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Chen W, Chung JOK, Lam KKW, Molassiotis A. End-of-life communication strategies for healthcare professionals: A scoping review. Palliat Med 2023; 37:61-74. [PMID: 36349371 DOI: 10.1177/02692163221133670] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Timely and effective communication about end-of-life issues, including conversations about prognosis and goals of care, are extremely beneficial to terminally ill patients and their families. However, given the context, healthcare professionals may find it challenging to initiate and facilitate such conversations. Hence, it is critical to improving the available communication strategies to enhance end-of-life communication practices. AIM To summarise the end-of-life communication strategies recommended for healthcare professionals, identify research gaps and inform future research. DESIGN A scoping review performed in accordance with the Arksey and O'Malley framework. DATA SOURCES A literature search was conducted between January 1990 and January 2022 using PubMed, CINAHL, Embase, PsycINFO, Web of Science, Scopus, Cochrane Library and China National Knowledge Infrastructure databases and Google, Google Scholar and ProQuest Dissertations & Theses Global. Studies that described recommended end-of-life communication strategies for healthcare professionals were included. RESULTS Fifty-nine documents were included. Seven themes of communication strategies were found: (a) preparation; (b) exploration and assessment; (c) family involvement; (d) provision and tailoring of information; (e) empathic emotional responses; (f) reframing and revisiting the goals of care; and (g) conversation closure. CONCLUSIONS The themes of communication strategies found in this review provide a framework to integrally promote end-of-life communication. Our results will help inform healthcare professionals, thereby promoting the development of specialised training and education on end-of-life communication.
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Affiliation(s)
- Weilin Chen
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China
| | - Joyce Oi Kwan Chung
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China
| | - Katherine Ka Wai Lam
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China
| | - Alex Molassiotis
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China.,Health and Social Care Research Centre, University of Derby, Derby, UK
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Abstract
The phenomenon of end-of-life (EOL) decision-making is a lived experience by which individuals or families make decisions about care they will receive prior to death. A postmodern philosophical approach suggests EOL decision-making is a varied contextual phenomenon that is highly influenced by subjectivity. Thus, there is no specific definition for the phenomenon of EOL decision-making. Watson's theory of human caring complements a postmodern approach in guiding the nursing process of caring for individuals as they experience EOL decision-making.
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Affiliation(s)
- Komal Patel Murali
- PhD Student, New York University, Rory Meyers College of Nursing, New York, NY, USA
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3
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Temple WJ. Inspiring hope-A physician's responsibility, translating the science into clinical practice. J Surg Oncol 2017; 117:545-550. [DOI: 10.1002/jso.24887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/23/2017] [Indexed: 12/27/2022]
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McDonald DD, Deloge JA, Joslin N, Petow WA, Severson JS, Votino R, Shea MD, Drenga JML, Brennan MT, Moran AB, Del Signore E. Communicating End-of-Life Preferences. West J Nurs Res 2016; 25:652-66; discussion 667-75. [PMID: 14528616 DOI: 10.1177/0193945903254062] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this survey was to explore how adults communicate their end-of-life preferences. Face-to-face interviews were conducted with 119 community-dwelling adults who had previously engaged in conversations about their end-of-life preferences. Factors that made it easier to initiate the discussion included having personal experience with illness or death (24.4%), being straightforward (24.4%), or having someone else facilitate the discussion (11.8%). Most described vague end-of-life preferences such as not wanting any machines (41.2%) or heroics (34.5%). Although 22.7% reported using a living will to make their preferences clear, only 5.9% mentioned repeating or reinforcing their preferences. In all, 21% had discussed their end-of-life preferences with their physicians. These findings show discussions about end-of-life preferences frequently lack the clarity and detail needed by significant others and health care providers to honor the preferences. Routine dialogue with health care providers and significant others about end-of-life preferences might provide greater clarity and comfort.
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Hardy JR, Douglas CM. Pining for the fjords(1). Intern Med J 2016; 46:651-2. [PMID: 27257147 DOI: 10.1111/imj.13105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- J R Hardy
- Department of Palliative and Supportive Care, Mater Health Services.,Mater Research-University of Queensland, Queensland, Australia
| | - C M Douglas
- Palliative and Supportive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Kaambwa B, Ratcliffe J, Bradley SL, Masters S, Davies O, Whitehead C, Milte C, Cameron ID, Young T, Gordon J, Crotty M. Costs and advance directives at the end of life: a case of the 'Coaching Older Adults and Carers to have their preferences Heard (COACH)' trial. BMC Health Serv Res 2015; 15:545. [PMID: 26645745 PMCID: PMC4673742 DOI: 10.1186/s12913-015-1201-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 11/30/2015] [Indexed: 12/31/2022] Open
Abstract
Background Total costs associated with care for older people nearing the end of life and the cost variations related with end of life care decisions are not well documented in the literature. Healthcare utilisation and associated health care costs for a group of older Australians who entered Transition Care following an acute hospital admission were calculated. Costs were differentiated according to a number of health care decisions and outcomes including advance directives (ADs). Methods Study participants were drawn from the Coaching Older Adults and Carers to have their preferences Heard (COACH) trial funded by the Australian National Health and Medical Research Council. Data collected included total health care costs, the type of (and when) ADs were completed and the place of death. Two-step endogenous treatment-regression models were employed to test the relationship between costs and a number of variables including completion of ADs. Results The trial recruited 230 older adults with mean age 84 years. At the end of the trial, 53 had died and 80 had completed ADs. Total healthcare costs were higher for younger participants and those who had died. No statistically significant association was found between costs and completion of ADs. Conclusion For our frail study population, the completion of ADs did not have an effect on health care utilisation and costs. Further research is needed to substantiate these findings in larger and more diverse clinical cohorts of older people. Trial registration This study was registered on 13/12/2007 with the Australian New Zealand Clinical Trial Registry (ACTRN12607000638437).
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Affiliation(s)
- Billingsley Kaambwa
- Flinders Health Economics group, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia. .,Billingsley Kaambwa, Flinders Health Economics Group, School of Medicine, Flinders University, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
| | - Julie Ratcliffe
- Flinders Health Economics group, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
| | - Sandra L Bradley
- CareSearch, Palliative care knowledge network, Palliative and Supportive Services, Flinders University, PO Box 2100, Adelaide, SA, 5001, Australia.
| | - Stacey Masters
- The Discipline of General Practice, Health Sciences Building, Flinders University, GPO Box 2100, SA, 5001, Adelaide, Australia.
| | - Owen Davies
- Department of Rehabilitation and Aged Care, Flinders University, C Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
| | - Craig Whitehead
- Department of Rehabilitation and Aged Care, Flinders University, C Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
| | - Catherine Milte
- School of Exercise and Nutrition Sciences, Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC, 3125, Melbourne, Australia.
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, University of Sydney, Level 13, Kolling Institute of Medical Research, Corner Reserve Road and Westbourne Avenue, Royal North Shore Hospital, St Leonards, NSW, 2065, Sydney, Australia.
| | - Tracey Young
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Jason Gordon
- Discipline of Public Health, University of Adelaide, 178 North Terrace, Terrace Towers, SA, 5005, Adelaide, Australia.
| | - Maria Crotty
- Department of Rehabilitation and Aged Care, Flinders University, C Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
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8
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Olsman E, Leget C, Onwuteaka-Philipsen B, Willems D. Should palliative care patients' hope be truthful, helpful or valuable? An interpretative synthesis of literature describing healthcare professionals' perspectives on hope of palliative care patients. Palliat Med 2014; 28:59-70. [PMID: 23587737 DOI: 10.1177/0269216313482172] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Healthcare professionals' perspectives on palliative care patients' hope influence communication. However, these perspectives have hardly been examined. AIM To describe healthcare professionals' perspectives on palliative care patients' hope found in the literature. DESIGN The interpretative synthesis consisted of a quality assessment and thematic analysis of included articles. DATA SOURCES Literature search of articles between January 1980 and July 2011 in PubMed, CINAHL, PsycINFO and EMBASE and references of included studies. SEARCH STRATEGY (palliat* or hospice or terminal* in title/abstract or as subject heading) AND (hope* or hoping or desir* or optimis* in title or as subject heading). RESULTS Of the 37 articles, 31 articles were of sufficient quality. The majority of these 31 articles described perspectives of nurses or physicians. Three perspectives on hope of palliative care patients were found: (1) realistic perspective - hope as an expectation should be truthful, and healthcare professionals focused on adjusting hope to truth, (2) functional perspective - hope as coping mechanism should help patients, and professionals focused on fostering hope, and (3) narrative perspective - hope as meaning should be valuable for patients, and healthcare professionals focused on interpreting it. CONCLUSIONS Healthcare professionals who are able to work with three perspectives on hope may improve their communication with their palliative care patients, which leads to a better quality of care.
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Affiliation(s)
- Erik Olsman
- 1Department of General Practice, Section of Medical Ethics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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10
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Understanding the needs of family caregivers of older adults dying with dementia. Palliat Support Care 2013; 12:223-31. [DOI: 10.1017/s1478951513000461] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectives:A challenge in understanding the needs of dementia family caregivers (DFC) within the purview of dementia as a terminal illness rests on the fact that literature in this area is dispersed across disciplines and not specifically grounded within the realm of palliative care. The objective of this paper is to describe the domains of DFC needs and their impact on the delivery of palliative care services.Methods:A literature search pertaining to dementia family caregivers and palliative/end-of-life care was conducted using the databases Medline, CINHAL, Ageline, PsychInfo, and Scopus for articles published in the English language between 1997 and 2011.Results:Supporting family caregivers of individuals with dementia throughout the disease trajectory requires consideration of caregivers : (1) physical, emotional, and psychological needs; (2) information and decisional support needs; and (3) instrumental support needs. The unique nature and prolonged duration of these needs directly influences the palliative care services and supports required by these family caregivers.Significance of results:Understanding the scope of DFC needs help further our understanding of how these needs may impact the delivery of palliative care services, and assists in developing a model of care for those dying from dementia and for their family caregivers.
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Evangelista LS, Motie M, Lombardo D, Ballard-Hernandez J, Malik S, Liao S. Does preparedness planning improve attitudes and completion of advance directives in patients with symptomatic heart failure? J Palliat Med 2012; 15:1316-20. [PMID: 22989252 DOI: 10.1089/jpm.2012.0228] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There is little evidence to support whether interventions that engage patients with symptomatic heart failure (HF) in preparedness planning impacts completion of advance directives (ADs). This study was conducted to assess the impact of a palliative care intervention on health perceptions, attitudes, receipt of information and knowledge of ADs, discussion of ADs with family and physicians, and completion of ADs in a cohort of patients with symptomatic HF. METHODS Thirty-six patients hospitalized for HF decompensation were recruited and referred for an outpatient consultation with a palliative care specialist in conjunction with their routine HF follow-up visit after discharge; telephone interviews to assess health status and attitudes toward ADs were conducted before and 3 months after the initial consultation using an adapted version of the Advance Directive Attitude Survey (ADAS). Information pertaining to medical history and ADs was verified through medical chart abstraction. RESULTS AND CONCLUSION The current study found support for enhancing attitudes and completion of ADs following a palliative care consultation in patients with symptomatic HF. Despite a significant increase in attitudes toward completion of ADs following the intervention, only 47% of the participants completed ADs. This finding suggests that although education and understanding of ADs is important and can result in more positive attitudes, it does not translate to completion of ADs in all patients.
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Affiliation(s)
- Lorraine S Evangelista
- 1Program of Nursing Science, University of California Irvine, Irvine, California 92697, USA.
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Jo KH. Development and Evaluation of Shared Medical Decision-Making Scale for End-of-Life Patients in Korea. J Korean Acad Nurs 2012; 42:453-65. [DOI: 10.4040/jkan.2012.42.4.453] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kae Hwa Jo
- Catholic University of Daegu, College of Nursing, Daegu, Korea.
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Powers BA, Norton SA, Schmitt MH, Quill TE, Metzger M. Meaning and practice of palliative care for hospitalized older adults with life limiting illnesses. J Aging Res 2011; 2011:406164. [PMID: 21584232 PMCID: PMC3092544 DOI: 10.4061/2011/406164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 01/22/2011] [Indexed: 11/20/2022] Open
Abstract
Objective. To illustrate distinctions and intersections of palliative care (PC) and end-of-life (EOL) services through examples from case-centered data of older adults cared for during a four-year ethnographic study of an acute care hospital palliative care consultation service. Methods. Qualitative narrative and thematic analysis. Results. Description of four practice paradigms (EOL transitions, prognostic uncertainty, discharge planning, and patient/family values and preferences) and identification of the underlying structure and communication patterns of PC consultation services common to them. Conclusions. Consistent with reports by other researchers, study data support the need to move beyond equating PC with hospice or EOL care and the notion that EOL is a well-demarcated period of time before death. If professional health care providers assume that PC services are limited to assisting with and helping patients and families prepare for dying, they miss opportunities to provide care considered important to older individuals confronting life-limiting illnesses.
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Affiliation(s)
- Bethel Ann Powers
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
| | - Sally A. Norton
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
| | - Madeline H. Schmitt
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
| | - Timothy E. Quill
- School of Medicine and Dentistry, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
| | - Maureen Metzger
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
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Warnock C, Tod A, Foster J, Soreny C. Breaking bad news in inpatient clinical settings: role of the nurse. J Adv Nurs 2010; 66:1543-55. [PMID: 20492016 DOI: 10.1111/j.1365-2648.2010.05325.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This paper is a report of an exploration of the role of the nurse in the process of breaking bad news in the inpatient clinical setting and the provision of education and support for nurses carrying out this role. BACKGROUND The term 'breaking bad news' is mostly associated with the moment when negative medical information is shared with a patient or relative. However, it can also be seen as a process of interactions that take place before, during and after bad news is broken. Little research has been conducted exploring the role of the nurse in the process of breaking bad news in the inpatient clinical setting. METHODS A questionnaire was developed using Likert scales and open text questions. Data collection took place in 2007. Fifty-nine inpatient areas took part in the study; 335 questionnaires were distributed in total and 236 were completed (response rate 70%). RESULTS Nurses engaged in diverse breaking bad news activities at many points in care pathways. Relationships with patients and relatives and uncontrolled and unplanned events shaped the context in which they provided this care. Little formal education or support for this work had been received. CONCLUSION Guidance for breaking bad news should encompass the whole process of doing this and acknowledge the challenges nurses face in the inpatient clinical area. Developments in education and support are required that reflect the challenges that nurses encounter in the inpatient care setting.
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Affiliation(s)
- Clare Warnock
- Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Hansen L, Goodell TT, DeHaven J, Smith M. Nurses' perceptions of end-of-life care after multiple interventions for improvement. Am J Crit Care 2009; 18:263-71; quiz 272. [PMID: 19411585 DOI: 10.4037/ajcc2009727] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Nurses working in intensive care units may lack knowledge and skills in end-of-life care, find caring for dying patients and the patients' families stressful, and lack support to provide this care. OBJECTIVES To describe nurses' perceptions of (1) knowledge and ability, (2) work environment, (3) support for staff, (4) support for patients and patients' families, and (5) stress related to specific work situations in the context of end-of-life care before (phase 1) and after (phase 2) implementation of approaches to improve end-of-life care. The approaches were a nurse-developed bereavement program for patients' families, use of a palliative medicine and comfort care team, preprinted orders for the withdrawal of life-sustaining treatment, hiring of a mental health clinical nurse specialist, and staff education in end-of-life care. METHODS Nurses in 4 intensive care units at a university medical center reported their perceptions of end-of-life care by using a 5-subscale tool consisting of 30 items scored on a 4-point Likert scale. The tool was completed by 91 nurses in phase 1 and 127 in phase 2. RESULTS Improvements in overall mean scores on the 5 sub-scales indicated that the approaches succeeded in improving nurses' perceptions. In phase 2, most of the subscale overall mean scores were higher than a desired criterion (<2.0, good). Analysis of variance indicated that some improvements occurred over time differently in the units; other improvements occurred uniformly. CONCLUSIONS Continued practice development is needed in end-of-life care issues.
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Affiliation(s)
- Lissi Hansen
- Lissi Hansen and Teresa Goodell are assistant professors, Josi DeHaven is a nursing practice and education coordinator, and MaryDenise Smith is a palliative care clinical nurse specialist at Oregon Health and Science University, Portland, Oregon
| | - Teresa T. Goodell
- Lissi Hansen and Teresa Goodell are assistant professors, Josi DeHaven is a nursing practice and education coordinator, and MaryDenise Smith is a palliative care clinical nurse specialist at Oregon Health and Science University, Portland, Oregon
| | - Josi DeHaven
- Lissi Hansen and Teresa Goodell are assistant professors, Josi DeHaven is a nursing practice and education coordinator, and MaryDenise Smith is a palliative care clinical nurse specialist at Oregon Health and Science University, Portland, Oregon
| | - MaryDenise Smith
- Lissi Hansen and Teresa Goodell are assistant professors, Josi DeHaven is a nursing practice and education coordinator, and MaryDenise Smith is a palliative care clinical nurse specialist at Oregon Health and Science University, Portland, Oregon
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Palan Lopez R. Doing what's best: decisions by families of acutely Ill nursing home residents. West J Nurs Res 2009; 31:613-26. [PMID: 19321882 DOI: 10.1177/0193945909332911] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
When nursing home residents experience acute illness, the preference of family members is a major consideration in the choice between aggressive treatment and palliative care. Grounded theory method was used to explore decision making by family members of acutely ill nursing home residents. Analysis of 12 in-depth interviews with family members resulted in a theory, "doing what's best," that describes the basic psychosocial problem and response of family members. The problem was to make treatment decisions in the face of uncertain circumstances, and the response consisted of five subprocesses: protecting life, creating comfort, relying on religion, honoring wishes, and seeking guidance. Application of this theory to nursing practice can help nurses identify sources of uncertainty and support family members to clarify priorities for life prolongation or comfort, rely on religious or spiritual solace, translate resident wishes into individualized care plans, and provide knowledgeable guidance and support throughout the decision-making process.
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Affiliation(s)
- Ruth Palan Lopez
- MGH Institute of Health Professions, Boston, University of Pennsylvania, Philadelphia, USA
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Kruse BG, Melhado LW, Convertine L, Stecher J. Evaluating strategies for changing acute care nurses' perceptions on end-of-life care. Am J Hosp Palliat Care 2009; 25:389-97. [PMID: 19047492 DOI: 10.1177/1049909108322368] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Providing quality care to the dying has become a primary concern in the United States. Eighty percent of deaths still occur in the hospital even though nurses report they do not think that good deaths are routinely possible within a hospital setting due to lack of appropriate education on end-of-life care. The aim of this pilot study was to test the best method for changing acute nurse's perceptions about end-of-life care. A 3-group experimental design tested the efficacy of a nurse-led hospice collaborative. Hypotheses were: (1) nurses who receive classroom instruction will have greater change in perceptions than the control group and (2) nurses who receive a combination of classroom and hospice experiences will demonstrate greater changes than the classroom or control group. No significant differences were found among the 3 groups. However, the intervention group showed increased guilt about not having enough time to spend with the dying.
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Affiliation(s)
- Barbara G Kruse
- School of Nursing, Florida Gulf Coast University, Fort Myers, FL 33965, USA.
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Bach V, Ploeg J, Black M. Nursing Roles in End-of-Life Decision Making in Critical Care Settings. West J Nurs Res 2009; 31:496-512. [PMID: 19208850 DOI: 10.1177/0193945908331178] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study used a grounded theory approach to formulate a conceptual framework of the nursing role in end-of-life decision making in a critical care setting. Fourteen nurses from an intensive care unit and cardio-respiratory care unit were interviewed. The core concept, Supporting the Journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses described being present with patients and families to validate feelings and give emotional support. Nursing work, while bridging the journey between life and death, imparted strength and resilience and helped overcome barriers to ensure that patients received holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.
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Clayton JM, Hancock K, Parker S, Butow PN, Walder S, Carrick S, Currow D, Ghersi D, Glare P, Hagerty R, Olver IN, Tattersall MHN. Sustaining hope when communicating with terminally ill patients and their families: a systematic review. Psychooncology 2008; 17:641-59. [DOI: 10.1002/pon.1288] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Tesfa A, Kaplan KO, Meyer ML, Coachman DM. Roles and Responsibilities of Health Care Agents: Views of Patients and Agents. J Gerontol Nurs 2008; 34:8-14. [DOI: 10.3928/00989134-20080601-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Goodridge D, Duggleby W, Gjevre J, Rennie D. Caring for critically ill patients with advanced COPD at the end of life: a qualitative study. Intensive Crit Care Nurs 2008; 24:162-70. [PMID: 18313923 DOI: 10.1016/j.iccn.2008.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Revised: 01/10/2008] [Accepted: 01/12/2008] [Indexed: 11/19/2022]
Abstract
Providing expert critical care for the high acuity patient with a diagnosis of COPD at the end of life is both complex and challenging. The purpose of this descriptive study was to examine intensive care unit (ICU) clinicians' perspectives on the obstacles to providing quality care for individuals with COPD who die within the critical care environment. Transcripts of three focus groups of ICU clinicians were analyzed using thematic analysis. The three themes of "managing difficult symptoms", "questioning the appropriateness of life-sustaining care" and "conflicting care priorities" were noted to be significant challenges in providing high quality end of life care to this population. Difficulties in palliating dyspnea and anxiety were associated with caregiver feelings of helplessness, empathy and fears about "killing the patient". A sense of futility, concerns about "torturing the patient" and questions about the patient/family's understanding of treatment pervaded much of the discourse about caring for people with advanced COPD in the ICU. The need to prioritize care to the most unstable ICU patients meant that patients with COPD did not always receive the attention clinicians felt they should ideally have. Organizational support must be made available for critical care clinicians to effectively deal with these issues.
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Affiliation(s)
- Donna Goodridge
- College of Nursing, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan S7T5E5, Canada.
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Eliott J, Olver I. Choosing between life and death: patient and family perceptions of the decision not to resuscitate the terminally ill cancer patient. BIOETHICS 2008; 22:179-189. [PMID: 18257804 DOI: 10.1111/j.1467-8519.2007.00620.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
In keeping with the pre-eminent status accorded autonomy within Australia, Europe, and the United States, medical practice requires that patients authorize do-not-resuscitate (DNR) orders, intended to countermand the default practice in hospitals of instituting cardiopulmonary-resuscitation (CPR) on all patients experiencing cardio-pulmonary arrest. As patients typically do not make these decisions proactively, however, family members are often asked to act as surrogate decision-makers and decide on the patient's behalf. Although the appropriateness of patients or their families having to decide about the provision of CPR has been challenged, there has been little examination of how patients and their families talk about and negotiate such decisions, particularly in the context of the patient's imminent death. In this article, part of a larger study analysing interviews with 28 patients (13 female) with cancer within weeks of their death, and 20 others (predominantly family) attending, we argue that a common assumption underpinning participants' talk about the DNR decision (i.e. forgoing CPR) is that it requires a choice between life and death. Using illustrative examples, we demonstrate that in making decisions about CPR, patients and their families are implicitly required to make moral judgements about the value of the patient's life, including their relationships with significant others. We identify some implications of these empirical observations for the development of ethically appropriate policies and practices regarding patient autonomy and surrogacy at the end of life.
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Affiliation(s)
- Jaklin Eliott
- Royal Adelaide Hospital Cancer Research Centre, and University of Adelaide, Adelaide, South Australia, Australia.
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Gutierrez BAO, Ciampone MHT. O processo de morrer e a morte no enfoque dos profissionais de enfermagem de UTIs. Rev Esc Enferm USP 2007; 41:660-7. [DOI: 10.1590/s0080-62342007000400017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Em relação ao processo de morrer e a morte, cada sociedade tem sua própria cultura, hábitos, crenças e valores, que a aproxima ou a diferencia de outras, oferece aos indivíduos uma orientação de como devem se comportar e o que devem ou não fazer diante desse fato. O objetivo deste estudo foi identificar as concepções culturais relacionadas ao processo de morrer e à morte no contexto de trabalho dos profissionais de enfermagem de UTIs. Os dados foram coletados por meio de entrevistas individuais e grupo focal e analisados segundo técnicas qualitativas. As narrativas mostram múltiplas dimensões determinantes das atitudes e ações profissionais, que vão além do conhecimento técnico. Fica evidente que esses profissionais procuram refúgio nas suas crenças e valores para suportar um trabalho que lhes impõe tantas cargas.
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Clayton JM, Hancock KM, Butow PN, Tattersall MHN, Currow DC, Adler J, Aranda S, Auret K, Boyle F, Britton A, Chye R, Clark K, Davidson P, Davis JM, Girgis A, Graham S, Hardy J, Introna K, Kearsley J, Kerridge I, Kristjanson L, Martin P, McBride A, Meller A, Mitchell G, Moore A, Noble B, Olver I, Parker S, Peters M, Saul P, Stewart C, Swinburne L, Tobin B, Tuckwell K, Yates P. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust 2007; 186:S77-S105. [PMID: 17727340 DOI: 10.5694/j.1326-5377.2007.tb01100.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 03/18/2007] [Indexed: 11/17/2022]
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Hancock K, Clayton JM, Parker SM, Wal der S, Butow PN, Carrick S, Currow D, Ghersi D, Glare P, Hagerty R, Tattersall MHN. Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliat Med 2007; 21:507-17. [PMID: 17846091 DOI: 10.1177/0269216307080823] [Citation(s) in RCA: 294] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis. A systematic review was conducted of 46 studies relating to truth-telling in discussing prognosis with patients with progressive, advanced life-limiting illnesses and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO and Cochrane Register of Controlled Trials) up to November 2004, with handsearching of studies, as well as inclusion of studies satisfying selection criteria reported in 2005 by the authors. The reference lists of identified studies were hand-searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Results showed that although the majority of HPs believed that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. Reasons include perceived lack of training, stress, no time to attend to the patient's emotional needs, fear of a negative impact on the patient, uncertainty about prognostication, requests from family members to withhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. Studies suggest that patients can discuss the topic without it having a negative impact on them. Differences and similarities in findings from different cultures are explored.
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Affiliation(s)
- Karen Hancock
- Medical Psychology Research Unit, University of Sydney, New South Wales, Australia
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31
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Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007; 35:1530-5. [PMID: 17452930 DOI: 10.1097/01.ccm.0000266533.06543.0c] [Citation(s) in RCA: 280] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). DESIGN A prospective pre/post nonequivalent control group design was used for this performance improvement study. SETTING Seventeen-bed adult MICU. PATIENTS Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. INTERVENTIONS Palliative care consultations. MEASUREMENTS AND MAIN RESULTS Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. CONCLUSIONS Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.
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Affiliation(s)
- Sally A Norton
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA.
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Parker SM, Clayton JM, Hancock K, Walder S, Butow PN, Carrick S, Currow D, Ghersi D, Glare P, Hagerty R, Tattersall MHN. A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information. J Pain Symptom Manage 2007; 34:81-93. [PMID: 17531434 DOI: 10.1016/j.jpainsymman.2006.09.035] [Citation(s) in RCA: 356] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 09/26/2006] [Indexed: 11/30/2022]
Abstract
Evidence-based recommendations concerning how to discuss dying, life expectancy, and likely future symptoms with patients with a limited life expectancy and their families are lacking. The aim of this systematic review was to review studies regarding prognostic/end-of-life communication with adult patients in the advanced stages of a life-limiting illness and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases up to November 2004. One hundred twenty-three studies met the criteria for the full review, and 46 articles reported on patient/caregiver preferences for content, style, and timing of information. The majority of the research was descriptive. Although there were individual differences, patients/caregivers in general had high levels of information need at all stages of the disease process regarding the illness itself, likely future symptoms and their management, and life expectancy and information about clinical treatment options. Patient and caregiver information needs showed a tendency to diverge as the illness progressed, with caregivers needing more and patients wanting less information. Patients and caregivers preferred a trusted health professional who showed empathy and honesty, encouraged questions, and clarified each individual's information needs and level of understanding. In general, most patients/caregivers wanted at least some discussion of these topics at the time of diagnosis of an advanced, progressive, life-limiting illness, or shortly after. However, they wanted to negotiate the content and extent of this information.
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Affiliation(s)
- Sharon M Parker
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
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Campbell MJ, Edwards MJ, Ward KS, Weatherby N. Developing a Parsimonious Model for Predicting Completion of Advance Directives. J Nurs Scholarsh 2007; 39:165-71. [PMID: 17535317 DOI: 10.1111/j.1547-5069.2007.00162.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To develop a theory-based model to assist nurses in promoting self-determination for completion of an advance directive (AD). DESIGN AND METHODS This descriptive study included data from a convenience sample of 118 community-dwelling older adults in Tennessee, USA. Multinomial logistic regression was used to estimate the influence of 15 factors and covariates on completion of an AD. FINDINGS The parsimonious model had three significant factors: receiving AD information; attitude index; and health literacy score. Participants were highly likely to complete ADs if they had positive attitudes toward ADs and had received information on ADs. As health literacy increased, the likelihood that participants completed ADs was reduced. This model explained 25% of the variation in AD completion. Chi-square fit for the parsimonious model was highly significant. CONCLUSIONS Of 15 factors and covariates that could influence completion of an AD, only receiving information about ADs, having positive attitudes toward ADs, and health literacy significantly affected the likelihood of participants completing ADs. More study is needed on this model and how nurses can assist patients with end-of-life decisions.
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Affiliation(s)
- Mary Judy Campbell
- Middle Tennessee State University, School of Nursing, Murfreesboro, TN 37132, USA.
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Baggs JG, Norton SA, Schmitt MH, Dombeck MT, Sellers CR, Quinn JR. Intensive care unit cultures and end-of-life decision making. J Crit Care 2007; 22:159-68. [PMID: 17548028 PMCID: PMC2214829 DOI: 10.1016/j.jcrc.2006.09.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2006] [Revised: 07/23/2006] [Accepted: 09/26/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM. MATERIALS AND METHODS Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit. RESULTS The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM. CONCLUSIONS As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.
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Affiliation(s)
- Judith Gedney Baggs
- School of Nursing, Oregon Health and Science University, Portland, OR 97239-2941, USA.
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Badzek LA, Leslie N, Schwertfeger RU, Deiriggi P, Glover J, Friend L. Advanced care planning: A study on home health nurses. Appl Nurs Res 2006; 19:56-62. [PMID: 16728288 DOI: 10.1016/j.apnr.2005.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2002] [Accepted: 04/25/2005] [Indexed: 11/17/2022]
Abstract
The purpose of this research was to assess home health nurses' (HHNs) knowledge, comfort levels, barriers, and personal participation in advanced care planning (ACP), a practice that recognizes patient preferences for health care treatment. Licensed nurses who identified home care as their primary area of practice (N = 519) were surveyed about their knowledge of laws governing ACP and their perceptions of patients' preferences for ACP. Most respondents were women (97%), and the average age of the respondents was 54 years. Most nurses felt knowledgeable and capable of educating patients on advance directives (ADs), although the nurses' knowledge of laws governing ACP was limited and often inaccurate. Generally, nurses felt comfortable during ACP discussions with patients and families. HHNs perceived patient or family reluctance as the greatest barrier hindering discussions of ACP. No association was found between level of education and whether a nurse had a personal AD. Twenty percent of the nurses had their valid personal AD. A greater knowledge base concerning ACP would facilitate HHN discussions with patients and families. Recognition of patient preferences can be enhanced by understanding and overcoming barriers that hinder discussions of ACP. Educational opportunities focusing on ACP are encouraged for all health care providers.
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Affiliation(s)
- Laurie A Badzek
- School of Nursing, West Virginia University, Morgantown, WV 26506, USA.
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West HF, Engelberg RA, Wenrich MD, Curtis JR. Expressions of nonabandonment during the intensive care unit family conference. J Palliat Med 2005; 8:797-807. [PMID: 16128654 DOI: 10.1089/jpm.2005.8.797] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Palliative care consultants play an increasing role in assisting critical care clinicians with end-of-life communication in the intensive care unit (ICU). One of the ethical principles these consultants may apply to such communication is nonabandonment of the patient. Limited data exist concerning expressions of nonabandonment in the ICU family conference. This analysis examines expressions of nonabandonment during ICU family conferences. Our goal was to categorize these expressions and develop a conceptual model for understanding this issue as it arises in the ICU setting. METHODS We identified family conferences in the ICUs of four hospitals. Conferences were eligible if the attending physician believed that discussion about withholding or withdrawing life support or the delivery of bad news was likely to occur. Fifty-one conferences were audiotaped, transcribed, and analyzed using grounded theory. RESULTS We identified categories capturing expressions of nonabandonment in the ICU family conference. Clinicians expressed nonabandonment of the patient or family in three ways: alleviating suffering/ensuring comfort, allowing family members to be present at the bedside for the death, and being accessible to patients and families. Families expressed their own nonabandonment of the patient or concern about abandonment of the patient by the health care team in five ways: ensuring the patient's suffering is eased, being present at the bedside, ensuring the patient's end-of-life preferences are respected, ensuring that everything possible be done to cure the patient, and "letting go." These categories were placed into a conceptual model that differentiates explicit and implicit statements of nonabandonment. CONCLUSIONS This paper describes categories and a conceptual model for understanding expressions of nonabandonment that may allow palliative care consultants to help critical care clinicians express nonabandonment and respond to families' expressions of nonabandonment in the ICU family conference. Future studies could use this model to develop a communication intervention for the ICU family conference.
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Affiliation(s)
- Heather F West
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Affiliation(s)
- Mary Thelen
- Mary Thelen is the nurse educator for the critical care unit at Luther Midelfort Mayo Health System, Eau Claire, Wis. Her work experience includes 18 years as a critical care nurse in 2 midwestern community hospitals. She is a recent graduate of the master’s degree program in nursing education at the University of Wisconsin, Eau Claire and is a member of the Indianhead chapter of the American Association of Critical-Care Nurses
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Anselm AH, Palda V, Guest CB, McLean RF, Vachon MLS, Kelner M, Lam-McCulloch J. Barriers to communication regarding end-of-life care: perspectives of care providers. J Crit Care 2005; 20:214-23. [PMID: 16253789 DOI: 10.1016/j.jcrc.2005.05.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Revised: 03/19/2005] [Accepted: 05/31/2005] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Communication regarding end-of-life care is frequently perceived as suboptimal, despite the intent of both health care providers and patients. We interviewed health care providers to determine their perspective regarding these barriers to communication. MATERIALS AND METHODS Eleven focus groups with a total of 10 attending physicians, 24 residents, and 33 nurses were convened to explore barriers to end-of-life discussions on the Internal Medicine service at a 600-bed tertiary care hospital in Toronto, Canada. An interview schedule was designed to elicit information regarding the process of end-of-life discussions, barriers to these discussions, and possible interventions for limiting such barriers. Transcripts were qualitatively analyzed by 6 raters who independently identified "themes." Themes were refined using the Delphi technique and classified under broader "categories." RESULTS Four main categories of barriers emerged, relating to (1) patients, (2) the health care system, (3) health care providers, and (4) the nature of this dialogue. Attending physicians and residents most frequently identified patient-related factors as barriers to discussions, followed by system, dialogue, and provider barriers (43%, 39%, 10%, and 8%, respectively, for attending physicians; 40%, 34%, 13%, and 13%, respectively, for residents). Nurses similarly identified patient-related and system barriers most frequently, but provider barriers were discussed more often than dialogue barriers (46%, 28%, 22%, and 4%, respectively). CONCLUSIONS Attending physicians, residents, and nurses perceive the recipients of their care, and the system within which they provide this care, to be the major source of barriers to communication regarding end-of-life care. This finding may impact on the effectiveness of quality-improvement initiatives in end-of-life care.
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Affiliation(s)
- Anjali H Anselm
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5
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Abstract
The purpose of this qualitative study was to explore spiritual care for dying nursing home residents from the perspectives of registered nurses, practical nurses, certified nursing assistants, advanced practice nurses, and physicians. Five major themes emerged: honoring the person's dignity, intimate knowing in the nursing home environment, wishing we could do more, personal knowing of self as caregiver, and struggling with end-of-life treatment decisions. Spiritual caring was described within the context of deep personal relationships, holistic care, and support for residents. Spiritual care responses and similarities and differences in the experiences of participants are presented. Education and research about how to assist residents and families as they struggle with difficult end-of-life decisions, adequate time and staff to provide the kind of care they "wished they could," and development of models that honor the close connection and attachment of staff to residents could enhance end-of-life care in this setting.
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Affiliation(s)
- Theris A Touhy
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL 33431, USA
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Clover A, Browne J, McErlain P, Vandenberg B. Patient approaches to clinical conversations in the palliative care setting. J Adv Nurs 2004; 48:333-41. [PMID: 15500527 DOI: 10.1111/j.1365-2648.2004.03202.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The aim of this paper is to report a study exploring patients' understanding of their discussions about end-of-life care with nurses in a palliative care setting. BACKGROUND It is assumed that nurses are central players in patients' major decisions about their care, yet minimal information is available about the complexity of patient-nurse interaction in palliative care, and patients' views of the impact of such interactions on decisions that are made. METHOD A modified version of grounded theory was used to collect and analyse interview data collected in 2001-2002 with a convenience sample of 11 patients in a palliative care setting. Interviews focused on each patient's selection of two decisions they had made in the past 6 months that had involved nurses in the decision-making process. FINDINGS Processes were identified between nurses and patients that facilitated or blocked open discussion and discernment of patients' preferences for care. Six approaches that patients used in their conversations with nurses about their care: wait and see, quiet acceptance, active acceptance, tolerating bossiness, negotiation and being adamant. These approaches are described in terms of how they assisted or impeded autonomous decision-making. CONCLUSION Palliative care patients often adopt passive roles and tend not to engage in important decision-making, for various reasons. Professionals need to be made aware of this, and should facilitate an open, trusting relationship with patients in order to ensure that important information passes freely in both directions. Professionals should learn to prioritize patient participation and negotiation in their work. With further research, it should be possible to identify the factors that will allow patients to take a more pro-active role in making decisions about their care, where desired.
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Eggenberger SK, Nelms TP. Artificial hydration and nutrition in advanced Alzheimer's disease: facilitating family decision-making. J Clin Nurs 2004; 13:661-7. [PMID: 15317505 DOI: 10.1111/j.1365-2702.2004.00967.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND As Alzheimer's disease progresses to its final stages of dementia and dysphagia, whereby patients can no longer swallow food and fluids, families suffer with difficult decisions regarding initiation of artificial hydration and nutrition. AIMS AND OBJECTIVES Through the use of a hypothetical family scenario, this theoretical article presents the ethical principals of beneficence and autonomy as a framework for use by nurses to hear and inform family decision-makers of the physiology of death in the advanced stages of Alzheimer's and examines the current literature related to benefits and burdens of artificial hydration and nutrition. CONCLUSIONS While a beneficial consideration, ethical principles are critiqued for their inability to provide an absolute answer and relieve family suffering in this clinical situation. RELEVANCE TO CLINICAL PRACTICE A nurse-lead consensus building process is proposed to guide family decision-making regarding artificial hydration and nutrition with advanced Alzheimer's disease.
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Mystakidou K, Parpa E, Tsilila E, Katsouda E, Vlahos L. Cancer information disclosure in different cultural contexts. Support Care Cancer 2004; 12:147-54. [PMID: 15074312 DOI: 10.1007/s00520-003-0552-7] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The relationship between truth telling and culture has been the subject of increasing attention in the literature. The issue of whether, how and how much to tell cancer patients concerning diagnosis is still approached differently depending on country and culture. The majority of physicians tell the truth more often today than in the past, in both developed and developing countries, but most of them prefer to disclose the truth to the next of kin. Nurses in Anglo-Saxon countries are considered to be the most suitable health-care professionals for the patients to share their thoughts and feelings with. Nevertheless, in most other cultures the final decision on information disclosure lies with the treating physician. Regardless of cultural origin, the diagnosis of cancer affects both family structure and family dynamics. In most cases patients' families, in an effort to protect them from despair and a feeling of hopelessness, exclude the patient from the process of information exchange. The health-care team-patient relationship is a triangle consisting of the health-care professional, the patient and the family. Each part supports the other two and is affected by the cultural background of each of the others as well as the changes that occur within the triangle.
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Affiliation(s)
- Kyriaki Mystakidou
- Pain Relief and Palliative Care Unit, Areteion Hospital, and Department of Radiology, University of Athens School of Medicine, Greece.
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Affiliation(s)
- Denice K Sheehan
- Palliative Care Program, the Breen School of Nursing, Ursuline College, Pepper Pike, OH, USA.
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Norton SA, Tilden VP, Tolle SW, Nelson CA, Eggman ST. Life Support Withdrawal: Communication and Conflict. Am J Crit Care 2003. [DOI: 10.4037/ajcc2003.12.6.548] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Skillful communication between and among clinicians and patients’ families at the patients’ end of life is essential for decision making. Yet communication can be particularly difficult during stressful situations such as when a family member is critically ill. This is especially the case when families are faced with choices about forgoing life-sustaining treatment.• Objectives Data from a larger study on treatment withdrawal (n = 74) indicated that the family members (n = 20) of some patients experienced conflict with clinicians during decision making. This secondary analysis was done to examine and describe the communication difficulties from the perspectives of patients’ family members who experienced conflict with clinicians about the care and treatment of the patients during withdrawal of life support.• Methods A qualitative descriptive analysis of family members (n = 20, representing 12 decedents) who experienced conflict.• Results Families described several unmet communication needs during the often rapid shift from aggressive treatment to palliative care. These needs included the need for timely information, the need for honesty, the need for clinicians to be clear, the need for clinicians to be informed, and the need for clinicians to listen.• Conclusions Although family members who experienced conflict were in the minority of the larger study sample, their concerns and needs are important for clinicians to examine. Paying careful attention to these communication needs could reduce the occurrence of conflict between clinicians and patients’ families in caring for dying patients and reduce stress for all involved.
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Affiliation(s)
- Sally A. Norton
- Center for Clinical Research on Aging, University of Rochester School of Nursing, Rochester, NY (SAN), Center for Ethics in Health Care (VPT, SWT), School of Nursing (VPT, CAN), and School of Medicine (SWT), Oregon Health & Science University, Portland, Ore (VPT is now with the College of Nursing, University of Nebraska Medical Center, Omaha, Neb); and Division of Social Work, California State University, Sacramento (STE)
| | - Virginia P. Tilden
- Center for Clinical Research on Aging, University of Rochester School of Nursing, Rochester, NY (SAN), Center for Ethics in Health Care (VPT, SWT), School of Nursing (VPT, CAN), and School of Medicine (SWT), Oregon Health & Science University, Portland, Ore (VPT is now with the College of Nursing, University of Nebraska Medical Center, Omaha, Neb); and Division of Social Work, California State University, Sacramento (STE)
| | - Susan W. Tolle
- Center for Clinical Research on Aging, University of Rochester School of Nursing, Rochester, NY (SAN), Center for Ethics in Health Care (VPT, SWT), School of Nursing (VPT, CAN), and School of Medicine (SWT), Oregon Health & Science University, Portland, Ore (VPT is now with the College of Nursing, University of Nebraska Medical Center, Omaha, Neb); and Division of Social Work, California State University, Sacramento (STE)
| | - Christine A. Nelson
- Center for Clinical Research on Aging, University of Rochester School of Nursing, Rochester, NY (SAN), Center for Ethics in Health Care (VPT, SWT), School of Nursing (VPT, CAN), and School of Medicine (SWT), Oregon Health & Science University, Portland, Ore (VPT is now with the College of Nursing, University of Nebraska Medical Center, Omaha, Neb); and Division of Social Work, California State University, Sacramento (STE)
| | - Susan Talamantes Eggman
- Center for Clinical Research on Aging, University of Rochester School of Nursing, Rochester, NY (SAN), Center for Ethics in Health Care (VPT, SWT), School of Nursing (VPT, CAN), and School of Medicine (SWT), Oregon Health & Science University, Portland, Ore (VPT is now with the College of Nursing, University of Nebraska Medical Center, Omaha, Neb); and Division of Social Work, California State University, Sacramento (STE)
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45
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Abstract
Care for the dying ICU patient and family should be inclusive of respect for their goals, preferences. and choices. Care should be comprehensive, inclusive of all the patient domains (physical, psychosocial and, spiritual), and inclusive of all the specialties and disciplines that can be helpful at this complex time. The families' concerns should be acknowledged and support given. Our ICUs need to develop supportive environments for those dying patients who stay in the unit. Quality improvement and ongoing evaluation will provide avenues of change for care of this special group of patients and families.
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Affiliation(s)
- Karin T Kirchhoff
- School of Nursing, University of Wisconsin, Madison 53792-2455, USA.
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46
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Norton SA, Bowers BJ. Working toward consensus: providers' strategies to shift patients from curative to palliative treatment choices. Res Nurs Health 2001; 24:258-69. [PMID: 11746057 PMCID: PMC3744156 DOI: 10.1002/nur.1028] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
End-of-life decision making is a complex phenomenon and providers, patients, and families often have different views about the appropriateness of treatment choices. The results presented here are part of a larger grounded-theory study of reconciling decisions near the end of life. In particular, we examined how providers (N = 15) worked near the end of patients' lives toward changing the treatment decisions of patients and families from those decisions that providers described as unrealistic (i.e., curative) to those that providers described as more realistic (i.e., palliative). According to providers, shifting patients' and families' choices from curative to palliative was usually accomplished by changing patients' and families' understanding of the patient's overall "big picture" to one that was consistent with the providers' understanding. Until patients and families shifted their understanding of the patient's condition-the big picture-they continued to make what providers judged as unrealistic treatment choices based on an inaccurate understanding of what was really going on. These unrealistic choices often precluded possibilities for a "good death." According to providers, the purpose of attempting to shift the patient or proxy's goals was that realistic goals lead to realistic palliative treatment choices that providers associated with a good death. In this article we review strategies used by providers when they believed a patient's death was imminent to attempt to shift patients' and families' understandings of the big picture, thus ultimately shifting their treatment decisions.
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Affiliation(s)
- S A Norton
- University of Rochester School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
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