The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: A cross-sectional study

Perspectives on Death and the Awareness of Mortality in Relatives of Intensive Care Patients: A Descriptive Study

BACKGROUND

Various factors, including their psychology, their perspective on the world, their religion, the culture in which they live and their previous experiences, may affect an individual's perception and awareness of mortality.

AIM

This study was conducted to determine perspectives on death and awareness of mortality in relatives of patients who were receiving treatment in the intensive care unit of a university hospital in Turkey.

STUDY DESIGN

This descriptive and correlational study was conducted at a university hospital in Turkey between July 15, 2022, and May 15, 2024. A total of 305 relatives of intensive care patients participated in the study. Data were collected using a Relatives' Introductory Information Form, the Multidimensional Mortality Awareness Measure (MMAM) and the Death Perspectives Scale (DPS). A structural equation model (SEM) was developed using the maximum likelihood approach to investigate the direct effects on the dependent variable. The impact of the DPS subscale scores on the MMAM scores was analysed through path analysis.

RESULTS

The path coefficients between the MMAM and the subscales of the DPS, specifically Afterlife-of-Reward (β = 0.213), Unknown (β = 0.125), Failure (β = 0.156) and Courage (β = 0.145), were found to be statistically significant. This model was found to explain 30.1% of the variation in the MMAM scores.

CONCLUSIONS

This study found a relationship between the levels of awareness of mortality and death perspective in the relatives of patients.

RELEVANCE TO CLINICAL PRACTICE

Intensive care nurses should provide family-centred care. Death counselling and education should be provided in order to prepare relatives to accept the impending death of the patient.

Investigating the Impact of the Family Interaction Model on the Anxiety and Mental Well-Being of Patients During Visit Restrictions in Intensive Care Units: A Mixed-Methods Study

BACKGROUND

Patients hospitalised in the intensive care unit (ICU) often experience feelings of isolation and a sense of profound loneliness. These individuals frequently report symptoms of anxiety, depression and other psychiatric disorders.

AIM

The aim of this study was to examine the impact of the family interaction model on the anxiety and mental well-being of patients during the visit restrictions in the ICUs. Additionally, the experiences of intensive care patients and their relatives regarding this process were investigated.

STUDY DESIGN

This research utilised a parallel design mixed-methods approach, incorporating both quantitative and qualitative designs. A qualitative research design was employed in the quasi-experimental framework to examine post-intervention experiences. The research sample consisted of 47 patients in the intervention group.

RESULTS

The intervention group, that received videos and messages from their relatives, exhibited a decrease in anxiety over time. In contrast, the control group demonstrated an increase in anxiety over time. The results indicated that 77% of these changes were due to the group variable (CI: -38.627 to -30.902; p < 0.05). Mental well-being scores demonstrated an increase over time in the intervention group, while a decrease was observed in the control group. The analysis revealed that 83.4% of this change could be attributed to the group variable (CI: 29.178-35.048; p < 0.05). In the interviews, three themes were obtained from both patients and the relatives of the patients in the intervention group. In the control group, four themes were found. In the qualitative interviews conducted with the patients in the intervention group, the subthemes regarding their feelings about the disease process and intensive care experience included fear, uncertainty and anxiety, and hopelessness and longing, while after the patients were shown the video, themes that overlapped with positive feelings were found. These subthemes were determined as happiness, excitement and hope. In the control group, the subthemes regarding their experiences of the disease process were determined as death anxiety, hopelessness and helplessness, uncertainty, agitation and physical discomfort (pain and fatigue).

CONCLUSIONS

The results of this study demonstrated that using remote communication methods to facilitate interaction between patients and their families was linked to reduced anxiety in patients, improved mental well-being and increased satisfaction among their relatives.

RELEVANCE TO CLINICAL PRACTICE

The primary strength of the study is its pioneering role in facilitating communication between intensive care patients and their relatives at the public hospital level during the pandemic period. Additionally, it has shed light on the emotional outcomes associated with this communication. Moreover, the project facilitated the transmission of the patient's final statements to their relatives, effectively serving as a verbal testament to the bond between the patient and their family. Primarily, communicating the final statements of deceased patients is of paramount humanitarian importance. The results of this study prove that intensive care nurses have an important role in enabling patients to connect with their loved ones in their final stages. Thus, nurses can support recovery, increase communication and ensure farewells.

User Experience of a Bespoke Videoconferencing System for Web-Based Family Visitation for Patients in an Intensive Care Unit: 1-Year Cross-Sectional Survey of Nursing Staff

Background

During the COVID-19 pandemic, in-person visitation within hospitals was restricted and sometimes eliminated to reduce the risk of transmission of SARS-CoV-2. Many health care professionals created novel strategies that were deployed to maintain a patient-centered approach. Although pandemic-related restrictions have eased, these systems, including videoconferencing or web-based bedside visits, remain relevant for visitors who cannot be present due to other reasons (lack of access to transport, socioeconomic restraints, geographical distance, etc).

Objective

The aims of this study were (1) to report the experience of intensive care nursing staff using a bespoke videoconferencing system called ICU FamilyLink; (2) to examine the scenarios in which the nursing staff used the system; and (3) to assess the future use of videoconferencing systems to enhance communication with families.

Methods

A modified Telehealth Usability questionnaire was administered to the nursing staff (N=22) of an intensive care unit in a model 4 tertiary hospital in Ireland 1 year after implementing the bespoke videoconferencing system.

Results

In total, 22 nurses working in the intensive care department at University Hospital Galway, Ireland, responded to the survey. A total of 23% (n=5) of participants were between the ages of 25 and 34 years, 54% (n=12) were between 35 and 44 years, and 23% (n=5) were between 45 and 54 years. Most (n=15, 68%) of the participants reported never using videoconferencing in the intensive care setting to communicate with family members before March 2020. The modified Telehealth Usability Questionnaire showed overall satisfaction scores for each subcategory of ease of use and learnability, interface quality, interaction quality, reliability, satisfaction and future use, and usefulness. In total, 21 (95%) participants agreed or strongly agreed with the statement, "I would use the ICU FamilyLink system in future circumstances in which family members cannot be physically present (ie, pandemics, abroad, inability to travel, etc)," and 1 participant responded neutrally. One participant highlighted a common scenario in intensive care settings in which a videoconferencing system can be used "Even without COVID, web-based communication is important when patients become unexpectedly ill and when families are abroad."

Conclusions

This study provides valuable insights into health care professionals' experience using a videoconferencing system to facilitate web-based visits for families. We conclude that videoconferencing systems when appropriately tailored to the environment with the users in mind can be an acceptable solution to maintain communication with family members who cannot be physically present at the bedside. The bespoke videoconferencing system had an overall positive response from 22 nursing staff who interacted with the system at varying frequency levels.

Health status in the era of digital transformation and sustainable economic development

BACKGROUND

In the contemporary landscape characterized by digital transformation and sustainable economic development, understanding the dynamics of health status is critically significant. This study investigates the complex relationship among healthcare expenditure, digital transformation, health status, and well-being within the European Union (EU) framework.

METHODS

Through structural equation modeling, the research examines the multidimensional interplay among these variables, while cluster analysis supports identifying distinct patterns within the data. The paper aims to provide a broad understanding of the impact of digital transformation and healthcare expenditure on health status and well-being at the EU level.

RESULTS

The findings unveil nuanced linkages among healthcare expenditure, digital transformation, health status, and well-being across distinct clusters of EU countries. While certain countries exhibit synergistic advancements resulting in enhanced healthcare outcomes, others confront challenges stemming from disparities in digital infrastructure, healthcare expenditure allocation, and health status.

CONCLUSIONS

This study underscores the imperative of fostering synergies between digital transformation and healthcare expenditure to enhance health status within the EU. Identifying pivotal determinants and barriers enables policymakers to formulate targeted strategies to mitigate disparities and foster inclusive growth to promote equitable healthcare access and advance overall societal well-being.

Terminal Care Performance of Nurses Caring for COVID-19 Patients: A Cross-Sectional Descriptive Study

AIMS

To identify the effects of moral distress and terminal care stress on the terminal care performance of nurses who cared for COVID-19 patients.

DESIGN

This study was cross-sectional descriptive research.

METHODS

Using a convenience sampling method from June to October 2022, nurses who provided terminal care for COVID-19 patients in a Korean tertiary hospital within the last 6 months from the time of the study were selected as participants. Socio-demographic and work characteristics of the participants were collected, and COVID-19 moral distress, terminal care stress and terminal care performance were assessed. A total of 140 self-report questionnaires were distributed and returned (response rate: 100%).

RESULTS

In the terminal care performance, it was found that nurses performed relatively well in the physical area, but less well in the emotional and spiritual areas. Moral distress and terminal care stress were both positively correlated with terminal care performance for nurses who cared for COVID-19 patients. The predictors of terminal care performance were moral distress (β = 0.27, p = 0.003), gender (β = 0.20, p = 0.015) and experience in a dedicated COVID-19 unit (β = 0.22, p = 0.020).

CONCLUSIONS

The study identified moral distress as the most significant factor influencing terminal care performance among nurses caring for COVID-19 patients. To enhance terminal care performance, it is crucial to address moral distress and provide clear guidelines and support, especially in the emotional and spiritual care domains. Future research should explore additional factors that may influence terminal care performance in pandemic situations.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Experiences of Family Members With Visitation Prohibition for Critically Ill Patients

BACKGROUND

Visitation plays a number of positive roles for critically ill patients and their families. It reduces the physical and mental stress of intensive care unit (ICU) patients and their families and allows family members to participate in patient care. Visit prohibition during the COVID-19 pandemic has raised unprecedented challenges to patients, family members, and health care providers.

OBJECTIVE

This qualitative study aimed to explore the experiences of families of patients in the ICU with no-visitor policies due to COVID-19.

METHODS

Data collection was conducted through 8 individual in-depth semi-structured interviews conducted between October 2021 and March 2022. Data analysis was performed following the qualitative method proposed by Colaizzi. The researchers independently analyzed the data, checked the findings, derived subthemes, and categorized them into overarching themes.

RESULTS

Four themes emerged from the data analysis: (a) experiencing emotional distress, (b) being fearful of in-person patient contact, (c) being dissatisfied with the access control policy in the ICU, and (d) making efforts to reach the patient.

CONCLUSIONS

It is critical to provide support and develop interventions for families denied visitation with loved ones in ICUs. Since in-person visits are crucial for families, hospitals should establish clear and reasonable visitation guidelines, communicate effectively with families, and offer alternative methods for them to connect with loved ones in the ICU.

Challenges of using body bags for COVID-19 deaths from the healthcare provider perspective - a qualitative study

BACKGROUND

During the COVID-19 pandemic, numerous issues regarding end-of-life care for COVID-19 patients have been discussed. Among these issues, challenges related to the use of body bags following the death of COVID-19 patients have been suggested. This study aimed to identify the challenges faced by healthcare professionals (HCPs) when using body bags after the death of patients infected with COVID-19 in medical settings.

METHODS

We conducted a qualitative descriptive study with semistructured in-depth interviews using inductive thematic analysis. From August to December 2021, we interviewed nurses and doctors who provided end-of-life care to COVID-19 patients focusing on their experiences with the use of body bags for the deceased.

RESULTS

Of the 25 interviewees who mentioned body bag use, 14 were nurses (56%) and 13 were women (52%). The mean interview length was 52.0 min (SD 9.6 min). Challenges associated with body bag use were classified into four themes with eight categories: preserving the dignity of the deceased, consideration for the bereaved saying a final goodbye to a loved one in a body bag, the physical and emotional impact on HCPs, and diverse opinions on body bag use.

CONCLUSION

Our findings include ethical concerns about the dignity of the deceased, empathy for the grief of bereaved families, and the emotional and physical distress experienced by HCPs struggling with the recommendation to use body bags based on limited evidence. The diverse perspectives of HCPs in this study highlight potential issues that developers should consider when formulating more appropriate and acceptable guidelines/guidance and policies.

Healthcare System Digital Transformation across Four European Countries: A Multiple-Case Study

Digitization has become involved in every aspect of life, including the healthcare sector with its healthcare professionals (HCPs), citizens (patients and their families), and services. This complex process is supported by policies: however, to date, no policy analysis on healthcare digitalization has been conducted in European countries to identify the main goals of digital transformation and its practical implementation. This research aimed to describe and compare the digital health policies across four European countries; namely, their priorities, their implementation in practice, and the digital competencies expected by HCPs. A multiple-case study was performed. Participants were the members of the Digital EducationaL programme invoLVing hEalth profEssionals (DELIVER), a project funded by the European Union under the Erasmus+ programme, involving three countries (Denmark, Italy, and Slovenia) and one autonomous region (Catalonia-Spain). Data were collected using two approaches: (a) a written interview with open-ended questions involving the members of the DELIVER project as key informants; and (b) a policy-document analysis. Interviews were analysed using the textual narrative synthesis and the word cloud policy analysis was conducted according to the Ready, Extract, Analyse and Distil approach. Results showed that all countries had established recent policies at the national level to address the development of digital health and specific governmental bodies were addressing the implementation of the digital transformation with specific ramifications at the regional and local levels. The words "health" and "care" characterized the policy documents of Denmark and Italy (309 and 56 times, 114 and 24 times, respectively), while "development" and "digital" (497 and 478 times, respectively) were common in the Slovenia document. The most used words in the Catalonia policy document were "data" and "system" (570 and 523 times, respectively). The HCP competencies expected are not clearly delineated among countries, and there is no formal plan for their development at the undergraduate, postgraduate, and continuing educational levels. Mutual understanding and exchange of good practices between countries may facilitate the digitalization processes; moreover, concrete actions in the context of HCP migration across Europe for employment purposes, as well as in the context of citizens' migration for healthcare-seeking purposes are needed to consider the differences emerged across the countries.

Thematic analysis of intensive care unit diaries kept by staff: insights for caring

OBJECTIVE

To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

Qualitative study.

SETTING

Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021.

METHODS

ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed.

FINDINGS

Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations).

CONCLUSION

The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them.

IMPLICATIONS FOR CLINICAL PRACTICE

The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.

Implementation of video-calls between patients admitted to intensive care unit during the COVID-19 pandemic and their families: a pilot study of psychological effects

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has caused over 530 million infections to date (June 2022), with a high percentage of intensive care unit (ICU) admissions. In this context, relatives have been restricted from visiting their loved ones admitted to hospital. This situation has led to an inevitable separation between patients and their families. Video communication could reduce the negative effects of such phenomenon, but the impact of this strategy on levels of anxiety, depression, and PTSD disorder in caregivers is not well-known.

METHODS

We conducted a prospective study (6 October 2020-18 February 2022) at the Policlinico University Hospital in Catania, including caregivers of both COVID-19 and non-COVID-19 ICU patients admitted during the second wave of the pandemic. Video-calls were implemented twice a week. Assessment of anxiety, depression, and PTSD was performed at 1-week distance (before the first, T1, and before the third, video-call, T2) using the following validated questionnaires: Impact of Event Scale (Revised IES-R), Center for Epidemiologic Studies Depression Scale (CES-D), and Hospital Anxiety and Depression Scale (HADS).

RESULTS

Twenty caregivers of 17 patients completed the study (T1 + T2). Eleven patients survived (n = 9/11 in the COVID-19 and n = 2/6 in the "non-COVID" group). The average results of the questionnaires completed by caregivers between T1 and T2 showed no significant difference in terms of CES-D (T1 = 19.6 ± 10, T2 = 22 ± 9.6; p = 0.17), HADS depression (T1 = 9.5 ± 1.6, T2 = 9 ± 3.9; p = 0.59), HADS anxiety (T1 = 8.7 ± 2.4, T2 = 8.4 ± 3.8; p = 0.67), and IES-R (T1 = 20.9 ± 10.8, T2 = 23.1 ± 12; p = 0.19). Similar nonsignificant results were observed in the two subgroups of caregivers (COVID-19 and "non-COVID"). However, at T1 and T2, caregivers of "non-COVID" patients had higher scores of CES-D (p = 0.01 and p = 0.04, respectively) and IES-R (p = 0.049 and p = 0.02, respectively), while HADS depression was higher only at T2 (p = 0.02). At T1, caregivers of non-survivors had higher scores of CES-D (27.6 ± 10.6 vs 15.3 ± 6.7, p = 0.005) and IES-R (27.7 ± 10.0 vs 17.2 ± 9.6, p = 0.03). We also found a significant increase in CES-D at T2 in ICU-survivors (p = 0.04).

CONCLUSIONS

Our preliminary results showed that a video-call implementation strategy between caregivers and patients admitted to the ICU is feasible. However, this strategy did not show an improvement in terms of the risk of depression, anxiety, and PTSD among caregivers. Our pilot study remains exploratory and limited to a small sample.