design and Environmental Analysis, Cornell University, Ithaca, New York, USA.
| | - Paul Eshelman
- Design and Environmental Analysis, Cornell University, Ithaca, New York, USA
| | - Judith Setla
- Department of Medicine Voluntary Faculty, SUNY Upstate Medical University, Syracuse, New York, USA; The Hospice of Central New York, Liverpool, New York, USA
| | - Laura Kennedy
- Design & Environmental Analysis, Cornell University, Portland, Oregon, USA
| | - Emily Hon
- New York Medical College, Valhalla, New York, USA
| | - Aleksa Basara
- Department of Economics, Cornell University, Ithaca, New York, USA
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9
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Relatives' perception of stressors and psychological outcomes – Results from a survey study. J Crit Care 2017; 39:172-177. [DOI: 10.1016/j.jcrc.2017.02.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/18/2017] [Accepted: 02/24/2017] [Indexed: 11/20/2022]
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10
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Doran M, Black P. Seeing for themselves - healthcare professionals' views about the presence of family members during brainstem death testing. J Clin Nurs 2017; 26:1597-1607. [PMID: 27486846 DOI: 10.1111/jocn.13488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To provide an insight into the views of healthcare professionals on the presence of family members during brainstem death testing. BACKGROUND Brainstem death presents families with a paradoxical death that can be difficult to define. International research suggests families should be given the choice to be present at brainstem death testing, yet it appears few units offer families the choice to be present and little attention has been paid to developing practice to enable effective facilitation of choice. DESIGN A qualitative, exploratory design was adopted to understand the perceptions of healthcare professionals. Individual semi-structured interviews were audio-taped and carried out over two months. METHODS A purposive sample of 10 nurses and 10 doctors from two tertiary intensive care units in the United Kingdom was interviewed, and transcripts were analysed using content analysis to identify emergent categories and themes. RESULTS Healthcare professionals indicated different perceptions of death in the context of catastrophic brainstem injury. The majority of participants favoured offering families the choice to be present while acknowledging the influence of organisational culture. Identified benefits included acceptance, closure and better understanding. Suggested challenges involved the assumption of trauma or disruption and sense of obligation for families to accept if choice was offered. Key issues involved improving knowledge and communication skills to individually tailor support for families involved. CONCLUSIONS If families are to be offered the choice of witnessing brainstem death testing, considering that needs and conventions will differ according to global cultural backgrounds, then key needs must be met to ensure that effective care and support is provided to families and clinicians. RELEVANCE TO CLINICAL PRACTICE A proactive approach to facilitating family choice to be present at testing requires the development of guidelines that accommodate cultural and professional variations to provide excellence in end-of-life care.
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Affiliation(s)
- Majella Doran
- Clinical Education Centre, Altnagelvin Hospital, Londonderry, Northern Ireland
| | - Pauline Black
- School of Nursing, Ulster University, Londonderry, Northern Ireland
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11
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Olding M, McMillan SE, Reeves S, Schmitt MH, Puntillo K, Kitto S. Patient and family involvement in adult critical and intensive care settings: a scoping review. Health Expect 2016; 19:1183-1202. [PMID: 27878937 PMCID: PMC5139045 DOI: 10.1111/hex.12402] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite international bodies calling for increased patient and family involvement, these concepts remain poorly defined within literature on critical and intensive care settings. OBJECTIVE This scoping review investigates the extent and range of literature on patient and family involvement in critical and intensive care settings. Methodological and empirical gaps are identified, and a future agenda for research into optimizing patient and family involvement is outlined. METHODS Searches of MEDLINE, CINAHL, Social Work Abstracts and PsycINFO were conducted. English-language articles published between 2003 and 2014 were retrieved. Articles were included if the studies were undertaken in an intensive care or critical care setting, addressed the topic of patient and family involvement, included a sample of adult critical care patients, their families and/or critical care providers. Two reviewers extracted and charted data and analysed findings using qualitative content analysis. FINDINGS A total of 892 articles were screened, 124 were eligible for analysis, including 61 quantitative, 61 qualitative and 2 mixed-methods studies. There was a significant gap in research on patient involvement in the intensive care unit. The analysis identified five different components of family and patient involvement: (i) presence, (ii) having needs met/being supported, (iii) communication, (iv) decision making and (v) contributing to care. CONCLUSION Three research gaps were identified that require addressing: (i) the scope, extent and nature of patient involvement in intensive care settings; (ii) the broader socio-cultural processes that shape patient and family involvement; and (iii) the bidirectional implications between patient/family involvement and interprofessional teamwork.
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Affiliation(s)
- Michelle Olding
- British Columbia Centre for Excellence in HIV/AIDSVancouverBCCanada
| | - Sarah E. McMillan
- Collaborative Academic PracticeUniversity Health NetworkTorontoONCanada
| | - Scott Reeves
- Centre for Health and Social Care ResearchKingston University and St. George's University of LondonLondonUK
| | | | | | - Simon Kitto
- Department of Innovation in Medical EducationFaculty of MedicineUniversity of OttawaOttawaONCanada
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12
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Henoch I, Carlander I, Holm M, James I, Kenne Sarenmalm E, Lundh Hagelin C, Lind S, Sandgren A, Öhlén J. Palliative Care Research - A Systematic Review of foci, designs and methods of research conducted in Sweden between 2007 and 2012. Scand J Caring Sci 2015; 30:5-25. [DOI: 10.1111/scs.12253] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/06/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Ingela Henoch
- Institute of Health and Care Sciences; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC); University of Gothenburg; Gothenburg Sweden
| | - Ida Carlander
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Maja Holm
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Karolinska Institutet; Stockholm Sweden
| | - Inger James
- School of Health and Medical Sciences; Örebro University; Örebro Sweden
| | - Elisabeth Kenne Sarenmalm
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Research and Development Centre; Skaraborg Hospital; Skövde Sweden
| | - Carina Lundh Hagelin
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
- Sophiahemmet University; Stockholm Sweden
- Research and Development Unit in Palliative care; Stockholms Sjukhem Foundation; Stockholm Sweden
| | - Susanne Lind
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Karolinska Institutet; Stockholm Sweden
| | - Anna Sandgren
- School of Health Sciences; Jönköping University; Jönköping Sweden
- Center for Collaborative Palliative Care; Department of Health and Caring Sciences; Linneaus University; Kalmar/Växjö Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC); University of Gothenburg; Gothenburg Sweden
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
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Slatyer S, Pienaar C, Williams AM, Proctor K, Hewitt L. Finding privacy from a public death: a qualitative exploration of how a dedicated space for end-of-life care in an acute hospital impacts on dying patients and their families. J Clin Nurs 2015; 24:2164-74. [PMID: 25940310 DOI: 10.1111/jocn.12845] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2015] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To explore the experiences and perceptions of hospital staff caring for dying patients in a dedicated patient/family room (named Lotus Room). BACKGROUND Dying in hospital is a common outcome for people across the world. However, noise and activity in acute environments present barriers to quality end-of-life care. This is of concern because care provided to dying patients has been shown to affect both the patients and the bereaved families. DESIGN A qualitative descriptive approach was used. METHODS Semi-structured interviews were conducted with 17 multidisciplinary staff and seven families provided information through an investigator-developed instrument. RESULTS Qualitative data analysis generated three categories describing: Dying in an hospital; The Lotus Room; and the Outcomes for patients and families. The Lotus Room was seen as a large, private and, ultimately, safe space for patients and families within the public hospital environment. Family feedback supported staff perspectives that the Lotus Room facilitated family presence and communication. CONCLUSIONS The privacy afforded by the Lotus Room within this acute hospital provided benefits for the dying patients and grieving families. Improved outcomes included a peaceful death for patients, which may have assisted the family with their bereavement. RELEVANCE TO CLINICAL PRACTICE This study provides evidence of how the physical environment can address well-established barriers to quality end-of-life care in acute hospitals.
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Affiliation(s)
- Susan Slatyer
- School of Nursing and Midwifery, Curtin University, Bentley, WA, Australia.,Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Catherine Pienaar
- School of Nursing and Midwifery, Curtin University, Bentley, WA, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Anne M Williams
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia.,Health Research, School of Health Professions, Murdoch University, Murdoch, WA, Australia
| | - Karen Proctor
- Palliative Care Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Laura Hewitt
- Palliative Care Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Abstract
Family support in the intensive care units is a challenge for nurses who take care of dying patients. This article aimed to determine the Iranian nurses' experience of supporting families in end-of-life care. Using grounded theory methodology, 23 critical care nurses were interviewed. The theme of family support was extracted and divided into 5 categories: death with dignity; facilitate visitation; value orientation; preparing; and distress. With implementation of family support approaches, family-centered care plans will be realized in the standard framework.
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15
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Fridh I. Caring for the dying patient in the ICU – The past, the present and the future. Intensive Crit Care Nurs 2014; 30:306-11. [DOI: 10.1016/j.iccn.2014.07.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/17/2014] [Indexed: 10/24/2022]
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16
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Chacko R, Anand JR, Rajan A, John S, Jeyaseelan V. End-of-life care perspectives of patients and health professionals in an Indian health-care setting. Int J Palliat Nurs 2014; 20:557-64. [DOI: 10.12968/ijpn.2014.20.11.557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ranjitha Chacko
- Junior Lecturer, College of Nursing, Medical Intensive Care Unit
| | | | - Amala Rajan
- Professor, College of Nursing, Medical Nursing Department
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17
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Souza TLD, Barilli SLS, Azeredo NSGD. Perspective of family members regarding the process of dying in the intensive care unit. TEXTO & CONTEXTO ENFERMAGEM 2014. [DOI: 10.1590/0104-07072014002200012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study aimed to investigate the perspective of family members on end-of-life in the Intensive Care Unit. This is an exploratory descriptive study with a qualitative approach. Semi-structured individual interviews were held with eight family members of terminally-ill patients receiving inpatient treatment in an Intensive Care Unit in a public hospital in Porto Alegre, in the State of Rio Grande do Sul . The method of content analysis was used for data analysis. During the process of dying, it was evident that the feelings experienced by the family members were diverse, including distress, insecurity, anger, guilt and missing the loved one. Also demonstrated by the family members were the importance of being with the loved person, and the desire to establish a link between the team-patient-family
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18
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Higginson IJ, Koffman J, Hopkins P, Prentice W, Burman R, Leonard S, Rumble C, Noble J, Dampier O, Bernal W, Hall S, Morgan M, Shipman C. Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty. BMC Med 2013; 11:213. [PMID: 24083470 PMCID: PMC3850793 DOI: 10.1186/1741-7015-11-213] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 08/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are widespread concerns about communication and support for patients and families, especially when they face clinical uncertainty, a situation most marked in intensive care units (ICUs). Therefore, we aimed to develop and evaluate an interventional tool to improve communication and palliative care, using the ICU as an example of where this is difficult. METHODS Our design was a phase I-II study following the Medical Research Council Guidance for the Development and Evaluation of Complex Interventions and the (Methods of Researching End-of-life Care (MORECare) statement. In two ICUs, with over 1900 admissions annually, phase I modeled a new intervention comprising implementation training and an assessment tool. We conducted a literature review, qualitative interviews, and focus groups with 40 staff and 13 family members. This resulted in the new tool, the Psychosocial Assessment and Communication Evaluation (PACE). Phase II evaluated the feasibility and effects of PACE, using observation, record audit, and surveys of staff and family members. Qualitative data were analyzed using the framework approach. The statistical tests used on quantitative data were t-tests (for normally distributed characteristics), the χ2 or Fisher's exact test (for non-normally distributed characteristics) and the Mann-Whitney U-test (for experience assessments) to compare the characteristics and experience for cases with and without PACE recorded. RESULTS PACE provides individualized assessments of all patients entering the ICU. It is completed within 24 to 48 hours of admission, and covers five aspects (key relationships, social details and needs, patient preferences, communication and information status, and other concerns), followed by recording of an ongoing communication evaluation. Implementation is supported by a training program with specialist palliative care. A post-implementation survey of 95 ICU staff found that 89% rated PACE assessment as very or generally useful. Of 213 family members, 165 (78%) responded to their survey, and two-thirds had PACE completed. Those for whom PACE was completed reported significantly higher satisfaction with symptom control, and the honesty and consistency of information from staff (Mann-Whitney U-test ranged from 616 to 1247, P-values ranged from 0.041 to 0.010) compared with those who did not. CONCLUSIONS PACE is a feasible interventional tool that has the potential to improve communication, information consistency, and family perceptions of symptom control.
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Affiliation(s)
- Irene J Higginson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, School of Medicine, Bessemer Road, Denmark Hill, London SE5 9PJ, UK.
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Birchley G. Doctor? Who? Nurses, patient's best interests and treatment withdrawal: when no doctor is available, should nurses withdraw treatment from patients? Nurs Philos 2013; 14:96-108. [PMID: 23480036 DOI: 10.1111/j.1466-769x.2012.00553.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Where a decision has been made to stop futile treatment of critically ill patients on an intensive care unit - what is termed withdrawal of treatment in the UK--yet no doctor is available to perform the actions of withdrawal, nurses may be called upon to perform key tasks. In this paper I present two moral justifications for this activity by offering answers to two major questions. One is to ask if it can be in patients' best interests for nurses to be the key actors in withdrawal of life-sustaining treatment. The other is to ask if there is any reason that the nursing profession should not undertake such tasks if this is so. Both these questions require the resolution of weighty moral and philosophical issues. Thus, while offering a serious attempt to provide moral justifications for nurses undertaking withdrawal, this paper also invites debate over both the aim of task division between nurses and doctors, and how we might decide what is in the best interests of patients.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
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Williams BR, Bailey FA, Woodby LL, Wittich AR, Burgio KL. "A room full of chairs around his bed": being present at the death of a loved one in Veterans Affairs Medical Centers. OMEGA-JOURNAL OF DEATH AND DYING 2013; 66:231-63. [PMID: 23617101 DOI: 10.2190/om.66.3.c] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Historically, death took place at home where family held vigil around the dying patient. Today, family presence is an important feature of death and dying in hospital settings. We used hermeneutic phenomenology to explore experiences of being present at the hospital death of a loved one. We conducted in-depth, face-to-face interviews with 78 recently bereaved next-of-kin of veterans who died in 6 Veterans Affairs (VA) Medical Centers in the Southeast United States. Two major themes emerged: 1) "settling in," characteristic of the experiences of wives and daughters in the initial phase of the patient's hospitalization; and 2) "gathering around," characteristic of the experiences of a wider array of family members as the patient neared death. An in-depth understanding of experiences of next-of-kin present at the hospital death of a loved one can increase staff awareness of family's needs and empower staff to develop policies and procedures for supporting family members.
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McCallum A, McConigley R. Nurses’ perceptions of caring for dying patients in an open critical care unit: a descriptive exploratory study. Int J Palliat Nurs 2013; 19:25-30. [DOI: 10.12968/ijpn.2013.19.1.25] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Amanda McCallum
- High Dependency Area, Royal Perth Hospital, East Perth, Western Australia 6001, Australia
| | - Ruth McConigley
- School of Nursing and Midwifery, Curtin University, GPO Box U 1987, Perth, Western Australia 6845, Australia
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Bailey FA, Williams BR, Goode PS, Woodby LL, Redden DT, Johnson TM, Taylor JW, Burgio KL. Opioid pain medication orders and administration in the last days of life. J Pain Symptom Manage 2012; 44:681-91. [PMID: 22765968 DOI: 10.1016/j.jpainsymman.2011.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 11/16/2011] [Accepted: 11/29/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT Most patients with serious and life-limiting illness experience pain at some point in the illness trajectory. OBJECTIVES To describe baseline pain management practices for imminently dying patients in Veterans Administration Medical Centers (VAMCs) and examine factors associated with these processes, including presence of opioid orders at the time of death and medication administration in the last seven days, 48 hours, and 24 hours of life. METHODS Data on orders and administration of opioid pain medication at the end of life were abstracted from the medical records of veterans who died in six VAMC hospitals in 2005. RESULTS Of 1068 patient records, 686 (64.2%) had an active order for an opioid medication at the time of death. Of these, 69.8% of patients had received the medication at some time within the last seven days of life, 61.2% within the last 48 hours, and 47.0% within the last 24 hours. In multivariable models, presence of an order for opioid pain medication at the time of death and administration within the last 24 hours were both significantly associated with having a Do Not Resuscitate (DNR) order (P < 0.0001/0.0002), terminal condition (P < 0.0001/< 0.0001), family presence (P < 0.0001/0.0023), location of death (P = 0.003/0.0005), and having pain noted in the care plan (P = 0.0073/0.0007). CONCLUSION Findings indicate a need for improving availability of opioids for end-of-life care in the inpatient setting. Modifiable factors, such as family presence and goals-of-care discussions, suggest potential targets for intervention to improve recognition of the dying process and proactive planning for pain control.
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Affiliation(s)
- F Amos Bailey
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, AL, USA
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Khalaila R. Patients' family satisfaction with needs met at the medical intensive care unit. J Adv Nurs 2012; 69:1172-82. [DOI: 10.1111/j.1365-2648.2012.06109.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2012] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE Dissatisfaction is an important threat to high-quality care. The aim of this study was to identify factors independently associated with dissatisfaction with critical care. DESIGN Prospectively collected observational cohort study. SETTING Nine intensive care units at a tertiary care university hospital in the United States. PARTICIPANTS Four hundred forty-nine family members of adult intensive care unit patients who completed the Family Satisfaction with Care in the Intensive Care Unit instrument. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Four family-and patient-related factors ascertainable at intensive care unit admission independently predicted low overall satisfaction: living in the same city as the hospital, disagreement within the family regarding care, having a cardiac comorbidity but being hospitalized in a noncardiac-care intensive care unit, and living in a different household than the patient. When three or more risk factors were present, 63% (95% confidence interval 48%-78%) of families were dissatisfied. Among factors ascertained at the end of the intensive care unit stay, dissatisfaction with six items was independently associated with overall dissatisfaction: 1) perceived competence of nurses (odds ratio for dissatisfaction=5.9, 95% confidence interval 2.3-15.2); 2) concern and caring by intensive care unit staff (odds ratio 5.0, 95% confidence interval 1.9-12.6); 3) completeness of information (odds ratio 4.4, 95% confidence interval 2.4-8.1); 4) dissatisfaction with the decision-making process (odds ratio 3.0, 95% confidence interval 1.6- 5.6); 5) atmosphere of the intensive care unit (odds ratio 2.6, 95% confidence interval 1.4-4.8); and 6) atmosphere of the waiting room (odds ratio 2.7, 95% confidence interval 1.2-6.0). CONCLUSION Specific factors ascertainable at intensive care unit admission identify families at high risk of dissatisfaction with care. Other discrete aspects of the patient/family experience that develop during the intensive care unit stay are also strongly associated with dissatisfaction with the critical care experience. These results may provide insight into the design of future evidence-based strategies to improve satisfaction with the intensive care unit experience.
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Brereton L, Gardiner C, Gott M, Ingleton C, Barnes S, Carroll C. The hospital environment for end of life care of older adults and their families: an integrative review. J Adv Nurs 2011; 68:981-93. [DOI: 10.1111/j.1365-2648.2011.05900.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kongsuwan W, Chaipetch O. Thai Buddhists' experiences caring for family members who died a peaceful death in intensive care. Int J Palliat Nurs 2011; 17:329-36. [PMID: 21841701 DOI: 10.12968/ijpn.2011.17.7.329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To describe the meaning of Thai Buddhists' lived experiences caring for family members who died a peaceful death in intensive care units. METHODS The study made use of hermeneutic phenomenology. The participants were nine family caregivers from the southern Thailand region. Data was generated from individual interviews, and Van Manen's approach was used to analyse and interpret the data. FINDINGS Nine themes structured the experiences and were reflected within the four lived worlds of relationality, corporeality, temporality, and spatiality. The participants struggled when making decisions about their family member's life in the context of changing hope. Feelings of stress and exhaustion were common. The participants valued empathetic understanding as a means for maintaining relationships with others in giving and receiving compassionate care. Caring for the self in order to give mindful care and doing one's best in the moment also significantly contributed to achieving a peaceful death. CONCLUSION The findings suggest nursing practice guidelines for models of family-centred care and family participation in end-of-life care in intensive care units.
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Affiliation(s)
- Waraporn Kongsuwan
- Medical Nursing Department, Prince of Songkla University, Songkhla, Thailand.
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Abstract
The purpose of this qualitative study was to explore and describe the characteristics of a good death as defined by 15 critical care nurses working in the intensive care unit (ICU) at a hospital in a mid-sized urban city. The target population was registered nurses employed in the intensive care unit where the study was conducted. Given the fact that the sample population was a very specific group, a purposive, convenience sample was utilized to explore the personal thoughts and feelings of the nurses who volunteered for this project. A nondirective, in-depth interview technique was the method of data collection. Interviews lasted up to 60 minutes, and data was collected by tape recorder, then immediately transcribed verbatim; basic demographic data was collected at the beginning of each interview and this information was used to describe the sample. In describing a good death in the ICU, most participants identified multiple themes. Eight main themes emerged from the nurses' responses to the research question, and of those, 3 were mentioned most often. The 3 most frequently mentioned themes were patient does not die alone, patient does not suffer (pain management/symptom management), and acceptance of death by the patient and/or loved ones. Much of what nurses described as elements of a good death in the ICU supports other published results. The themes that were identified in this research study provide an initial framework that is important for further research in the area of critical care nursing.
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Doing one's utmost: Nurses’ descriptions of caring for dying patients in an intensive care environment. Intensive Crit Care Nurs 2009; 25:233-41. [DOI: 10.1016/j.iccn.2009.06.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 06/18/2009] [Accepted: 06/22/2009] [Indexed: 11/23/2022]
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Latour JM, Fulbrook P, Albarran JW. EfCCNa survey: European intensive care nurses’ attitudes and beliefs towards end-of-life care. Nurs Crit Care 2009; 14:110-21. [DOI: 10.1111/j.1478-5153.2008.00328.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Halvorsen K, Førde R, Nortvedt P. Value choices and considerations when limiting intensive care treatment: a qualitative study. Acta Anaesthesiol Scand 2009; 53:10-7. [PMID: 19032565 DOI: 10.1111/j.1399-6576.2008.01793.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To shed light on the values and considerations that affect the decision-making processes and the decisions to limit intensive care treatment. METHOD Qualitative methodology with participant observation and in-depth interviews, with an emphasis on eliciting the underlying rationale of the clinicians' actions and choices when limiting treatment. RESULTS Informants perceived over-treatment in intensive care medicine as a dilemma. One explanation was that the decision-making base was somewhat uncertain, complex and difficult. The informants claimed that those responsible for taking decisions from the admitting ward prolonged futile treatment because they may bear guilt or responsibility for something that had gone wrong during the course of treatment. The assessments of the patient's situation made by physicians from the admitting ward were often more organ-oriented and the expectations were less realistic than those of clinicians in the intensive care unit who frequently had a more balanced and overall perspective. Aspects such as the personality and the speciality of those involved, the culture of the unit and the degree of interdisciplinary cooperation were important issues in the decision-making processes. CONCLUSION Under-communicated considerations jeopardise the principle of equal treatment. If intensive care patients are to be ensured equal treatment, strategies for interdisciplinary, transparent and appropriate decision-making processes must be developed in which open and hidden values are rendered visible, power structures disclosed, employees respected and the various perspectives of the treatment given their legitimate place.
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Affiliation(s)
- K Halvorsen
- Faculty of Nursing Education, Akershus University College, Lillestrøm, Norway.
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Fridh I, Forsberg A, Bergbom I. Close relatives' experiences of caring and of the physical environment when a loved one dies in an ICU. Intensive Crit Care Nurs 2008; 25:111-9. [PMID: 19112022 DOI: 10.1016/j.iccn.2008.11.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 11/10/2008] [Accepted: 11/11/2008] [Indexed: 10/21/2022]
Abstract
AIM The aim of this study was to explore close relatives' experiences of caring and the physical environment when a loved one dies in an intensive care unit (ICU). METHOD Interviews were conducted with 17 close relatives of 15 patients who had died in three adult ICUs. The interviews were analysed using a phenomenological-hermeneutic method. FINDINGS The analysis resulted in seven themes; Being confronted with the threat of loss, Maintaining a vigil, Trusting the care, Adapting and trying to understand, Facing death, The need for privacy and togetherness and Experiencing reconciliation. The experience of a caring relationship was central, which meant that the carers piloted the close relatives past the hidden reefs and through the dark waters of the strange environment, unfamiliar technology, distressing information and waiting characterised by uncertainty. Not being piloted meant not being invited to enter into a caring relationship, not being allowed access to the dying loved one and not being assisted in interpreting information. CONCLUSION The participants showed forbearance with the ICU-environment. Their dying loved one's serious condition and his or her dependence on the medical-technical equipment were experienced as more frightening than the equipment as such. Returning for a follow-up-visit provided an opportunity for reconciliation and relief from guilt.
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Affiliation(s)
- Isabell Fridh
- Sahlgrenska Academy at Gothenburg University, Institute of Health and Care Sciences, PO Box 457, Göteborg SE 405 30, Sweden.
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Exploring parents' environmental needs at the time of a child's death in the pediatric intensive care unit. Pediatr Crit Care Med 2008; 9:623-8. [PMID: 18838930 DOI: 10.1097/pcc.0b013e31818d30d5] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Many childhood deaths in the United States occur in intensive care settings. The environmental needs of parents experiencing their child's death in a pediatric intensive care unit must be understood to design facilities that comfort at the time of death and promote healing after loss. The purpose of this study is to explore parents' environmental needs during their child's hospitalization and death in the pediatric intensive care unit. DESIGN Descriptive qualitative study. SETTING A university-affiliated children's hospital. PARTICIPANTS Thirty-three parents of 26 children who died in a pediatric intensive care unit. INTERVENTIONS Semistructured, in-depth, videotaped interviews were conducted with parents 2 yrs after their child's death. Interviews were analyzed by an interdisciplinary research team using established qualitative methods. MEASUREMENTS AND MAIN RESULTS Environmental themes identified through parent interviews included 1) places remembered, 2) spatial characteristics, 3) services for daily living, 4) parent caregiving, 5) access, and 6) presence of people. Places remembered by parents in most detail included the pediatric intensive care unit patient rooms and waiting room. Spatial characteristics pertaining to these places included the need for privacy, proximity, adequate space, control of sensory stimuli, cleanliness, and safety. Parents needed facilities that enabled self-care such as a place to eat, shower, and sleep. Parents also needed access to their child and opportunities to participate in their child's care. Parents described the physical presence of people, such as those who provide professional and personal support, as another important environmental need. CONCLUSIONS The pediatric intensive care unit environment affects parents at the time of their child's death and produces memories that are vivid and long lasting. Positive environmental memories can contribute to comfort during bereavement whereas negative memories can compound an already devastating experience. Parents' perspectives of the pediatric intensive care unit environment can provide insight for adapting existing spaces and designing new facilities.
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Hynninen M, Klepstad P, Petersson J, Skram U, Tallgren M. Process of foregoing life-sustaining treatment: a survey among Scandinavian intensivists. Acta Anaesthesiol Scand 2008; 52:1081-5. [PMID: 18840108 DOI: 10.1111/j.1399-6576.2008.01636.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND How ethical issues are dealt with varies considerably depending on the geographic and religious background of individuals. The views of Scandinavian physicians on end-of-life care were studied using a survey. The aim of this study was to clarify the actual processes of foregoing life-sustaining treatment in Scandinavia. METHODS A questionnaire was developed and sent to 78 intensive care physicians working in Denmark, Finland, Norway and Sweden. RESULTS Forty-four responses were obtained (13 from Denmark, eight from Finland, 12 from Norway and 11 from Sweden); 89% of the respondents were from University Hospitals. Withholding and withdrawing of treatment were practiced in all intensive care units (ICUs) concerned, but written guidelines on end-of-life care existed in only one ICU. End-of-life care is usually arranged in the ICU. Religious support is available in most hospitals during office hours, but lacking in 26% of ICUs outside office hours. Vasoactive medication, renal replacement therapy, and artificial nutrition are among the therapies most likely to be discontinued during withdrawal of life support. Certain types of monitoring and organ support are still continued in many centers during end-of-life care. CONCLUSION Local written guidelines on end-of-life care are scarce in Scandinavian ICUs, which may explain the observed variability in the practices. Development of guidelines and monitoring how these instructions are carried out may help to improve the quality of care of dying ICU patients.
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Affiliation(s)
- M Hynninen
- Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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