Death and Dying in Intensive Care: Emotional Labour of Nurses

Nurses' Participation in Limited Resuscitation: Gray Areas in End of Life Decision-Making

Historically nurses have lacked significant input in end-of-life decision-making, despite being an integral part of care. Nurses experience negative feelings and moral conflict when forced to aggressively deliver care to patients at the EOL. As a result, nurses participate in slow codes, described as a limited resuscitation effort with no intended benefit of patient survival. The purpose of this study was to explore and understand the process nurses followed when making decisions about participation in limited resuscitation. Five core categories emerged that describe this theory: (1) recognition of patient and family values at the EOL; (2) stretching time and reluctance in decision-making; (3) harm and suffering caused by the physical components of CPR; (4) nurse's emotional and moral response to delivering aggressive care, and; (5) choosing limited resuscitation with or without a physician order. Several factors in end-of-life disputes contribute to negative feelings and moral distress driving some nurses to perform slow codes in order to preserve their own moral conflict, while other nurses refrain unless specifically ordered by physicians to provide limited care through tailored orders.

Cuidado humanizado en pacientes con limitación del esfuerzo terapéutico en cuidados intensivos, desafíos para enfermería

En las unidades de cuidados intensivos (UCI) el equipo de salud utiliza todas las medidas posibles para preservar la vida de sus pacientes. No obstante, cuando las terapias son fútiles, se decide limitar el esfuerzo terapéutico (LET). Este artículo tiene como objetivo describir los factores que pueden llevar a enfermería a deshumanizar sus cuidados en pacientes en LET en UCI. Revisión de la literatura en bases de datos, con las palabras clave: critical care, intensive care unit, limitation of therapeutic effort, end of life care, humanized/human care, nursing. Los hallazgos fueron agrupados en seis categorías que pueden influir en la deshumanización del cuidado en UCI. Se concluye que en el cuidado humanizado se destacan los roles de enfermería como defensora de los intereses del paciente y como agente comunicador.

Perceived needs for support among care home staff providing end of life care for people with dementia: a qualitative study

OBJECTIVE

The aim of the current exploratory study was to investigate the impact on care home staff when working with people with dementia at the end of life and to explore how they cope with this aspect of their work. With UK policy encouraging death in the place of residence, rather than hospital, more people with dementia are dying in care homes.

METHOD

A qualitative approach was employed; 20 care home staff working in five English care homes were interviewed. Thematic Analysis was used to analyse the data.

RESULTS

Care home staff found the external demands on them and difficulties associated with interacting with people with dementia sometimes challenging, stressful and anxiety-provoking, particularly as residents approached end of life. Emotional aspects of caring for dying residents were sometimes heightened by close attachments with residents and their families. Staff were able to recognise these unmet needs and identified a need for further training and emotional support to manage these stressors.

CONCLUSIONS

This study revealed rich and complex understandings of the practice dimensions of caring for people with dementia at the end of life and the impact these have on staff. There is a need to develop effective psychosocial interventions that focus on emotional support for care home staff. There will be challenges in providing this in employment settings that are generally low paid, low status, have high turnover and are reliant on temporary or migrant staff, where training is not rewarded, mandatory or culturally valued. Copyright © 2016 John Wiley & Sons, Ltd.

Compassionate care during withdrawal of treatment: A secondary analysis of ICU nurses' experiences

BACKGROUND:

Withdrawal of treatment is a common practice in intensive care units when treatment is considered futile. Compassion is an important aspect of care; however, it has not been explored much within the context of treatment withdrawal in intensive care units.

OBJECTIVES:

The aim was to examine how concepts of compassion are framed, utilised and communicated by intensive care nurses in the context of treatment withdrawal.

DESIGN:

The study employed a qualitative approach conducting secondary analysis of an original data set. In the primary study, 13 nurses were recruited from three intensive care units within a large hospital in United Kingdom. Deductive framework analysis was used to analyse the data in relation to compassionate care.

ETHICAL CONSIDERATIONS:

The primary study was approved by the local Research Ethics Committee and the hospital's Research and Development services.

FINDINGS:

Compassionate care was mostly directed to the patient's family and was demonstrated through care and emotional support to the family. It was predominantly expressed through attempts to maintain the patient's dignity by controlling symptoms, maintaining patient cleanliness and removing technical apparatus.

CONCLUSION:

This study's findings provide insight about compassionate care during treatment withdrawal which could help to understand and develop further clinicians' roles. Prioritising the family over the patient raised concerns among nurses, who motivated by compassion, may feel justified in taking measures that are in the interests of the family rather than the patient. Further work is needed to explore the ethics of this.

Nurses’ moral experiences of assisted death: A meta-synthesis of qualitative research

Background:

Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses’ experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses’ experiences of caring for people who request this option.

Aim:

To synthesize what has been learned about nurses’ experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.

Design:

Qualitative meta-synthesis.

Methods:

Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.

Results:

The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.

Discussion:

The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses’ moral agency that operate in everyday end-of-life care.

Ethical considerations:

Research ethics board approval was not required for this synthesis of previously published literature.

Conclusion:

In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.

Facing death in the intensive care unit. A phenomenological study of nurses' experiences

BACKGROUND

Nurses may experience considerable emotional burden due to patient death, in part as they are generally the professionals who have the most contact with patients.

OBJECTIVE

To describe the lived experience of Spanish nurses working in intensive care units regarding how they face the death of their patients.

METHODS

A qualitative phenomenological study was performed. A purposeful sample was used. The data collection strategies used included in-depth unstructured and semi-structured interviews, field notes and personal documents. Afterwards, data were analyzed using the Giorgi proposal.

RESULTS

22 nurses participated, with a mean age of 40.8 years and a mean work experience of 13.8 years. Three themes were identified: 1) dealing with expectations of recovery, 2) accepting the age of death, and 3) experiencing emotional attachment.

CONCLUSIONS

Nurses in intensive care units report a great emotional burden derived from patients death, Support programs for nurses should be organised within these units.

The care of dying people in nursing homes and intensive care units: a qualitative mixed-methods study

Background

In England and Wales the two most likely places of death are hospitals (52%) and nursing homes (22%). The Department of Health published its National End of Life Care Strategy in July 2008 (Department of Health.End of Life Care Strategy: Promoting High Quality Care For All Adults at the End of Life. London: Department of Health; 2008) to improve the provision of care, recommending the use of the Liverpool Care Pathway for the Dying Patient (LCP).

Aim

The original aim was to assess the impact of the LCP on care in two settings: nursing homes and intensive care units (ICUs).

Design

Qualitative, matched case study.

Methods

Data were collected from 12 ICUs and 11 nursing homes in England: (1) documentary analysis of provider end-of-life care policy documents; (2) retrospective analysis of 10 deaths in each location using written case notes; (3) interviews with staff about end-of-life care; (4) observation of the care of dying patients; (5) analysis of the case notes pertaining to the observed patient’s death; (6) interview with a member of staff providing care during the observed period; (7) interview with a bereaved relative present during the observation; (8) economic analysis focused on the observed patients; and (9) strict inclusion and selection criteria for nursing homes and ICUs applied to match sites on LCP use/non-LCP use.

Results

It was not possible to meet the stated aims of the study. Although 23 sites were recruited, observations were conducted in only 12 sites (eight using the LCP). A robust comparison on the basis of LCP use could not, therefore, take place. Although nurses in both settings reported that the LCP supported good care, the LCP was interpreted and used differently across sites, with the greatest variation in ICUs. Although not able to address the original research question, this study provides an unprecedented insight into care at the end of life in two different settings. The majority of nursing homes had implemented some kind of ‘pathway’ for dying patients and most homes participating in the observational stage were using the LCP. However, training in care of the dying was variable and specific issues were identified relating to general practitioner involvement, the use of anticipatory drugs and the assessment of consciousness and the swallowing reflex. In ICUs, end-of-life care was inextricably linked with the withdrawal of active treatment and controlling the pace of death. The data highlight how the decision to withdraw was made and, importantly, how relatives were involved in this process. The fact that most patients died soon after the withdrawal of interventions was reported to limit the appropriateness of the LCP in this setting.

Limitations

Although the recruitment of matched sites was achieved, variable site participation resulted in a skewed sample. Issues with the sample size and a blurring of LCP use and non-use limit the extent to which the ambitious aims of the study were achieved.

Conclusions

This study makes a unique contribution to understanding the complexity of care at the end of life in two very different settings. More research is needed into the ways in which an organisational culture can be created within which the principles of good end-of-life care become translated into practice.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Life after the Liverpool Care Pathway (LCP): a qualitative study of critical care practitioners delivering end-of-life care

AIM

To explore the experiences, challenges and practices of critical care practitioners since the discontinuation of the Liverpool Care Pathway in critical care settings.

BACKGROUND

The Liverpool Care Pathway was widely used with an aim to improve communication and care for dying individuals and their relatives. However, widespread media criticism prompted a review, which resulted in the discontinuation of the Liverpool Care Pathway across all UK clinical settings.

DESIGN

A qualitative study.

METHOD

The study was carried out in two large acute hospitals in England. Semi-structured interviews were conducted with 14 critical care practitioners, 6 months after discontinuation of the Liverpool Care Pathway. Transcribed verbatim data were analysed using framework analysis.

RESULTS

Three key themes emerged: 'lessons learned', 'uncertainties and ambivalences' and 'the future'. Critical care practitioners reported that life after the Liverpool Care Pathway in critical care settings often involved various clinical ambivalences, uncertainties and inconsistencies in the delivery of end-of-life care, especially for less experienced practitioners. Critical care practitioners had 'become accustomed' to the components of the Liverpool Care Pathway, which still guide them in principle to ensure quality end-of-life care. The Liverpool Care Pathway's structured format was perceived to be a useful clinical tool, but was also criticized as a 'tick-box exercise' and for lacking in family involvement.

CONCLUSIONS

This study posits two key conclusions. Despite experienced critical care practitioners being able to deliver quality end-of-life care without using the Liverpool Care Pathway, junior nursing and medical staff need clear guidelines and support from experienced mentors in practice. Evidence-based guidelines related to family involvement in end-of-life care planning in critical care settings are also needed to avoid future controversies.