Assessing palliative care practices in intensive care units and interpreting them using the lens of appropriate care concepts. An umbrella review

PURPOSE

Intensive care units (ICUs) have significant palliative care needs but lack a reliable care framework. This umbrella review addresses them by synthesising palliative care practices provided at end-of-life to critically ill patients and their families before, during, and after ICU admission.

METHODS

Seven databases were systematically searched for systematic reviews, and the umbrella review was conducted according to the guidelines laid out by the Joanna Briggs Institute (JBI).

RESULTS

Out of 3122 initial records identified, 40 systematic reviews were included in the synthesis. Six key themes were generated that reflect the palliative and end-of-life care practices in the ICUs and their outcomes. Effective communication and accurate prognostications enabled families to make informed decisions, cope with uncertainty, ease distress, and shorten ICU stays. Inter-team discussions and agreement on a plan are essential before discussing care goals. Recording care preferences prevents unnecessary end-of-life treatments. Exceptional end-of-life care should include symptom management, family support, hydration and nutrition optimisation, avoidance of unhelpful treatments, and bereavement support. Evaluating end-of-life care quality is critical and can be accomplished by seeking family feedback or conducting a survey.

CONCLUSION

This umbrella review encapsulates current palliative care practices in ICUs, influencing patient and family outcomes and providing insights into developing an appropriate care framework for critically ill patients needing end-of-life care and their families.

Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study

Background and aim

While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored.

Methods

There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes.

Results

About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC.

Conclusion

Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians.

How to cite this article

Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Nurses' perceptions of barriers and supportive behaviors in end-of-life care in the intensive care unit: a cross-sectional study

BACKGROUND AND AIM

Patient deaths are common in the intensive care unit, and a nurse's perception of barriers to and supportive behaviors in end-of-life care varies widely depending upon their cultural background. The aim of this study was to describe the perceptions of intensive care nurses regarding barriers to and supportive behaviors in providing end-of-life care in a Chinese cultural context.

METHODS

A cross-sectional survey was conducted among intensive care nurses in 20 intensive care units in 11 general hospitals in central and eastern China. Instruments used in this study were general survey and Beckstrand's questionnaire. Data were collected via online survey platform. Descriptive analysis was used to describe general characteristics of participants and mean and standard deviations of the barriers and supportive behaviors. The mean and standard deviation were used to describe the intensity and frequency of each barrier or supportive behavior following Beckstrand's method to calculate the score of barriers and supportive behaviors. Content analysis was used to analyze the responses to open-ended questions.

RESULTS

The response rate was 53% (n = 368/700). Five of the top six barriers related to families and the other was the nurse's lack of time. Supportive behaviors included three related to families and three related to healthcare providers. Nurses in the intensive care unit felt that families should be present at the bedside of a dying patient, there is a need to provide a quiet, independent environment and psychological support should be provided to the patient and family. Nurses believe that if possible, families can be given flexibility to visit dying patients, such as increasing the number of visits, rather than limiting visiting hours altogether. Families need to be given enough time to perform the final rites on the dying patient. Moreover, it is remarkable that nurses' supportive behaviors almost all concern care after death.

CONCLUSIONS

According to ICU-nurses family-related factors, such as accompany of the dying patients and acceptence of patient's imminent death, were found the major factors affecting the quality of end-of-life care. These findings identify the most prominent current barriers and supportive behaviors, which may provide a basis for addressing these issues in the future to improve the quality of end-of-life care.

An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile

BACKGROUND

Deaths in the intensive care unit (ICU) represent an experience of suffering for patients, their families, and professionals. End-of-life (EOL) care has been added to the responsibilities of the ICU team, but the evidence supporting EOL care is scarce, and there are many barriers to implementing the clinical recommendations that do exist.

OBJECTIVES

To explore the experiences and perspectives of the various members of an ICU care team in Chile regarding the EOL care of their patients.

METHODS

A qualitative study was performed in the ICU of a high-complexity academic urban hospital. The study used purposive sampling with focus groups as a data collection method. A narrative analysis based on grounded theory was done.

RESULTS

Four discipline-specific focus groups were conducted; participants included 8 nurses, 6 nursing assistants, 8 junior physicians, and 6 senior physicians. The main themes that emerged in the analysis were emotional impact and barriers to carrying out EOL care. The main barriers identified were cultural difficulties related to decision-making, lack of interprofessional clinical practice, and lack of effective communication. Communication difficulties within the team were described along with lack of self-efficacy for family-centered communication.

CONCLUSION

These qualitative findings expose gaps in care that must be filled to achieve high-quality EOL care in the ICU. Significant emotional impact, barriers related to EOL decision-making, limited interprofessional clinical practice, and communication difficulties were the main findings cross-referenced.

Transferring home to die from critical care units: A scoping review of international practices

PURPOSE

To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

MATERIALS AND METHODS

A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019.

RESULTS

Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes.

CONCLUSIONS

Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.

Soliciting organ donations by medical personnel and organ donation coordinators: A factor analysis

The literature on organ donation in Taiwan lacks a discussion of the roles of medical staff, organ donors, and transplant coordinators in organ donation. The biggest plight of organ donation is lack of the organ donations. When we probed the possibilities of not finish the organ donation procedure, such as religions, traditions and cultural belief, disease cognitions, and the failure of persuasion or the loss of organ donors. There are lots of research literature shown that the attitude of medical personnel would influence the willingness of organ donation or persuasion. This study considered such personnel and their participation in organ donation, specifically analyzing factors influencing their effectiveness. Snowball sampling was adopted to recruit medical staff, organ donors, and transplant coordinators for an online survey. The results revealed that some participants were unclear as to how to initiate the organ donation process and what practical operations are involved. Even with the necessary qualifications, some participants remained passive when soliciting organ donations in clinical practice. Organ donation coordinators with experience in caring for organ donors who attended organ donation courses performed well in soliciting organ donations. The researchers recommend that training courses on clinical planning and organ donation are incorporated into intensive care training and that they serve as the basis for counsellors soliciting organ donations to increase nurses' willingness to solicit organ donations.

Self-Care in the Bereavement Process

Critical care nurses frequently provide end-of-life and bereavement care. This type of care is rewarding, but can put nurses at risk for moral distress, compassion fatigue, and burnout. By incorporating self-care into their routine, critical care nurses minimize this risk and maintain their own health and well-being. This article provides suggestions for promoting physical, emotional, and spiritual self-care for nurses caring for dying intensive care unit patients and their families. A case scenario illustrates the importance of this concept. Practical examples of self-care are highlighted along with discussion on how leadership can support self-care and maintain a healthy work environment.

A qualitative meta-synthesis investigating the experiences of the patient's family when treatment is withdrawn in the intensive care unit

AIM

To synthesize qualitative studies of patients' families' experiences and perceptions of end-of-life care in the intensive care unit when life-sustaining treatments are withdrawn.

DESIGN

Qualitative meta-synthesis.

DATA SOURCES

Comprehensive search of 18 electronic databases for qualitative studies published between January 2005 - February 2019.

REVIEW METHOD

Meta-aggregation.

RESULTS

Thirteen studies met the inclusion criteria. A conceptual 'Model of Preparedness' was developed reflecting the elements of end-of-life care most valued by families: 'End-of-life communication'; 'Valued attributes of patient care'; 'Preparing the family'; 'Supporting the family'; and 'Bereavement care'.

CONCLUSION

A family-centred approach to end-of-life care that acknowledges the values and preferences of families in the intensive care unit is important. Families have unmet needs related to communication, support, and bereavement care. Effective communication and support are central to preparedness and if these care components are in place, families can be better equipped to manage the death, their sadness, loss, and grief. The findings suggest that health professionals may benefit from specialist end-of-life care education to support families and guide the establishment of preparedness.

IMPACT

Understanding the role and characteristics of preparedness during end-of-life care will inform future practice in the intensive care unit and may improve family member satisfaction with care and recovery from loss. Nurses are optimally positioned to address the perceived shortfalls in end-of-life care. These findings have implications for health education, policies, and standards for end-of-life care in the intensive care unit.