Voices From the Pandemic: A Qualitative Study of Family Experiences and Suggestions Regarding the Care of Critically Ill Patients

The facilitators and barriers to implementing virtual visits in intensive care units: A mixed-methods systematic review

BACKGROUND

Visitation has a positive effect on patients and families, yet, it can disrupt intensive care unit (ICU) care and increase the risk of patient infections, which previously favoured face-to-face visits. The coronavirus disease 2019 (COVID-19) pandemic has raised the importance of virtual visits and led to their widespread adoption globally, there are still many implementation barriers that need to be improved. Therefore, this review aimed to explore the use of ICU virtual visit technology during the COVID-19 pandemic and the barriers and facilitators of virtual visits to improve virtual visits in ICUs.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six databases (CINAHL, China National Knowledge Infrastructure [CNKI], PubMed, Cochrane, VIP and Wang Fang databases) were searched for empirical studies published between 1 January 2020 and 22 October 2023. Studies that investigated and reported barriers to and facilitators of implementing virtual visits in ICUs during the COVID-19 pandemic were included. Evidence from the included studies was identified and thematically analysed using Thomas and Harden's three-step approach. Study quality was appraised with the Mixed-Methods Appraisal Tool.

RESULTS

A total of 6770 references were screened, of which 35 studies met the inclusion criteria after a full-text review. Eight main barriers to virtual visits use were identified: technical difficulties; insufficient resources; lack of physical presence and nonverbal information; low technical literacy; differences in families' perceptions of visual cues; privacy and ethics issues; inequitable access and use of virtual visit technology; and lack of advance preparation. Four facilitating factors of virtual visit use were identified: providing multidimensional professional support; strengthening coordination services; understanding the preferences of patients and their families; and enhancing privacy and security protection. In the quality appraisal of 35 studies, 12 studies were rated as low, five as medium and 18 as high methodological quality.

CONCLUSION

This review identified key facilitating factors and barriers to ICU virtual visits, which can foster the development of infrastructure, virtual visiting workflows, guidelines, policies and visiting systems to improve ICU virtual visiting services. Further studies are necessary to identify potential solutions to the identified barriers.

Nursing strategies to mitigate separation between hospitalized acute and critical care patients and families: A scoping review

OBJECTIVE

To describe the nursing strategies used to mitigate the impact of forced separation between hospitalized acute and critical care patients and their families during the COVID-19 pandemic.

RESEARCH METHODOLOGY/DESIGN

A scoping review was performed in accordance with JBI methodology.

SETTINGS

Those acute and critical care areas in which sudden, often unexpected, emergent episodes of illness or injury were treated.

MAIN OUTCOME MEASURES

Articles written in English and French between March 2020 and September 2023 in Medline, CINAHL Complete, APA PsycInfo, Embase and the Cochrane COVID-19 study register databases that met our inclusion criteria were included. Gray literature included dissertations, theses and Base Bielefeld Academic Search Engines.

RESULTS

Among the 1,357 articles screened, 46 met the criteria for inclusion. Most of the articles were published in North America. Adult critical care units were the most frequently reported settings, followed by neonatal intensive care units. The most frequently reported strategies were virtual telephone or video communications. A majority of the innovative strategies involved interprofessional collaboration at the unit level. Core components included the provision of relational nursing practices, virtual visits, tailored information, fostering relationships between family members, palliative care support regarding end of life, and general information about hospitalization and COVID-19. Pediatric care settings were more likely than adult care settings to accommodate physical visitation.

CONCLUSION

Nurses used synchronous, episodic, and structured virtual interactions, either alone or as part of an interprofessional team, to mitigate separation between patients and families during the COVID-19 pandemic in acute and critical care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

Permanent policy changes are needed across acute and critical care settings to provide support for nurses in mitigating patient and family separation. We recommend that family members be considered as caregivers and care receivers, not visitors in patient and family-centered care in acute and critical care settings.

Impact of restricted family presence during the COVID-19 pandemic on critically ill patients, families, and critical care clinicians: a qualitative systematic review

BACKGROUND

We aimed to synthesize the qualitative evidence on the impacts of COVID-19-related restricted family presence policies from the perspective of patients, families, and healthcare professionals from neonatal (NICU), pediatric (PICU), or adult ICUs.

METHODS

We searched MEDLINE, EMBASE, Cochrane Databases of Reviews and Clinical Trials, CINAHL, Scopus, PsycINFO, and Web of Science. Two researchers independently reviewed titles/abstracts and full-text articles for inclusion. Thematic analysis was completed following appraising article quality and assessing confidence in the individual review findings using standardized tools.

RESULTS

We synthesized 54 findings from 184 studies, revealing the impacts of these policies in children and adults on: (1) Family integrated care and patient and family-centered care (e.g., disruption to breastfeeding/kangaroo care, dehumanizing of patients); (2) Patients, families, and healthcare professionals (e.g., negative mental health consequences, moral distress); (3) Support systems (e.g., loss of support from friends/families); and (4) Relationships (e.g., loss of essential bonding with infant, struggle to develop trust). Strategies to mitigate these impacts are reported.

CONCLUSION

This review highlights the multifaceted impacts of restricted visitation policies across distinct care settings and strategies to mitigate the harmful effects of these policies and guide the creation of compassionate family presence policies in future health crises.

REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290263 .

Relationships Between Personality Traits and Perceived Stress in Surrogate Decision-Makers of Intensive Care Unit Patients

INTRODUCTION

Personality traits, specifically neuroticism, are related to stress in surrogate decision-makers (SDMs) in outpatient settings. We hypothesized that intrinsic traits are related to SDM stress in the intensive care unit (ICU) to determine if personality considerations should be included in interventions to support SDMs.

METHODS

Eligible participants (adult SDMs of non-capacitated ICU patients) completed validated questionnaires including stress (Impact of Events Scale-Revised, IES-R) and personality (Big Five Inventory, BFI) within 72 hours of ICU admission and again at 3 months post-ICU discharge (in addition to a qualitative interview). Bivariate Pearson correlations explored the relationship between BFI and IES-R at each time point (95% CI) and t-tests explored the relationship between stress and COVID-19. Mixed-methods analysis integrated qualitative and quantitative data.

RESULTS

Of 32 SDMs, 71.9% were female, 93.8% white, and 97.0% were family members. Neuroticism was not significantly correlated to IES-R at 72 hours (r = 0.09; p = 0.64), but r increased 3 months post-discharge (r = 0.32; p = 0.07). Other BFI traits did not show similar patterns. Total stress was greater in surrogates of COVID-19-positive patients (COVID-19-positive: 60.6; COVID-19-negative: 49.8; p = 0.025). Mixed-methods analysis demonstrated that participants with high neuroticism scores had poorer emotional regulation than those with low neuroticism scores.

CONCLUSIONS

This study supports that personality, particularly neuroticism, influences the stress of SDMs in the ICU. Further study of personality traits may identify surrogates who are at higher risk of stress-related disorders, which can guide future interventions.

Novel Definitions of Wellness and Distress among Family Caregivers of Patients with Acute Cardiorespiratory Failure: A Qualitative Study

Rationale: Family caregivers of patients with acute cardiorespiratory failure are at high risk for distress, which is typically defined as the presence of psychological symptoms such as anxiety, depression, or posttraumatic stress. Interventions to reduce caregiver distress and increase wellness have been largely ineffective to date. An incomplete understanding of caregiver wellness and distress may hinder efforts at developing effective support interventions. Objectives: To allow family caregivers to define their experiences of wellness and distress 6 months after patient intensive care unit (ICU) admission and to identify moderators that influence wellness and distress. Methods: Primary family caregivers of adult patients admitted to the medical ICU with acute cardiorespiratory failure were invited to participate in a semistructured interview 6 months after ICU admission as part of a larger prospective cohort study. Interview guides were used to assess caregiver perceptions of their own well-being, record caregiver descriptions of their experiences of family caregiving, and identify key stress events and moderators that influenced well-being during and after the ICU admission. This study was guided by the Chronic Traumatic Stress Framework conceptual model, and data were analyzed using the five-step framework approach. Results: Among 21 interviewees, the mean age was 58 years, 67% were female, and 76% were White. Nearly half of patients (47%) had died before the caregiver interview. At the time of the interview, 9 caregivers endorsed an overall sense of distress, 10 endorsed a sense of wellness, and 2 endorsed a mix of both. Caregivers defined their experiences of wellness and distress as multidimensional and composed of four main elements: 1) positive versus negative physical and psychological outcomes, 2) high versus low capacity for self-care, 3) thriving versus struggling in the caregiving role, and 4) a sense of normalcy versus ongoing life disruption. Postdischarge support from family, friends, and the community at large played a key role in moderating caregiver outcomes. Conclusions: Caregiver wellness and distress are multidimensional and extend beyond the absence or presence of psychological outcomes. Future intervention research should incorporate novel outcome measures that include elements of self-efficacy, preparedness, and adaptation and optimize postdischarge support for family caregivers.

Epidemiology and outcomes of previously healthy critically ill patients with COVID-19: A population-based cohort

Comorbid conditions represent a major risk for severe illness among persons with COVID-19. Previously healthy people with COVID-19 can also develop severe illness, but are expected to have better outcomes than those with comorbid conditions. Nevertheless, recent data suggest that the former may have, counterintuitively, higher risk of death among those with non-COVID sepsis. However, the epidemiology and outcomes of previously healthy people among critically ill patients with COVID-19 are unknown. We used statewide data to identify intensive care unit (ICU) admissions aged ≥18 years in Texas with COVID-19 in 2020. Multilevel logistic regression was used to estimate the association of comorbid state with short-term mortality (defined as in-hospital mortality or discharge to hospice) overall and with higher illness severity among ICU admissions. Among 52,776 ICU admissions with COVID-19, 6373 (12.1%) were previously healthy. Short-term mortality among previously healthy ICU admissions and those with comorbidities was 16.9% versus 34.6%. On adjusted analyses, the odds of short-term mortality were lower among the previously healthy compared to those with comorbidities overall (adjusted odds ratio (aOR) 0.84 (95% CI: 0.73-0.98)), but did not differ among those with ≥3 organ dysfunctions (aOR 1.11 (95% CI: 0.84-1.46)) and the mechanically ventilated (aOR 0.87 (95% CI: 0.68-1.12)), while being higher among those with do-not-resuscitate status (aOR 1.40 (95% CI: 1.04-1.89)). Over one in eight ICU admissions with COVID-19 were previously healthy. Although being previously healthy was associated with lower risk of death compared to those with comorbidities overall, it had no prognostic advantage among the more severely ill.

Disparities in Palliative Care Among Critically Ill Patients With and Without COVID-19 at the End of Life: A Population-Based Analysis

Background

The surge in critical illness and associated mortality brought by the coronavirus virus disease 2019 (COVID-19) pandemic, coupled with staff shortages and restrictions of family visitation, may have adversely affected delivery of palliative measures, including at the end of life of affected patients. However, the population-level patterns of palliative care (PC) utilization among septic critically ill patients with and without COVID-19 during end-of-life hospitalizations are unknown.

Methods

A statewide dataset was used to identify patients aged ≥ 18 years with intensive care unit (ICU) admission and a diagnosis of sepsis in Texas, who died during hospital stay during April 1 to December 31, 2020. COVID-19 was defined by the International Classification of Diseases, 10th Revision (ICD-10) code U07.1, and PC was identified by ICD-10 code Z51.5. Multivariable logistic models were fitted to estimate the association of COVID-19 with use of PC among ICU admissions. A similar approach was used for sensitivity analyses of strata with previously reported lower and higher than reference use of PC.

Results

There were 20,244 patients with sepsis admitted to ICU during terminal hospitalization, and 9,206 (45.5%) had COVID-19. The frequency of PC among patients with and without COVID-19 was 32.0% vs. 37.1%, respectively. On adjusted analysis, the odds of PC use remained lower among patients with COVID-19 (adjusted odds ratio (aOR): 0.84, 95% confidence interval (CI): 0.78 - 0.90), with similar findings on sensitivity analyses.

Conclusions

PC was markedly less common among critically ill septic patients with COVID-19 during terminal hospitalization, compared to those without COVID-19. Further studies are needed to determine the factors underlying these findings in order to reduce disparities in use of PC.

Experiences with remote communication in adult intensive care units during the COVID-19 pandemic: a systematic review protocol

OBJECTIVE

The objective of this review is to explore the lived experiences of critically ill adults, their families, or health care professionals with remote communication in intensive care units (ICUs) during the COVID-19 pandemic.

INTRODUCTION

Family visiting restrictions in ICUs during the COVID-19 pandemic imposed significant challenges to communication between critically ill adults, their families, and the health care team. Evidence shows that several communication strategies were developed and implemented in ICUs during the COVID-19 pandemic to promote family engagement; however, the experiences of critically ill adults, their families, and health care professionals with these strategies are scattered across primary qualitative studies.

INCLUSION CRITERIA

This review will consider qualitative studies that include critically ill adults, their families, or health care professionals, focusing on their experiences with remote communication strategies in ICUs during the COVID-19 pandemic.

METHODS

This review will be conducted in accordance with JBI methodology. The search strategy will aim to locate both published and unpublished qualitative studies in English, Spanish, and Portuguese. Studies published after January 2020 will be included. Study selection, critical appraisal, and data extraction will be performed independently by 2 reviewers. Data will be presented in narrative format and synthesized using the JBI meta-aggregation process. A ConQual Summary of Findings will be presented.

REVIEW REGISTRATION

PROSPERO CRD42022383603.

"We Aren't Meant to Go Through the Hardest Parts of Our Lives Alone": Family Experience With Restricted PICU Presence During the COVID-19 Pandemic

CONTEXT

PICUs across Canada restricted family presence (RFP) in response to the COVID-19 pandemic from allowing two or more family members to often only one family member at the bedside. The objective of this study was to describe the experiences and impact of RFP on families of critically ill children to inform future policy and practice.

HYPOTHESIS

RFP policies negatively impacted families of PICU patients and caused moral distress.

METHODS AND MODELS

National, cross-sectional, online, self-administered survey. Family members of children admitted to a Canadian PICU between March 2020 and February 2021 were invited to complete the survey. RFP-attributable distress was measured with a modified distress thermometer (0-10). Closed-ended questions were reported with descriptive statistics and multivariable linear regression assessed factors associated with RFP-attributable distress. Open-ended questions were analyzed using inductive content analysis.

RESULTS

Of 250 respondents who experienced RFP, 124 (49.6%) were restricted to one family member at the bedside. The median amount of distress that families attributed to RFP policies was 6 (range: 0-10). Families described isolation, removal of supports, and perception of trauma related to RFP. Most families (183, 73.2%) felt that policies were enforced in a way that made them feel valued by PICU clinicians, which was associated with less RFP-attributable distress. Differential impact was seen where families with lower household income indicated higher RFP-attributable distress score (2.35; 95% CI, 0.53-4.17; p = 0.03). Most respondents suggested that future policies should allow at least two family members at the bedside.

INTERPRETATIONS AND CONCLUSIONS

Families of children admitted to PICUs during the COVID-19 pandemic described increased distress, trauma, and removal of supports due to RFP policies. Vulnerable families showed an increased odds of higher distress. Healthcare professionals played an important role in mitigating distress. Allowance of at least two family members at the bedside should be considered for future policy.

Relatives' experiences of visiting restrictions during the COVID-19 pandemic's first wave: a PREMs study in Valais Hospital, Switzerland

BACKGROUND

During the COVID-19 pandemic, most countries introduced temporary visiting restrictions on the relatives of acute care hospital patients, whether or not they were infected with SARS-CoV-2. This affected relatives' psychological and emotional states and how closely they could be involved in their loved one's hospitalization.

STUDY AIMS

Investigate relatives' experiences of visiting restrictions during the COVID-19 pandemic's first wave and the support offered by Valais Hospital's healthcare staff.

METHODS

Relatives and patients who had been discharged between February 28 and May 13, 2020, were asked to complete a patient-reported experience measures (PREMs) questionnaire, whether or not they had been infected by SARS-CoV-2. Relatives were asked about how visiting restrictions had affected them, their perceptions of the severity of the COVID-19 pandemic, the quality of communication concerning their loved ones' health status during their hospitalization, and the information received from healthcare staff. Descriptive and inferential statistics were computed.

RESULTS

Of 866 PREMs questionnaires returned, 818 were analyzable, and 543 relatives had experienced visiting restrictions to their loved ones: 92 relatives (87%) of COVID-19 patients and 451 relatives (66%) of non-infected patients, with heterogenous effects on their psychological and affective status. Overall, whether or not relatives were subjected to visiting restrictions, they perceived themselves to be well treated, well informed, and that communication with hospital healthcare staff was satisfactory. However, relatives subjected to visiting restrictions reported significantly lower scores on the quality of communication than other relatives. The relatives of patients in gynecology/obstetrics and internal medicine wards were significantly more affected by visiting restrictions than were the relatives of patients in other wards. Numerous relatives subjected to visiting restrictions reported regular communication with their loved ones or with healthcare staff, at least once a day (n = 179), either via videoconferences using FaceTime®, WhatsApp®, Zoom®, or Skype® or via mobile phone text messages.

CONCLUSION

Visiting restrictions affected relatives differently depending on the wards their loved ones were hospitalized. Healthcare institutions should investigate the utility of visiting restrictions on patients, how they affect relatives, and how to improve personalized patient-relative communications. Future research should attempt to develop reliable, validated measurement instruments of relatives' experiences of acute-care visiting restrictions during pandemics.

Psychiatric nurses' perception of dignity in patients who attempted suicide

BACKGROUND

Maintaining the dignity of patients who attempted suicide is one of the caregivers' main ethical duties. Yet, in many cases, these patients are not treated with dignity. The concept of dignity is abstract, and there is no research on the dignity of suicidal patients. So, the present study is done to investigate psychiatric nurses' perception of dignity in patients who attempted suicide.

OBJECTIVE

The present study explores the concept of dignity in patients who attempted suicide from the perspective of psychiatric nurses.

RESEARCH DESIGN

The present study is a qualitative, descriptive work of research.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 20 psychiatric nurses from 2 hospitals affiliated with a university of medical sciences in the southeast of Iran were selected via purposeful sampling.

ETHICAL CONSIDERATIONS

The Research Ethics Committee of the Hamadan University of Medical Sciences approved the study's protocol, and ethical principles were followed in general.

FINDINGS

From the findings of the study, three main themes, namely " respect for personal; identity," "management of psychological tension," and "compassion-focused therapy," with 12 sub-themes were extracted.

DISCUSSION AND CONCLUSION

In the perspective of caregivers, patients who attempted suicide need to be cared for in supportive environments with compassionate and respectful behaviors to control their psychological tensions. These conditions would maintain such patients' dignity and result in appropriate behavioral outcomes. Policy-makers and administrators can use the present study's findings to create an appropriate clinical environment in which the dignity of patients who attempted suicide is properly maintained.

Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study

Background

During the pandemic, traditional family meetings were replaced by remote telecommunications. We assessed the families' satisfaction with these communications using a survey-based questionnaire.

Methods

The study involved 20-minute telephonic surveys conducted with the family member who was updated during the hospitalization of the patient. A thematic-based questionnaire with responses on a scale of 5 ranging from very dissatisfied to very satisfied was used. The responses were dichotomized into bad and good reports for analysis.

Results

A total of 196 patients were eligible. Only 154 patients' family representatives consented to the study. The frequency and content of the telephonic updates were satisfactory. The bad report was assigned to 5% of families only. Among features assessing empathy of communication providers, the satisfaction rate was much higher with 3% of families alone providing a bad report. The response was significantly biased against the final outcome of the patient with poor review often provided by relatives of patients who had succumbed to the illness. The dissatisfaction rate was much higher, above 12% for the trust of communication and ICU visitation. However, the final outcome of the patient did not affect the trust in the information conveyed by the physician.

Interpretation

This study highlights several drawbacks in the communication strategy during the second surge of coronavirus disease-2019 (COVID-19). The final outcome of the patient was the key decisive factor for the response to most of the questionnaire. Sustained faith in communication by the physician despite the final outcome of the patient, re-emphasizes the need for emotional connection and training for breaking bad news.

How to cite this article

Varghese MP, Selwyn T, Nair S, Samuel S, Chacko B, Pichamuthu K. Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study. Indian J Crit Care Med 2023;27(8):537-544.

Support for relatives in the intensive care unit: lessons from a cross-sectional multicentre cohort study during the COVID-19 pandemic

BACKGROUND

Support for relatives is highly important in the intensive care unit (ICU). During the first COVID-19 wave  support for relatives had to be changed considerably. The alternative support could have decreased the quality and sense of support. We aimed to evaluate how support for relatives in Dutch ICUs was organised during the first COVID-19 wave and how this was experienced by these relatives in comparison to relatives from pre-COVID-19 and the second wave. Additionally, we aimed to investigate which elements of support are associated with positive experiences.

METHODS

We performed a cross-sectional multicentre cohort study in six Dutch ICUs in the Netherlands. Written questionnaires were distributed among relatives of ICU patients from pre-COVID-19, the first wave and the second wave. The questionnaire included questions on demographics, the organisation of support, and the experiences and satisfaction of relatives with the support.

RESULTS

A total of 329 relatives completed the questionnaire (52% partner, 72% woman and 63% ICU stay of 11 days or longer). Support for relatives of ICU patients during the first COVID-19 wave differed significantly from pre-COVID-19 and the second wave. Differences were found in all categories of elements of support: who, when, how and what. Overall, relatives from the three time periods were very positive about the support. The only difference in satisfaction between the three time periods, was the higher proportion of relatives indicating that healthcare professionals had enough time for them during the first wave. Elements of support which were associated with many positive experiences and satisfaction were: fixed timeslot, receiving information (e.g. leaflets) on ≥ 2 topics, discussing > 5 topics with healthcare professionals, and being offered emotional support.

CONCLUSIONS

Although, support for relatives in the ICU changed considerably during the COVID-19 pandemic, relatives were still positive about this support. The altered support gave insight into avenues for improvement for future comparable situations as well as for normal daily ICU practice: e.g. daily contact at a fixed timeslot, offering video calling between patients and relatives, and offering emotional support. ICUs should consider which elements need improvement in their practice.

Written Communication, Visitation Policies, and Awareness of Medical Issues Among Intensive Care Unit Families

BACKGROUND

Open intensive care unit (ICU) visitation policies facilitate communication between clinicians and patients' families. Restrictive visitation policies (eg, during a pandemic) may reduce families' comprehension of information.

OBJECTIVES

To determine whether written communication increased awareness of medical issues among ICU families and whether the effect size depended on the visitation policies in place when participants were enrolled.

METHODS

Families of ICU patients were randomly assigned to receive usual care with or without daily written patient care updates from June 2019 to January 2021. Participants were asked whether patients had experienced 6 ICU problems at up to 2 time points during the ICU stay. Responses were compared with the study investigators' consensus.

RESULTS

Of 219 participants, 131 (60%) were restricted from visiting. Participants in the written communication group were more likely than participants in the control group to correctly identify shock, renal failure, and weakness and were just as likely as participants in the control group to correctly identify respiratory failure, encephalopathy, and liver failure. Participants in the written communication group were more likely than participants in the control group to correctly identify the patient's ICU problems when all 6 were grouped as a composite outcome, with the adjusted odds ratio of correct identification tending to be higher among participants enrolled during restricted versus open visitation periods: 2.9 (95% CI, 1.9-4.2; P < .001) vs 1.8 (95% CI, 1.1-3.1; P = .02), P = .17 for difference.

CONCLUSIONS

Written communication helps families correctly identify ICU issues. The benefit may be enhanced when families cannot visit the hospital. ClinicalTrials.gov Identifier: NCT03969810.

Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies: an American College of Physicians Position Paper

Public health emergencies create challenges for the accommodation of visitors to hospitals and other care facilities. To mitigate the spread of COVID-19 early in the pandemic, health care institutions implemented severe visitor restrictions, many remaining in place more than 2 years, producing serious unintended harms. Visitor restrictions have been associated with social isolation and loneliness, worse physical and mental health outcomes, impaired or delayed decision-making, and dying alone. Patients with disabilities, communication challenges, and cognitive or psychiatric impairments are particularly vulnerable without caregiver presence. This paper critically examines the justifications for, and harms imposed by, visitor restrictions during the COVID-19 pandemic and offers ethical guidance on family caregiving, support, and visitation during public health emergencies. Visitation policies must be guided by ethical principles; incorporate the best available scientific evidence; recognize the invaluable roles of caregivers and loved ones; and involve relevant stakeholders, including physicians, who have an ethical duty to advocate for patients and families during public health crises. Visitor policies should be promptly revised as new evidence emerges regarding benefits and risks in order to prevent avoidable harms.

Restricted family presence for hospitalized surgical patients during the COVID-19 pandemic: How hospital care providers and families navigated ethical tensions and experiences of institutional betrayal

Early in the COVID-19 pandemic restricted family presence in hospitals was a widespread public health intervention to preserve critical resources and mitigate the virus's spread. In this study, we explore the experiences of surgical care providers and family members of hospitalized surgical patients during the period of highly restricted visiting (March 2020 to April 2021) in a large Canadian academic hospital. Thirty-four interviews were completed with hospital providers, family members and members of the hospital's visitor task force. To understand hospital providers' experiences, we highlight the ethical tensions produced by the biomedical and public health ethics frameworks that converged during COVID-19 in hospital providers' bedside practice. Providers grappled with mixed feelings in support of and against restricted visiting, while simultaneously experiencing gaps in resources and care and acting as patient gatekeepers. To understand family members' experiences of communication and care, we use the theory of institutional betrayal to interpret the negative impacts of episodic and systemic communication failures during restricted visiting. Family members of the most vulnerable patients (and patients) experienced short- and long-term effects including anxiety, fear, and refusal of further care. Our analysis draws attention to the complex ways that hospital care providers and families of hospitalized surgical patients sought to establish and reconfigure how trust and patient-centeredness could be achieved under these unprecedented conditions. Practical learnings from this study suggest that if family presence in hospitals must be limited in the future, dedicated personnel for communication and emotional support for patients, families and staff must be prioritized.

Evidence-informed consensus statements to guide COVID-19 patient visitation policies: results from a national stakeholder meeting

PURPOSE

Hospital policies forbidding or limiting families from visiting relatives on the intensive care unit (ICU) has affected patients, families, healthcare professionals, and patient- and family-centered care (PFCC). We sought to refine evidence-informed consensus statements to guide the creation of ICU visitation policies during the current COVID-19 pandemic and future pandemics and to identify barriers and facilitators to their implementation and sustained uptake in Canadian ICUs.

METHODS

We created consensus statements from 36 evidence-informed experiences (i.e., impacts on patients, families, healthcare professionals, and PFCC) and 63 evidence-informed strategies (i.e., ways to improve restricted visitation) identified during a modified Delphi process (described elsewhere). Over two half-day virtual meetings on 7 and 8 April 2021, 45 stakeholders (patients, families, researchers, clinicians, decision-makers) discussed and refined these consensus statements. Through qualitative descriptive content analysis, we evaluated the following points for 99 consensus statements: 1) their importance for improving restricted visitation policies; 2) suggested modifications to make them more applicable; and 3) facilitators and barriers to implementing these statements when creating ICU visitation policies.

RESULTS

Through discussion, participants identified three areas for improvement: 1) clarity, 2) accessibility, and 3) feasibility. Stakeholders identified several implementation facilitators (clear, flexible, succinct, and prioritized statements available in multiple modes), barriers (perceived lack of flexibility, lack of partnership between government and hospital, change fatigue), and ways to measure and monitor their use (e.g., family satisfaction, qualitative interviews).

CONCLUSIONS

Existing guidance on policies that disallowed or restricted visitation in intensive care units were confusing, hard to operationalize, and often lacked supporting evidence. Prioritized, succinct, and clear consensus statements allowing for local adaptability are necessary to guide the creation of ICU visitation policies and to optimize PFCC.

Communication and visiting policies in Italian intensive care units during the first COVID-19 pandemic wave and lockdown: a nationwide survey

BACKGROUND

During the first coronavirus disease 2019 (COVID-19) pandemic wave, an unprecedented number of patients with respiratory failure due to a new, highly contagious virus needed hospitalization and intensive care unit (ICU) admission. The aim of the present study was to describe the communication and visiting policies of Italian intensive care units (ICUs) during the first COVID-19 pandemic wave and national lockdown and compare these data with prepandemic conditions.

METHODS

A national web-based survey was conducted among 290 Italian hospitals. Each ICU (active between February 24 and May 31, 2020) was encouraged to complete an individual questionnaire inquiring the hospital/ICU structure/organization, communication/visiting habits and the role of clinical psychology prior to, and during the first COVID-19 pandemic wave.

RESULTS

Two hundred and nine ICUs from 154 hospitals (53% of the contacted hospitals) completed the survey (202 adult and 7 pediatric ICUs). Among adult ICUs, 60% were dedicated to COVID-19 patients, 21% were dedicated to patients without COVID-19 and 19% were dedicated to both categories (Mixed). A total of 11,102 adult patients were admitted to the participating ICUs during the study period and only approximately 6% of patients received at least one visit. Communication with family members was guaranteed daily through an increased use of electronic devices and was preferentially addressed to the same family member. Compared to the prepandemic period, clinical psychologists supported physicians more often regarding communication with family members. Fewer patients received at least one visit from family members in COVID and mixed-ICUs than in non-COVID ICUs, l (0 [0-6]%, 0 [0-4]% and 11 [2-25]%, respectively, p < 0.001). Habits of pediatric ICUs were less affected by the pandemic.

CONCLUSIONS

Visiting policies of Italian ICUs dedicated to adult patients were markedly altered during the first COVID-19 wave. Remote communication was widely adopted as a surrogate for family meetings. New strategies to favor a family-centered approach during the current and future pandemics are warranted.

Stress-Related Disorders of Family Members of Patients Admitted to the Intensive Care Unit With COVID-19

IMPORTANCE

The psychological symptoms associated with having a family member admitted to the intensive care unit (ICU) during the COVID-19 pandemic are not well defined.

OBJECTIVE

To examine the prevalence of symptoms of stress-related disorders, primarily posttraumatic stress disorder (PTSD), in family members of patients admitted to the ICU with COVID-19 approximately 90 days after admission.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, multisite, mixed-methods observational cohort study assessed 330 family members of patients admitted to the ICU (except in New York City, which had a random sample of 25% of all admitted patients per month) between February 1 and July 31, 2020, at 8 academic-affiliated and 4 community-based hospitals in 5 US states.

EXPOSURE

Having a family member in the ICU with COVID-19.

MAIN OUTCOMES AND MEASURES

Symptoms of PTSD at 3 months, as defined by a score of 10 or higher on the Impact of Events Scale 6 (IES-6).

RESULTS

A total of 330 participants (mean [SD] age, 51.2 [15.1] years; 228 [69.1%] women; 150 [52.8%] White; 92 [29.8%] Hispanic) were surveyed at the 3-month time point. Most individuals were the patients' child (129 [40.6%]) or spouse or partner (81 [25.5%]). The mean (SD) IES-6 score at 3 months was 11.9 (6.1), with 201 of 316 respondents (63.6%) having scores of 10 or higher, indicating significant symptoms of PTSD. Female participants had an adjusted mean IES-6 score of 2.6 points higher (95% CI, 1.4-3.8; P < .001) than male participants, whereas Hispanic participants scored a mean of 2.7 points higher compared with non-Hispanic participants (95% CI, 1.0-4.3; P = .002). Those with graduate school experience had an adjusted mean score of 3.3 points lower (95% CI, 1.5-5.1; P < .001) compared with those with up to a high school degree or equivalent. Qualitative analyses found no substantive differences in the emotional or communication-related experiences between those with high vs low PTSD scores, but those with higher scores exhibited more distrust of practitioners.

CONCLUSIONS AND RELEVANCE

In this cohort study, symptoms of PTSD among family members of ICU patients with COVID-19 were high. Hispanic ethnicity and female gender were associated with higher symptoms. Those with higher scores reported more distrust of practitioners.

Low and No-Contact Euthanasia: Associated Ethical Challenges Experienced by Veterinary Team Members during the Early Months of the COVID-19 Pandemic

Simple Summary

During the COVID-19 pandemic, many veterinary practices have been required to move to a low or no-contact consultation model to minimise the risk of SARS-CoV-2. Utilising data from a global survey, we explored the experiences of veterinary team members performing low and no-contact euthanasia during the early months of the COVID-19 pandemic. We found that low and no-contact euthanasia were encountered as common and/or stressful ethical challenges in the pandemic. In order to minimise the potential negative impacts of low and no-contact euthanasia on veterinary team members, clients and animal patients, there is a need for a toolkit of protocols to assist veterinary team members in provision of low-contact euthanasia, and avoidance of no-contact euthanasia wherever possible.

Abstract

Background: During the ongoing COVID-19 pandemic, many veterinary practices around the world have shifted to a low or no-contact consultation model to ensure the safety of their team members and clients, and comply with public health orders, while continuing to provide veterinary care. Methods: We performed reflexive thematic analysis on a subset of data collected using a mixed-methods survey of veterinary team members globally. Results: There were 540 valid responses available for analysis. Low and no-contact euthanasia we raised as a common and/or stressful ethical challenge for 22.8% of respondents. We identified five key themes: no-contact euthanasia as a unique ethical challenge; balancing veterinary team safety with the emotional needs of clients; low and no-contact protocols may cause or exacerbate fear, anxiety and distress in veterinary patients; physical distancing was more challenging during euthanasia consultations; and biosecurity measures complicated communication around euthanasia and end-of-life decision making. Recommendations: In light of concerns highlighted by respondents, we recommend the development of a toolkit of protocols that will assist veterinary team members in performing low-contact euthanasia in a range of circumstances, in alignment with their values and professional ethical codes. Professional bodies may be involved in developing, updating and disseminating this information, and ensuring a continuous supply chain of PPE.