The Family Navigator: A Pilot Intervention to Support Intensive Care Unit Family Surrogates

Evaluation of the effect of a nurse navigation program developed for postpartum mothers on maternal health: A randomized controlled study

OBJECTIVE

This study aimed to determine the effects of a nurse navigation program on the capability for self-care, quality of life, risk of anxiety and depression, and severity of the physical symptoms of postpartum mothers.

METHODS

This prospective, parallel-group, randomized controlled study included 64 primiparous pregnant women (32 women each in the intervention and control groups) at ≥36 gestational weeks admitted to the pregnancy outpatient clinic of a public hospital in Turkey. The intervention group received navigation program-based nursing care comprising three home visits, four phone calls, and five text messages aside from the standard hospital care during delivery and the postpartum period. Meanwhile, the control group received only the standard hospital care during delivery and the postpartum period. Data were collected using a sociodemographic data form, the Self-Care Power Scale, the Maternal Postpartum Quality of Life Instrument (MPQoL-I), the Postpartum Specific Anxiety Scale (PSAS), the Edinburgh Postnatal Depression Scale (EPDS), and the Postpartum Physical Symptom Severity Scale.

RESULTS

Mean scores for the capability for self-care and quality of life were higher, while those for the risk of depression and anxiety were lower for the intervention group than the control group (p < .05).

CONCLUSIONS

Navigation program-based care provided to primiparous mothers improved maternal health.

The Impact of Randomized Family-Centered Interventions on Family-Centered Outcomes in the Adult Intensive Care Unit: A Systematic Review

Objective: To review the literature for randomized family-centered interventions with family-centered outcomes in the adult intensive care unit (ICU). Data Sources: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library database from inception until February 2023. Study Selection: We included articles involving randomized controlled trials (RCTs) in the adult critical care setting evaluating family-centered interventions and reporting family-centered outcomes. Data Extraction: We extracted data on author, year of publication, setting, number of participants, intervention category, intervention, and family-centered outcomes. Data Synthesis: There were 52 RCTs included in the analysis, mostly involving communication and receiving information (38%) and receiving care and meeting family member needs (38%). Nearly two-thirds of studies (N = 35; 67.3%) found improvements in at least 1 family-centered outcome. Most studies (N = 24/40; 60%) exploring the impact of family-centered interventions on mental health outcomes showed improvement. Improvements in patient-centered outcomes (N = 7/17; 41%) and healthcare worker outcomes (N = 1/5; 20%) were less commonly found. Conclusions: Family-centered interventions improve family-centered outcomes in the adult ICU and may be beneficial to patients and healthcare workers.

How to communicate with family members of the critically ill in the intensive care unit: A scoping review

OBJECTIVE

To map the existing approaches to communication with family members of the critically ill in the intensive care unit and the corresponding implementation requirements and benefits.

METHODS

We conducted a scoping review in February 2022 by searching PubMed, CINAHL, APA PsycINFO, and Cochrane Library for articles published between 2000 and 2022. We included records of all designs that met our inclusion criteria and applied frequency counts and qualitative coding.

RESULTS

The search yielded 3749 records, 63 met inclusion criteria. The included records were of an interventional (43 %) or observational (14 %) study design or review articles (43 %), and provided information in three categories: communication platforms, strategies, and tools. For implementation in the intensive care unit, the approaches required investing time and resources. Their reported benefits were an increased quality of communication and satisfaction among all parties involved, improved psychological outcome among family members, and reduced intensive care unit length of stay and costs.

CONCLUSION

The current approaches to communication with patients' family members offer insights for the development and implementation of communication pathways in the intensive care unit of which the benefits seem to outweigh the efforts. Structured interprofessional frameworks with standardised tools based on empathic communication strategies are encouraged.

The impact of the intensive care unit family liaison nurse role on communication during the COVID-19 pandemic: A qualitative descriptive study of healthcare professionals' perspectives

BACKGROUND

The COVID-19 pandemic has deeply impacted patient and family communication and patient- and family-centred care in the intensive care unit (ICU). A new role-the ICU Family Liaison Nurse (FLN)-was introduced in an Australian metropolitan hospital ICU to facilitate communication between patient and family and ICU healthcare professionals, although there is limited knowledge about the impact of this from the ICU healthcare professionals' perspectives.

OBJECTIVE

The aim of this study was to explore the impact of the ICU FLN role on communication with patients and their family during the COVID-19 pandemic, from the ICU healthcare professionals' perspectives.

METHODS

A qualitative descriptive study was conducted. Seven participants including ICU FLNs, ICU doctors, nurses, and social workers who worked with the ICU FLNs were interviewed. Thematic analysis was used to analyse the data.

RESULTS

Two main themes related to the ICU FLN role were identified. First, the COVID-19 pandemic posed challenges to patient and family communication, but it also created opportunities to improve patient and family communication. Second, the ICU FLN role brought beneficial impacts to the ICU healthcare professionals' workflow and work experience, as well as patient and family communication. The ICU FLN role has potential benefits that extend beyond the pandemic.

CONCLUSION

We found that during the COVID-19 pandemic, the ICU FLN role was acceptable, beneficial, and appreciated from the ICU healthcare professionals' perspectives. Further research should continue the evaluation of the ICU FLN role during and post the pandemic.

Communication Between Registered Nurses and Family Members of Intensive Care Unit Patients

Background

Effective communication between intensive care unit patients and their families and nurses promotes relationship-centered care and improves nurses’ ability to meet patient and family needs. However, communication with these patients is challenging because of their critical illness. Families often become surrogate decision makers for adult intensive care unit patients.

Objective

To systematically assess available evidence on communication between adult intensive care unit patients and their families and nurses as the initial step in developing nursing strategies to strengthen communication skills.

Methods

In this integrative review, the method of Whittemore and Knafl was used to synthesize findings from qualitative and quantitative (descriptive and experimental) research.

Results

The review revealed a variety of research designs, measurement tools, and types of interventions. The qualitative findings suggest that nurses can strengthen relationship-centered care by regularly updating patients’ families and providing information that can assist with decision-making. The quantitative findings suggest that nurses should be mindful of family members’ needs for assurance, comfort, and support. Providing information on patient status can help alleviate family concerns.

Conclusions

Improved communication between patients and families and intensive care unit nurses is essential to strengthen relationship-centered care. Additional research is needed to better understand the communication needs of adult patients and their families in the intensive care unit.

Do Interventions Improve Symptoms Among ICU Surrogates Facing End-of-Life Decisions? A Prognostically-Enriched Systematic Review and Meta-Analysis

OBJECTIVES

Evaluate the efficacy of interventions to improve symptoms for ICU surrogates at highest risk of developing psychologic distress: those facing end-of-life care decisions.

DATA SOURCES

MEDLINE, CINAHL, PsycInfo, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched through April 16, 2022.

STUDY SELECTION

Following an a priori protocol, randomized trials of interventions delivered to surrogates of adult ICU patients who died or had high likelihood of mortality evaluating surrogate symptoms were identified.

DATA EXTRACTION

Two reviewers performed screening and data extraction and assessed risk of bias (Cochrane Risk of Bias [RoB] 2 tool). Trials were eligible for meta-analysis if group mean symptom scores were provided at 3 or 6 months. Pooled effects were estimated using a random effects model. Heterogeneity was assessed (Cochrane Q, I2 ). Certainty of evidence was assessed (Grading of Recommendations Assessment, Development and Evaluation).

DATA SYNTHESIS

Of 1,660 records, 10 trials met inclusion criteria representing 3,824 surrogates; eight were included in the meta-analysis. Overall RoB was rated Some Concerns. Most ( n = 8) interventions focused on improving communication and enhancing psychologic support in the ICU. All trials measured anxiety, depression, and posttraumatic stress. Significant improvement was seen at 3 months (depression, mean difference [MD], -0.68; 95% CI, -1.14 to -0.22, moderate certainty; posttraumatic stress, standardized MD, -0.25; 95% CI, -0.49 to -0.01, very low certainty) and 6 months (anxiety, MD, -0.70; 95% CI, -1.18 to -0.22, moderate certainty). Sensitivity analyses suggest significant findings may be unstable. Subgroup analyses demonstrated differences in effect by trial location, interventionist, and intervention dose.

CONCLUSIONS

Communication and psychological support interventions in the ICU yielded small but significant improvement in psychological symptoms with moderate to very low certainty evidence in a prognostically-enriched sample of ICU surrogates facing end-of-life care decisions. A new approach to interventions that extend beyond the ICU may be needed.

A multicomponent family support intervention in intensive care units: study protocol for a multicenter cluster-randomized trial (FICUS Trial)

Background

Family members of critically ill patients face considerable uncertainty and distress during their close others’ intensive care unit (ICU) stay. About 20–60% of family members experience adverse mental health outcomes post-ICU, such as symptoms of anxiety, depression, and posttraumatic stress. Guidelines recommend structured family inclusion, communication, and support, but the existing evidence base around protocolized family support interventions is modest and requires substantiation.

Methods

To test the clinical effectiveness and explore the implementation of a multicomponent, nurse-led family support intervention in ICUs, we will undertake a parallel, cluster-randomized, controlled, multicenter superiority hybrid-type 1 trial. It will include eight clusters (ICUs) per study arm, with a projected total sample size of 896 family members of adult, critically ill patients treated in the German-speaking part of Switzerland. The trial targets family members of critically ill patients with an expected ICU stay of 48 h or longer. Families in the intervention arm will receive a family support intervention in addition to usual care. The intervention consists of specialist nurse support that is mapped to the patient pathway with follow-up care and includes psycho-educational and relationship-focused family interventions, and structured, interprofessional communication, and shared decision-making with families. Families in the control arm will receive usual care. The primary study endpoint is quality of family care, operationalized as family members’ satisfaction with ICU care at discharge. Secondary endpoints include quality of communication and nurse support, family management of critical illness (functioning, resilience), and family members’ mental health (well-being, psychological distress) measured at admission, discharge, and after 3, 6, and 12 months. Data of all participants, regardless of protocol adherence, will be analyzed using linear mixed-effects models, with the individual participant as the unit of inference.

Discussion

This trial will examine the effectiveness of the family support intervention and generate knowledge of its implementability. Both types of evidence are necessary to determine whether the intervention works as intended in clinical practice and could be scaled up to other ICUs. The study findings will make a significant contribution to the current body of knowledge on effective ICU care that promotes family participation and well-being.

Trial registration

ClinicalTrials.gov NCT05280691. Prospectively registered on 20 February 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06454-y.

Ethical reflection support for potential organ donors' relatives: A narrative review

BACKGROUND

Even in countries with an opt-out or presumed consent system, relatives have a considerable influence on the post-mortem organ harvesting decision. However, their reflection capacity may be compromised by grief, and they are, therefore, often prone to choose refusal as default option. Quite often, it results in late remorse and dissatisfaction. So, a high-quality reflection support seems critical to enable them to gain a stable position and a long-term peace of mind, and also avoid undue loss of potential grafts. In practice, recent studies have shown that the ethical aspects of reflection are rarely and often poorly discussed with relatives and that no or incomplete guidance is offered. No review of the literature is available to date, although it could be of value to improve the quality of the daily practice.

OBJECTIVES

The objective was to review and synthesize the main concepts and approaches, theories and practices of ethical reflection support of the relatives or surrogates of potential post-mortem organ donors.

RESEARCH DESIGN

A narrative review was performed in the medical, psychological and ethical fields using PubMed, PsycArticles and Web of Science databases (1980-2020).

RESULTS

Out of 150 papers, 25 were finally retained. Four themes were drawn: the moral status of the potential post-mortem organ donor, the principlistic approach with its limits and critics, the narrative approach and the transcendental approach.

DISCUSSION

This review suggests an extension of psychological support towards ethical reflection support. The process of helping relatives in their ethical exploration of post-mortem organ donation is psychologically and morally characterized. The need for specialized professionals educated and experienced both in clinical psychology and in health ethics to carry out this task is discussed.

PRACTICAL IMPACT

This review could contribute to optimize the quality of the ethical reflection support by initiating an evolution from an empirical, partial and individual-dependent support to a more systematized, professionalized and exhaustive support.

In-hospital interventions to promote relational practice with families in acute care settings: A scoping review

Relational practice is characterised by genuine interaction between families and healthcare professionals that promotes trust and empowerment. Positive clinical outcomes have been associated with relational practice. To assess and examine in-hospital interventions designed to promote relational practice with families in acute care settings of emergency departments, intensive care units and high care units. The preferred reporting Items for Systematic Reviews and Meta-Analyses guidelines informed the design of this scoping review. To identify relevant studies, databases (Academic Search Complete; CINAHL; PubMed; PsyInfo) and the search engine Google Scholar were searched using terms for core elements of relational practice and family engagement. Of the 117 articles retrieved, eight interventional studies met the search criteria. The interventions focused on relational practice elements of collaborating with and creating safe environments for families, whilst only one addressed healthcare professionals being respectful of families’ needs and differences. In relation to the nature of engagement of families in interventions, the focus was mainly on improving family functioning. Family engagement in the interventions was focused on involving families in decision-making. The scoping review revealed a limited number of in-hospital interventions designed to promote relational practice with families in acute care settings. Further research is encouraged to develop such interventions.

Making Family-Centered Care for Adults in the ICU a Reality

Despite the value of family-centered care (FCC) in intensive care units (ICUs), this approach is rarely a reality in this context. This article aims to increase the likelihood that ICU-based care incorporates best practices for FCC. Consistent with this goal, this article begins by overviewing FCC and its merits and challenges in ICUs. It then offers a systemic framework for conceptualizing FCC in this challenging environment, as such a model can help guide the implementation of this invaluable approach. This systemic framework combined with previous guidelines for FCC in the ICU are used to inform the series of recommended best practices for FCC in the ICU that balance the needs and realities of patients, families, and the interprofessional healthcare team. These best practices reflect an integration of the existing literature and previously published guidelines as well as our experiences as healthcare providers, family members, and patients. We encourage healthcare leaders and interprofessional ICU healthcare teams to adopt these best practices and modify them for the specific healthcare needs of the patients they serve and their families.

Nurse perceptions of a nurse family liaison implemented during the COVID-19 pandemic: A qualitative thematic analysis

Objective

Stress among family members of hospitalised intensive care unit patients may be amplified in the context of a global pandemic and strict visitor restrictions. A nurse family liaison role in the COVID-19 units was implemented to serve as a connection between the care team and a designated family member. Our objective was to describe the experience of a nurse family liaison role implemented during the COVID-19 pandemic from the perspective of nurses who functioned in the liaison role and intensive care nurses who worked with the liaisons.

Research method/design

This was a qualitative study using thematic analysis involving a one-time semi-structured interview. A convenience sample of nurses were invited to participate. The analytic approach involved (1) becoming familiar with the data; (2) finding meaning in the data; (3) organising meaningful statements into patterns to generate themes.

Setting/participants

Nurses who functioned in the liaison role and intensive care nurses who worked with the liaisons in an adult academic health center in the Midwest United States.

Main outcome measure

To describe the psychosocial experience of nurse family liaison role implementation.

Findings

The sample (n = 11) mean age was 36 years (range 26–49) and the majority were female (n = 10; 90%), White/non-Hispanic (n = 11; 100%), Bachelor prepared (n = 10; 90%), and had an average of 10 years of experience as a nurse (range 4–25). The major themes identified by participants were living in a pandemic, establishing the role and workflow and experiencing human connection.

Conclusion

Hospital organisations should consider how they can provide family-centred care, specifically within the context of a global crisis such as a pandemic. Participant descriptions of the role indicate that liaison implementation alleviated nurse moral distress and fostered development of close family connections. Findings can help inform implementation of similar roles in hospital settings.

The Effect of Chaplain Patient Navigators and Multidisciplinary Family Meetings on Patient Outcomes in the ICU: The Critical Care Collaboration and Communication Project

OBJECTIVES

To assess the effectiveness of a chaplain patient navigator in improving outcomes and reducing costs in the ICU setting.

DESIGN

A randomized controlled trial at a large, urban, academic community hospital in Baltimore, Maryland.

SETTING/PATIENTS

All patients admitted to the Johns Hopkins Bayview Medical Center Cardiac and Medical ICUs between March 2015 and December 2015.

INTERVENTIONS

Patients in the intervention group were assigned a chaplain patient navigator to facilitate communication, offer support, and setup multidisciplinary family meetings.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were hospital and ICU length of stay. Secondary outcomes included total and ICU charges, 60- and 90-day readmission rates, and the number of palliative care consults. For all outcomes, patients were included in the intention-to-treat analyses only if they remained in the ICU greater than 24 hours. In total, 1,174 were randomly assigned to "usual care" (n = 573) or to the intervention (n = 601). In the intervention group, 44.8% (269/601) had meetings within 24 hours of admission and, of those patients, 32.8% (88/268) took part in the larger multidisciplinary family meeting 2-3 days later. The intervention group had longer mean adjusted hospital length of stay (7.78 vs 8.63 d; p ≤ 0.001) and mean ICU length of stay (3.65 vs 3.87 d; p = 0.029). In addition, they had greater total and ICU charges. There were no differences in other outcomes. Of note, only differences in total and ICU charges remained when controlling for case-mix index, which were greater in the intervention group.

CONCLUSIONS

Although the chaplain patient navigator anecdotally enhanced communication, our study found an increase in hospital and ICU length of stay as well as cost. Since other studies have shown benefits in some clinical outcomes, projects focused on patient navigators may learn lessons from our study in order to better prioritize family meetings, gather indicators of communication quality, and identify the optimal patient navigator operational context.

Nursing interventions to cover patients' basic needs in the intensive care context - A systematic review

Aim

To examine the content, theoretical frameworks and effectiveness of nursing interventions utilizing patient‐reported outcome measures (PROMs) in the intensive care unit (ICU).

Design

A systematic review and narrative synthesis following the guidelines of the preferred reporting items for systematic reviews and meta‐analysis checklist.

Methods

We searched the MEDLINE, CINAHL, PsycINFO, SweMed and Cochrane controlled trials register (CENTRAL) databases for studies evaluating interventions primarily delivered by nurses in the ICU. Two independent reviewers performed study selection, data extraction and risk of bias.

Results

Twenty‐two studies were included, whereas only seven studies used a theoretical framework. The interventions were heterogeneous in content, duration and choice of PROMs. Outcomes were related to covering patients' and families' basic needs, described by Henderson as essential functions of nursing. Several studies reported positive intervention effects, and nurses' communication and psychosocial care were considered essential components of nursing interventions in the ICU.

Family Satisfaction in the Adult Intensive Care Unit: A Concept Analysis

Admission of patients to an intensive care unit is often a stressful event for family members. In the context of patient- and family-centered care, family satisfaction is recognized as a quality indicator of intensive care unit care. However, family satisfaction has not been consistently used or conceptualized in the literature. A modified version of Walker and Avant's method for concept analysis was utilized to examine the concept of family satisfaction in the adult intensive care unit. Antecedents, attributes, consequences, and empirical referents of family satisfaction are presented and implications for practice, research, and policy.

In This Together: Navigating Ethical Challenges Posed by Family Clustering during the Covid-19 Pandemic

Harrowing stories reported in the media describe Covid-19 ravaging through families. This essay reports professional experiences of this phenomenon, family clustering, as encountered during the pandemic's spread across Southern California. We identify three ethical challenges following from it: Family clustering impedes shared decision-making by reducing available surrogate decision-makers for incapacitated patients, increases the emotional burdens of surrogate decision-makers, and exacerbates health disparities for and the suffering of people of color at increased likelihood of experiencing family clustering. We propose that, in response to these challenges, efforts in advance care planning be expanded, emotional support offered to surrogates and family members be increased, more robust state guidance be issued on ethical decision-making for unrepresented patients, ethics consultation be increased in the setting of conflict following from family clustering dynamics, and health care professionals pay more attention to systemic and personal racial biases and inequities that affect patient care and the surrogate experience.

Validation and Analysis of the European Quality Questionnaire in Italian Language

The European Quality Questionnaire (euroQ2) is the culturally-adapted version to the European context of the Family Satisfaction in Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) tools in a single instrument divided into three parts (the last is optional). These tools were created for an adult setting. The aim of this study was the Italian validation and analysis of the euroQ2 tool. The Italian version of euroQ2 questionnaire was administered to the relatives, over 18 years of age, of adult intensive care unit patients, with the Hospital Anxiety and Depression Scale (HADS) and the Impact of Event Scale—Revised (IES-r). For the re-test phase the questionnaire was administered a second time. One hundred questionnaires were filled in. The agreement between test and retest was between 17–19 out of 20 participants with an upward trend in the re-test phase. A measure of coherence and cohesion between the euroQ2 variables was given by Cronbach’s alpha: in the first part of the questionnaire alpha was 0.82, in the second part it was 0.89. The linear Pearson’s correlation coefficients between all questions showed a weak positive correlation. The results obtained agreed with the original study. This study showed a good stability of the answers, an indication of an unambiguous understanding of the Italian translation.

Family ward rounds in intensive care: An integrative review of the literature

BACKGROUND

The involvement of family members in the ward rounds is a novel but under-researched family-centered care intervention in adult intensive care units, with limited evidence on the impact it has on patient and family-centered outcomes.

OBJECTIVES

This integrative review aimed to understand how family rounds are implemented in critical care and to appraise the evidence on outcomes for patients, family members, and healthcare professionals.

DESIGN

An integrative review methodological framework permitted the inclusion of all research designs.

DATA SOURCES

MEDLINE; CINAHL; PsycINFO; Cochrane Library; Web of Science Current Contents Connect; Web of Science-Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global, Embase were systematically searched.

REVIEW METHODS

We reviewed studies that referred to or used as an intervention the involvement of family members in daily critical care team rounds. We included primary research in adult intensive care units regardless of patients' length of stay. We excluded patients receiving end-of-life care. We considered any outcome related to the critically ill patient and/or their family member, outcomes related to the healthcare professionals, and outcomes related to clinical and/or nursing treatment. The Mixed Methods Appraisal Tool was used to appraise the quality of the studies. The review was registered in the Prospero database.

RESULTS

From the 541 articles initially retrieved, 15 studies met the inclusion criteria and were included in the review. Studies originated from the United States of America and Canada since 2003, and a variety of designs were used. Four before and after studies and a non-randomized experimental study explored the impact of structured family rounds on family and staff satisfaction, showing limited improvement in satisfaction. Six cross-sectional survey studies explored family members' and clinicians' perceptions and demonstrated a positive attitude towards family-centered rounds, but some concerns were raised from the nursing staff. Three qualitative studies and a mixed-methods study identified structural and cultural factors influencing healthcare professionals' and families' acceptance of family rounds. Most studies were of poor to moderate quality, with limited confidence in the outcomes reported.

CONCLUSIONS

Most studies reported improved family satisfaction as the main outcome. Future research should focus on longitudinal patient and family-centered outcomes, including mental health outcomes, and on qualitative data to understand the processes, barriers, and facilitators to implement family-centered rounds in intensive care units.

A Randomized Comparative Trial to Evaluate a PICU Navigator-Based Parent Support Intervention

OBJECTIVES

Communication breakdowns in PICUs contribute to inadequate parent support and poor post-PICU parent outcomes. No interventions supporting communication have demonstrated improvements in parental satisfaction or psychologic morbidity. We compared parent-reported outcomes from parents receiving a navigator-based parent support intervention (PICU Supports) with those from parents receiving an informational brochure.

DESIGN

Patient-level, randomized trial.

SETTING

Two university-based, tertiary-care children's hospital PICUs.

PARTICIPANTS

Parents of patients requiring more than 24 hours in the PICU.

INTERVENTIONS

PICU Supports included adding a trained navigator to the patient's healthcare team. Trained navigators met with parents and team members to assess and address communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and did a post-PICU discharge parent check-in. The comparator arm received an informational brochure providing information about PICU procedures, terms, and healthcare providers.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was percentage of "excellent" responses to the Pediatric Family Satisfaction in the ICU 24 decision-making domain obtained 3-5 weeks following PICU discharge. Secondary outcomes included parental psychologic and physical morbidity and perceptions of team communication. We enrolled 382 families: 190 received PICU Supports, and 192 received the brochure. Fifty-seven percent (216/382) completed the 3-5 weeks post-PICU discharge survey. The mean percentage of excellent responses to the Pediatric Family Satisfaction in the ICU 24 decision-making items was 60.4% for PICU Supports versus 56.1% for the brochure (estimate, 3.57; SE, 4.53; 95% CI, -5.77 to 12.90; p = 0.44). Differences in secondary outcomes were not statistically significant. Most parents (91.1%; 113/124) described PICU Supports as "extremely" or "somewhat" helpful.

CONCLUSIONS

Parents who received PICU Supports rated the intervention positively. Differences in decision-making satisfaction scores between those receiving PICU Supports and a brochure were not statistically significant. Interventions like PICU Supports should be evaluated in larger studies employing enhanced recruitment and retention of subjects.

Family and health professional experience with a nurse-led family support intervention in ICU: A qualitative evaluation study

OBJECTIVES

To investigate family and health professional experience with a nurse-led family support intervention in intensive care.

DESIGN

Qualitative evaluation study.

SETTING

A twelve-bed surgical intensive care unit in a 900-bed University Hospital in Switzerland.

MAIN OUTCOME MEASURES

Data were collected through 16 semi-structured interviews with families (n = 19 family members) and three focus group interviews with critical care staff (n = 19) and analysed using content analysis strategies.

FINDINGS

Four themes related to the new family support intervention were identified. First, families and staff described it as a valuable and essential part of ICU care. Second, it facilitated staff-family interaction and communication. Third, from staff perspective, it promoted the quality of family care. Fourth, staff believed that the family support intervention enabled them to better care for families through increased capacity for developing and sustaining relationships with families.

CONCLUSIONS

An advanced practice family nursing role coupled with a family support pathway is an acceptable, appreciated and beneficial model of care delivery in the inttensive care unit from the perspective of families and critical care staff. Further research is needed to investigate the intervention's effectiveness in the intensive care unit.

Stressors and strains of next of kin of patients with ARDS in intensive care: A qualitative interview study using a stress-strain approach

OBJECTIVES

This study aims to explore and analyse the stressors and strains of next of kin of acute respiratory distress syndrome (ARDS) patients during their stay in the intensive care unit utilising the stressors and strain approach as a theoretical framework.

METHODS

Data collection was performed as semi-standardised qualitative interviews. 35 families of patients with ARDS were approached when visiting the intensive care unit. Participants were recruited until thematic saturation was reached; finally, 17 persons (age ranging from 26 to 71 years, nine women) took part. Systematic content analysis was conducted on the theoretical foundations of the stressors and strain approach.

FINDINGS

Numerous stressors were identified; they can be divided into three main categories: in relation to organising the visit, occurring during the visit and arising at home. These stressors were reported highly consistently throughout participants. However, the strains resulting from these stressors were varying in manifestation and level.

CONCLUSIONS

This study explores the manifold stressors and strains of next of kin of a critically ill patient. Some stressors are inherent to the life-threatening condition of a family member; others arise from the health care system and could be modified. The level of strain experienced depends on social support, individual coping skills and life circumstances.

An informative nursing intervention for families of patients admitted to the intensive care unit regarding the satisfaction of their needs: The INFOUCI study

AIM

To evaluate whether an informative intervention by nursing professionals through Short Message Service (SMS) improved patients' family members' satisfaction with the intensive care experience.

METHODS/DESIGN

This was an exploratory, two-armed, randomised, non-pharmacological, prospective study. The intervention consisted of providing information to the contact persons of patients admitted to the ICU of the University Hospital La Princesa (Madrid, Spain) through SMS based on the patient's nursing assessment. Nursing diagnoses established by NANDA and based on the Virginia Henderson model were used as a reference. The main result was the satisfaction levels of the contacts of patients admitted to the intensive care unit, which was evaluated with the Critical Care Family Needs Inventory.

RESULTS

The total score on the Critical Care Family Needs Inventory was significantly better in the intervention group (16.6 ± 3.3 vs. 19.1 ± 4.7; p = 0.012) compared with the control group. All participants included in the intervention considered it useful to some degree. Even when the contact person received negative information, there was no demand for information outside established hours, which was included as a possible adverse effect of the intervention.

CONCLUSION

Support in the form of additional nursing information implied an increase in the satisfaction of the needs perceived by the contact persons of patients admitted to the intensive care unit, together with a better perception of the quality of intensive care unit care and a reassuring and beneficial effect.

Association of Surrogate Decision-making Interventions for Critically Ill Adults With Patient, Family, and Resource Use Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity.

OBJECTIVE

To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use.

DATA SOURCES

A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018.

STUDY SELECTION

Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms included surrogate or substitute decision-maker, critically ill, randomized controlled trials, and their respective related terms.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use).

RESULTS

Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08; P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, -2.11 days; 95% CI, -4.16 to -0.07; P = .04), but not in the overall population (mean difference, -0.79 days; 95% CI, -2.33 to 0.76 days; P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, -0.11; 95% CI, -0.29 to 0.08; P = .26; anxiety: ratio of means, -0.08; 95% CI, -0.25 to 0.08; P = .31; or posttraumatic stress disorder: ratio of means: -0.04; 95% CI, -0.21 to 0.13; P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention; P = .04).

CONCLUSIONS AND RELEVANCE

Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.

Conditional Permission to Not Resuscitate: A Middle Ground for Resuscitation

Every decision to perform or withhold cardiopulmonary resuscitation (CPR) has ethical implications that are not always well understood. Value-based decisions with far-reaching consequences are made rapidly, based on incomplete or possibly inaccurate information. For some patients, skilled, timely CPR can restore spontaneous circulation, but for others, success may either be unobtainable or bring serious iatrogenic consequences. Because CPR is an aggressive process yielding mixed results, patients must be informed about the likelihood of its positive and adverse outcomes. In considering whether to accept or refuse it, patients should also be given a realistic set of alternatives. Current protocols limit patients' options by restricting them to a choice between accepting or refusing CPR. Adding a "middle" code, DNAR-X (Do Not Attempt Resuscitation-Except), significantly expands patients' right to control what happens to their bodies by allowing them to stipulate CPR in some circumstances but not in others.

Nurse-Family Communication During and After Family Meetings in the Intensive Care Unit

PURPOSE

To explore nurse-family communication during and after family meetings.

DESIGN

A cross-sectional study in which 36 family meetings were audio-recorded in two intensive care units in an urban, community hospital.

METHODS

Data were analyzed using conversation analysis, a qualitative method.

FINDINGS

Nurses spoke during 10 (28%) of the family meetings. During the family meetings, nurses mostly self-selected to take a turn by interrupting a physician or family member, finishing their sentences, responding to questions, and, in one instance, asking a question. Nurses were mostly selected as the next speaker to address logistical issues, but were also asked questions. Most of nurses' turns were short and simple, and aimed to provide clarification, reassurance, and information regarding the patient's status. Immediately after the family meetings, nurses offered to provide family members clarification or gestures of empathy, but these offers were met with resistance from family members.

CONCLUSIONS

Despite calls for nurses to take a more active role in surrogate decision making, nurses minimally participated during family meetings. Empowering nurses to share their expertise is one solution for nurses to contribute during family meetings. Further research is needed to explore nurse-family bedside interactions to improve our understanding of the nurse's role in the surrogate decision-making process.

CLINICAL RELEVANCE

Findings from this exploration of nurse communication during and after family meetings can inform how nurses may best assist families during surrogate decision making in the intensive care unit.

Information or education interventions for adult intensive care unit (ICU) patients and their carers

BACKGROUND

During intensive care unit (ICU) admission, patients and their carers experience physical and psychological stressors that may result in psychological conditions including anxiety, depression, and post-traumatic stress disorder (PTSD). Improving communication between healthcare professionals, patients, and their carers may alleviate these disorders. Communication may include information or educational interventions, in different formats, aiming to improve knowledge of the prognosis, treatment, or anticipated challenges after ICU discharge.

OBJECTIVES

To assess the effects of information or education interventions for improving outcomes in adult ICU patients and their carers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO from database inception to 10 April 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), and planned to include quasi-RCTs, comparing information or education interventions presented to participants versus no information or education interventions, or comparing information or education interventions as part of a complex intervention versus a complex intervention without information or education. We included participants who were adult ICU patients, or their carers; these included relatives and non-relatives, including significant representatives of patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and applied GRADE criteria to assess certainty of the evidence.

MAIN RESULTS

We included eight RCTs with 1157 patient participants and 943 carer participants. We found no quasi-RCTs. We identified seven studies that await classification, and three ongoing studies.Three studies designed an intervention targeted at patients, four at carers, and one at both patients and carers. Studies included varied information: standardised or tailored, presented once or several times, and that included verbal or written information, audio recordings, multimedia information, and interactive information packs. Five studies reported robust methods of randomisation and allocation concealment. We noted high attrition rates in five studies. It was not feasible to blind participants, and we rated all studies as at high risk of performance bias, and at unclear risk of detection bias because most outcomes required self reporting.We attempted to pool data statistically, however this was not always possible due to high levels of heterogeneity. We calculated mean differences (MDs) using data reported from individual study authors where possible, and narratively synthesised the results. We reported the following two comparisons.Information or education intervention versus no information or education intervention (4 studies)For patient anxiety, we did not pool data from three studies (332 participants) owing to unexplained substantial statistical heterogeneity and possible clinical or methodological differences between studies. One study reported less anxiety when an intervention was used (MD -3.20, 95% confidence interval (CI) -3.38 to -3.02), and two studies reported little or no difference between groups (MD -0.40, 95% CI -4.75 to 3.95; MD -1.00, 95% CI -2.94 to 0.94). Similarly, for patient depression, we did not pool data from two studies (160 patient participants). These studies reported less depression when an information or education intervention was used (MD -2.90, 95% CI -4.00 to -1.80; MD -1.27, 95% CI -1.47 to -1.07). However, it is uncertain whether information or education interventions reduce patient anxiety or depression due to very low-certainty evidence.It is uncertain whether information or education interventions improve health-related quality of life due to very low-certainty evidence from one study reporting little or no difference between intervention groups (MD -1.30, 95% CI -4.99 to 2.39; 143 patient participants). No study reported adverse effects, knowledge acquisition, PTSD severity, or patient or carer satisfaction.We used the GRADE approach and downgraded certainty of the evidence owing to study limitations, inconsistencies between results, and limited data from few small studies.Information or education intervention as part of a complex intervention versus a complex intervention without information or education (4 studies)One study (three comparison groups; 38 participants) reported little or no difference between groups in patient anxiety (tailored information pack versus control: MD 0.09, 95% CI -3.29 to 3.47; standardised general ICU information versus control: MD -0.25, 95% CI -4.34 to 3.84), and little or no difference in patient depression (tailored information pack versus control: MD -1.26, 95% CI -4.48 to 1.96; standardised general ICU information versus control: MD -1.47, 95% CI -6.37 to 3.43). It is uncertain whether information or education interventions as part of a complex intervention reduce patient anxiety and depression due to very low-certainty evidence.One study (175 carer participants) reported fewer carer participants with poor comprehension among those given information (risk ratio 0.28, 95% CI 0.15 to 0.53), but again this finding is uncertain due to very low-certainty evidence.Two studies (487 carer participants) reported little or no difference in carer satisfaction; it is uncertain whether information or education interventions as part of a complex intervention increase carer satisfaction due to very low-certainty evidence. Adverse effects were reported in only one study: one participant withdrew because of deterioration in mental health on completion of anxiety and depression questionnaires, but the study authors did not report whether this participant was from the intervention or comparison group.We downgraded certainty of the evidence owing to study limitations, and limited data from few small studies.No studies reported severity of PTSD, or health-related quality of life.

AUTHORS' CONCLUSIONS

We are uncertain of the effects of information or education interventions given to adult ICU patients and their carers, as the evidence in all cases was of very low certainty, and our confidence in the evidence was limited. Ongoing studies may contribute more data and introduce more certainty when incorporated into future updates of the review.

Factors Associated with Family Caregivers' Confidence in Future Surrogate Decision Making for Persons with Cancer

Background: Improving family caregiver preparation for surrogate decision making is a critical priority. Objective: Determine a parsimonious set of intrapersonal factors associated with family caregivers' confidence in making future medical decisions for their relatives with cancer. Methods: Cross-sectional mail survey. Family caregivers of Medicare beneficiaries with pancreatic, lung, brain, ovarian, head and neck, hematologic, and stage IV cancers from communities of eight U.S. cancer centers. Participants completed validated measures of their social and mental health, self-care behaviors, coping styles, and surrogate decision-making confidence. Using linear modeling, the Bayesian information criterion was used to identify factors associated with decision-making confidence. A bootstrap approach was used to conduct penalized inference on the selected model coefficients. Model fit validation was assessed with a random forest ensemble. Results: Caregivers (n = 294) were on average 65.5 years old, mostly female (72.8%), and care recipients' spouse/partner (60.2%). The parsimonious set of factors associated with low caregiver decision-making confidence included less engagement in spiritual growth self-care, more use of avoidant coping, low emotional social support, and younger care recipient age (in-sample R² = 0.22). These factors were also identified by a random forest approach. After overfitting adjustment (shrunken R² = 0.09), the strongest associations with low surrogate decision-making confidence were low spiritual growth self-care (adjusted standardized B = 0.17, p = 0.005) and high use of avoidant coping (adjusted standardized B = -0.12, p = 0.049). Discussion: Identifying strategies to enhance spiritual growth and reduce avoidant coping may be promising targets for interventions to improve family caregivers' confidence in future surrogate decision making.

Improving end-of-life care in an intensive care unit: a collaborative quality improvement project

BACKGROUND

The shift from curative to palliative care is one of the most challenging situations in intensive care units.

AIMS

The purpose of this collaborative project was to develop and implement a pilot intervention aimed at improving end-of-life care for patients in an open intensive care unit in Quebec City, Canada.

METHODS

Individual and group interviews were first conducted to identify strengths and needs for improvement in care. After the main needs for improvement were determined, interventions were implemented in a concerted manner. These included training in end-of-life care as well as the adaptation of tools to promote communication with the patient and his or her family, or to facilitate interdisciplinary work.

RESULTS

Preliminary results obtained through individual interviews indicate participant satisfaction with the project, but additional data need to be gathered to evaluate improvements in practice.

CONCLUSIONS

Other collaborative quality improvement projects need to be implemented to improve end-of-life practices in intensive care units.