Withholding Treatment From the Dying Patient: The Influence of Medical School on Students' Attitudes

PURPOSE

To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students.

METHODS

This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status.

RESULTS

Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen.

DISCUSSION

Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.

Long-term follow-up for Psychological stRess in Intensive CarE (PRICE) survivors: study protocol for a multicentre, prospective observational cohort study in Australian intensive care units

INTRODUCTION

There are little published data on the long-term psychological outcomes in intensive care unit (ICU) survivors and their family members in Australian ICUs. In addition, there is scant literature evaluating the effects of psychological morbidity in intensive care survivors on their family members. The aims of this study are to describe and compare the long-term psychological outcomes of intubated and non-intubated ICU survivors and their family members in an Australian ICU setting.

METHODS AND ANALYSIS

This will be a prospective observational cohort study across four ICUs in Australia. The study aims to recruit 150 (75 intubated and 75 non-intubated) adult ICU survivors and 150 family members of the survivors from 2015 to 2018. Long-term psychological outcomes and effects on health-related quality of life (HRQoL) will be evaluated at 3 and 12 months follow-up using validated and published screening tools. The primary objective is to compare the prevalence of affective symptoms in intubated and non-intubated survivors of intensive care and their families and its effects on HRQoL. The secondary objective is to explore dyadic relations of psychological outcomes in patients and their family members.

ETHICS AND DISSEMINATION

The study has been approved by the relevant human research ethics committees (HREC) of Australian Capital Territory (ACT) Health (ETH.11.14.315), New South Wales (HREC/16/HNE/64), South Australia (HREC/15/RAH/346). The results of this study will be published in a peer-reviewed medical journal and presented to the local intensive care community and other stakeholders.

TRIAL REGISTRATION NUMBER

ACTRN12615000880549; Pre-results.

Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With Advanced Heart Failure

BACKGROUND

Conversations about goals of care and cardiopulmonary resuscitation (CPR)/intubation for patients with advanced heart failure can be difficult. This study examined the impact of a video decision support tool and patient checklist on advance care planning for patients with heart failure.

METHODS

This was a multisite, randomized, controlled trial of a video-assisted intervention and advance care planning checklist versus a verbal description in 246 patients ≥64 years of age with heart failure and an estimated likelihood of death of >50% within 2 years. Intervention participants received a verbal description for goals of care (life-prolonging care, limited care, and comfort care) and CPR/intubation plus a 6-minute video depicting the 3 levels of care, CPR/intubation, and an advance care planning checklist. Control subjects received only the verbal description. The primary analysis compared the proportion of patients preferring comfort care between study arms immediately after the intervention. Secondary outcomes were CPR/intubation preferences and knowledge (6-item test; range, 0-6) after intervention.

RESULTS

In the intervention group, 27 (22%) chose life-prolonging care, 31 (25%) chose limited care, 63 (51%) selected comfort care, and 2 (2%) were uncertain. In the control group, 50 (41%) chose life-prolonging care, 27 (22%) selected limited care, 37 (30%) chose comfort care, and 8 (7%) were uncertain (P<0.001). Intervention participants (compared with control subjects) were more likely to forgo CPR (68% versus 35%; P<0.001) and intubation (77% versus 48%; P<0.001) and had higher mean knowledge scores (4.1 versus 3.0; P<0.001).

CONCLUSIONS

Patients with heart failure who viewed a video were more informed, more likely to select a focus on comfort, and less likely to desire CPR/intubation compared with patients receiving verbal information only.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01589120.

Differentiating DNI from DNR: combating code status conflation

Goals of care discussions, including those focused on code status, are meant to foster autonomous decision making. Unfortunately, these discussions often conflate decisions regarding the use of cardiopulmonary resuscitation for cardiac arrest and mechanical ventilation for prearrest respiratory failure. They also exclude discussions of outcomes, particularly those associated with prearrest respiratory failure. In doing so, they may fail in their intention of extending patient autonomy. Journal of Hospital Medicine 2014;9:669-670. © 2014 Society of Hospital Medicine.

[Obtaining informed consent in the training of endotracheal intubation by emergency medical technicians]

BACKGROUND

There are some problems in the training of endotracheal intubation enforced for the emergency medical technicians. It is important to obtain the informed consent from preoperative patients which is difficult, and time is spent. In addition, patients sometimes refuse in spite of full explanation about this training.

METHODS

We examined the situation where we can obtain the informed consent and what were the reasons the patient refuse this training.

RESULTS

The refusal rate was 22.5% and women of their 50's to 60's of ages tended to decline more. And there seemed to be difference in each department slightly. The reasons of the patients who refused the informed consent were an anxiety to the training of endotracheal intubation and unwilling to be sacrificed for that. These reasons comprised about 66%.

CONCLUSIONS

We could not find the important point to obtain more informed consent. But it was thought that we should know these results to obtain consent more effectively from now.

[Non-verbal communication of patients submitted to heart surgery: from awaking after anesthesia to extubation]

Preoperative orientation is an essential tool for patient's communication after surgery. This study had the objective of evaluating non-verbal communication of patients submitted to cardiac surgery from the time of awaking from anesthesia until extubation, after having received preoperative orientation by nurses. A quantitative cross-sectional study was developed in a reference hospital of the state of Rio Grande do Sul, Brazil, from March to July 2006. Data were collected in the pre and post operative periods. A questionnaire to evaluate non-verbal communication on awaking from sedation was applied to a sample of 100 patients. Statistical analysis included Student, Wilcoxon, and Mann Whittney tests. Most of the patients responded satisfactorily to non-verbal communication strategies as instructed on the preoperative orientation. Thus, non-verbal communication based on preoperative orientation was helpful during the awaking period.

[Physiological and behavioral responses of newborns at risk to nurse's care]

Daily tasks carried out by nurses working at the Neonatal Unit (NU) require expanding practice and observation skills, from the perspective of professional activities. The aim of this study was to investigate physiological and behavioral responses of newborns (NB) at risk being cared by NU nurses. This exploratory-descriptive study was carried out with 33 NB at risk admitted to the NU of a public maternity ward, in Fortaleza, Ceara, Brazil, from December/2004 to March/2005. Direct observation of care provided by, nurses to the NB, and medical records on birth conditions were used. The most frequent physiological response was change in the heart rate, followed by changes in oxygen saturation and skin color. It was also observed that, by means of face expression, body movement, and crying, that infants tried to communicate their feelings.

Communication interaction in ICU—Patient and staff experiences and perceptions

Patients on intensive care units (ICU) have difficulty with communication [Menzel LK. Factors related to the emotional responses of intubated patients to being unable to speak. Heart Lung 1998; 27(4):245-52]. Feelings of anger and low mood have been reported, which can lead to reduced participation in rehabilitation. For members of the multidisciplinary team breakdown in communication with patients may be frustrating and related to a limited knowledge of strategies and resources to facilitate communication. The NHS Modernisation Agency Critical Care Programme (2002) identified speech and language therapists (SLTs) as having a role in the assessment and management of patients with communication difficulties on ICU. This multi-centre pilot study aimed to investigate staff and patient perceptions and experiences of communication within ICUs. A short questionnaire was devised using semi-structured interviews to collect quantitative and qualitative information. Patterns were identified including insights into SLT service delivery and possible directions for future research and development.

BIS monitoring in a patient with history of awareness and a difficult airway

We describe a case where bispectral index (BIS) monitoring was used successfully to guide an inhaled induction technique for a difficult airway. The patient was a 34 years old male who had a previous history of awareness during anaesthesia. He was also morbidly obese with a Mallampatti score of III on preoperative examination.

School-age children's perceptions of their PICU hospitalization

The aim of this cross-sectional study was to explore the effects of a PICU hospitalization on critically ill school- age children. Few studies have examined the impact of the PICU experience on children themselves. A convenience sample was recruited of 21 developmentally appropriate children who were aged 7-12 years and had never been hospitalized. Children were asked open-ended questions related to their PICU experience, frequency and effectiveness of coping strategies was measured, and drawings were used to evaluate anxiety. Although not detailed, most children did have some recollection of their PICU stay. People in the PICU (i.e., nurses, physicians) were remembered as good, while feelings the children had (i.e., tired, didn't like it) were described as what was bad about the PICU. Children's coping strategies scores were very low. Most children had an average level of anxiety based on analysis of their drawings. Children's repertoire of coping strategies may be limited by the PICU, especially while intubated. Nurses should never underestimate the effect their behavior and responsiveness has on children. Feasible coping strategies and use of therapeutic play for PICU children should be explored further.

Evaluation of a decision aid for making choices about intubation and mechanical ventilation in chronic obstructive pulmonary disease

To assist patients with chronic obstructive pulmonary disease (COPD) in advance planning for life-threatening exacerbations, we developed a structured decision aid that describes the process, risks, and outcomes of intubation and mechanical ventilation (MV). Thirty-three patients with severe COPD took part in a before-after evaluation study. At baseline, only two participants (6%) reported that they had already made an advance decision about MV. After reviewing the decision aid, 31 participants (94%) reported that they had made a choice, which in 23 cases (74% of those deciding) was to forego MV. These choices were associated with more accurate expectations of MV outcome, and reduced decisional conflict. Qualitatively, participants who would accept MV emphasized their wish to prolong life, whereas those who would forego MV were more influenced by the burdens of treatment and the perception of a poor long-term outcome. However, there was evidence that 24% of participants did not completely comprehend the decision aid and 27% found the experience to be stressful. These findings indicate that a decision aid for MV helps patients plan for life-threatening exacerbations, and may be a useful adjunct to counseling for some patients with severe COPD.

[Pain indicators in critical care]

In this descriptive/qualitative study, focus groups and individual interviews were completed with 48 critical care nurses and 12 critical care physicians. Results showed that many indicators are used by those clinicians for pain assessment in intubated patients, whatever their level of consciousness. Nurses and physicians mentioned giving weight to the patient's self-assessmen tof pain even when intubated, communication then being by means of signs. Behavioural and physiological indicators also provide clinicians with valuable information for pain assessment. However, for the most part these indicators are not specific to pain, limiting their usefulness in this context. The study aslo suggests recommendations for nursing practice and ideas for nursing resarch.

The identification of family members' contribution to patients' care in the intensive care unit: a naturalistic inquiry

The admission of a patient to an intensive care unit (ICU) is recognized as being a stressful experience for their families. Many studies have focused on the needs of families within ICU, but few have highlighted the unique contribution that family members make towards patient care and recovery. Using a naturalistic approach, data were collected through observation, video recording, in-depth interviewing and reflective video analysis to explore the processes and factors underpinning families' contribution to patient care. The findings can be grouped into three themes: getting to know the patient through the family, family contribution to care and the nurses' role in supporting families of ICU patients. Families can have a very positive influence on the patient's care and recovery from ICU, but both the family members, and in turn the nursing staff, need to be supported appropriately if this valuable contribution to patient care is to be maximized and maintained.

Discomfort and factual recollection in intensive care unit patients

INTRODUCTION

A stay in the intensive care unit (ICU), although potentially life-saving, may cause considerable discomfort to patients. However, retrospective assessment of discomfort is difficult because recollection of stressful events may be impaired by sedation and severe illness during the ICU stay. This study addresses the following questions. What is the incidence of discomfort reported by patients recently discharged from an ICU? What were the sources of discomfort reported? What was the degree of factual recollection during patients' stay in the ICU? Finally, was discomfort reported more often in patients with good factual recollection?

METHODS

All ICU patients older than 18 years who had needed prolonged (>24 hour) admission with tracheal intubation and mechanical ventilation were consecutively included. Within three days after discharge from the ICU, a structured, in-person interview was conducted with each individual patient. All patients were asked to complete a questionnaire consisting of 14 questions specifically concerning the environment of the ICU they had stayed in. Furthermore, they were asked whether they remembered any discomfort during their stay; if they did then they were asked to specify which sources of discomfort they could recall. A reference group of surgical ward patients, matched by sex and age to the ICU group, was studied to validate the questionnaire.

RESULTS

A total of 125 patients discharged from the ICU were included in this study. Data for 123 ICU patients and 48 surgical ward patients were analyzed. The prevalence of recollection of any type of discomfort in the ICU patients was 54% (n = 66). These 66 patients were asked to identify the sources of discomfort, and presence of an endotracheal tube, hallucinations and medical activities were identified as such sources. The median (min-max) score for factual recollection in the ICU patients was 15 (0-28). The median (min-max) score for factual recollection in the reference group was 25 (19-28). Analysis revealed that discomfort was positively related to factual recollection (odds ratio 1.1; P < 0.001), especially discomfort caused by the presence of an endotracheal tube, medical activities and noise. Hallucinations were reported more often with increasing age. Pain as a source of discomfort was predominantly reported by younger patients.

CONCLUSION

Among postdischarge ICU patients, 54% recalled discomfort. However, memory was often impaired: the median factual recollection score of ICU patients was significantly lower than that of matched control patients. The presence of an endotracheal tube, hallucinations and medical activities were most frequently reported as sources of discomfort. Patients with a higher factual recollection score were at greater risk for remembering the stressful presence of an endotracheal tube, medical activities and noise. Younger patients were more likely to report pain as a source of discomfort.

A description of patients' report of endotracheal tube discomfort

The purpose of this descriptive study was to describe the type, location, and amount of endotracheal tube (ETT) discomfort. Twenty-two subjects (mean age 49.2 years) who had experienced ETT intubation for at least 6 hours (mean: 25.9 hours) after cardiac surgery, completed a 100-mm Visual Analogue Scale related to their experience with the endotracheal tube within 24 hours after extubation. A semi-structured interview was also conducted. There was no relationship between the duration of intubation and the level of discomfort described (r = -0.24; P = 0.29) or between the duration of intubation and whether medications relieved the discomfort (r = 0.34; P = 17). All subjects described some level of discomfort. The majority stated the discomfort was in the throat area. However, 27% (n = 6) described the discomfort as located in the chest. There was no difference in the level of discomfort based on discomfort location (f = -0.14; P = 0.71). The discomfort locations support the notion that ETT irritation occurs at multiple levels (i.e. pharyngeal, laryngeal, and tracheal mucosal areas). In addition, interventions that focus on ETT stability will not be sufficient to reduce discomfort but must re-focus nursing attention on reducing ETT movement as well as the movement of all ventilator tubing.

Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit

OBJECTIVE

To describe stressful experiences of adult patients who received mechanical ventilation for > or =48 hrs in an intensive care unit.

DESIGN

Prospective cohort study.

SETTING

Four intensive care units within an East Coast tertiary-care university medical center.

PATIENTS

Patients were 150 adult intensive care unit patients receiving mechanical ventilation for > or =48 hrs.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

As part of a study of the long-term outcomes of adult patients requiring prolonged mechanical ventilation, we used a 32-item questionnaire to collect data on patients' stressful experiences, both psychological (e.g., fearfulness, anxiety) and physical (e.g., pain, difficulty breathing), associated with the mechanical ventilation endotracheal tube and with being in an intensive care unit. Of 554 patients who met study criteria and survived prolonged mechanical ventilation, 150 consented and were oriented to person, place, and situation. Two thirds of these patients remembered the endotracheal tube and/or being in an intensive care unit. The median numbers of endotracheal tube and intensive care unit experiences remembered were 3 (of 7) and 9 (of 22), respectively. If a patient remembered an experience in the questionnaire, it was likely to be moderately to extremely bothersome. Some of the items that many patients found to be moderately to extremely bothersome were pain, fear, anxiety, lack of sleep, feeling tense, inability to speak/communicate, lack of control, nightmares, and loneliness. Stressful experiences associated with the endotracheal tube were strongly associated with subjects' experiencing spells of terror, feeling nervous when left alone, and poor sleeping patterns.

CONCLUSIONS

Subjects were more likely to remember experiences that were moderately to extremely bothersome. This might be because the more bothersome experiences were easier to recall or because most of these experiences are common and significant stressors to many of these patients. In either case, these data indicate that these patients are subject to numerous stressful experiences, which many find quite bothersome. This suggests the potential for improved symptom management, which could contribute to a less stressful intensive care unit stay and improved patient outcomes.

Early extubation after cardiac surgery: emotional status in the early postoperative period

OBJECTIVE

To compare the emotional state during the first 3 days after coronary artery surgery of patients who had undergone early versus conventional extubation.

DESIGN

A prospective, randomized, controlled trial.

SETTING

University hospital, single center.

PARTICIPANTS

Eligible patients (n = 100) presenting for elective coronary artery surgery, randomized to an early extubation group or a conventional extubation group.

INTERVENTIONS

Emotional status was measured by the Hospital Anxiety and Depression Scale (HAD), the Self Assessment Manikin (SAM), and the Multiple Affect Adjective Check List-Revised (MAACL-R). Tests were administered preoperatively and on the 1st and 3rd days postoperatively.

MEASUREMENTS AND MAIN RESULTS

Of patients in the conventional extubation group, 30% showed moderate-to-severe depressive symptoms (HAD score >10) on day 3 postoperatively compared with 8% of patients in the early extubation group (p = 0.02). There was a clinically insignificant increase in MAACL-R depression score on the 1st postoperative day within both groups but no other differences within or between groups in SAM or MAACL-R scores.

CONCLUSION

Early extubation results in fewer patients displaying depressive symptoms on the 3rd postoperative day but appears to have little effect on other measurements of emotional status. Anesthetic management during coronary artery bypass graft surgery may play an important role in the overall well-being of the patient by decreasing the incidence of postoperative depression.

Common factors of spontaneous self-extubation in a critical care setting

A prospective, concurrent study was conducted of all patients who self-extubated in a mixed critical care setting during a 14-month period. The purpose of the study was to identify the incidence and common factors associated with spontaneous self-extubation (SSE). A total of 75 cases of SSE occurred in 68 patients who had an incidence of 38.5 SSEs per 100 intubated days. The analysis of common factors of the total population found the following: 60 cases (80%) were restrained; 44 cases (59%) required reintubation; 66 cases (88%) followed commands or localized painful stimuli at the time of SSE; and 67 cases (89%) elicited spontaneous eye opening or opened eyes to verbal command at the time of SSE. Only 18 cases (24%) had analgesia administered within 1 to 2 hours of SSE. Twenty-four cases (32%) had anxiolytics administered within 4 hours of SSE. Of the 56 cases of SSE that were witnessed, 43 cases (73% of those observed) were considered deliberate rather than accidental. The practice of using intravenous boluses on an "as needed" dosing frequency for administering sedation and analgesia was a common factor in SSE. Adequate doses of sedation and analgesia delivered by continuous infusion may prevent SSE in alert, intubated patients.

Cosmetic tracheostomy locket: an attempt to improve the aesthetic component of tracheostomy tubes

This paper demonstrates the need for a cosmetic device as a necessary adjunct to long-term tracheostomy care. Such devices are not available, at present, from tracheostomy tube manufacturers. The cosmetic tracheostomy cover plate is based on a silver Negus tracheostomy tube, to which the silver chain and cover plate (locket) are attached. The result, for the patient who tried it, was excellent.

Intubation and mechanical ventilation for COPD: development of an instrument to elicit patient preferences

BACKGROUND

Whether to simply provide palliative care or to intubate and use mechanical ventilation (MV) in a patient with severe COPD in acute respiratory failure is a difficult decision. The outcome of MV cannot be accurately predicted. Some patients cannot be weaned from the ventilator; those who are weaned often return to chronic severe respiratory disability. It is important that patients participate in this decision, but assistance is required. To address these issues, we developed and pilot-tested an aid to assist patients with MV decisions.

METHODS

A scenario-based decision aid was developed consisting of an audiocassette and a booklet describing intubation and MV and its possible outcomes. We used a probability tradeoff technique to elicit the patients' preferences and a decisional conflict scale to evaluate satisfaction.

RESULTS

With the assistance of the decision aid, all patients (10 men and 10 women) reached a decision. Two men and all 10 women declined MV. Mean decisional conflict was low (2.2 of a possible 5; SD, 0.9). At 1 year, only two patients (11%) had changed their decision. The agreement between physicians and patients was 65%; between next-of-kin and patients, there was uniform disagreement.

CONCLUSION

With the decision aid, stable decisions were made with satisfaction and confidence. Proxy decisions were incongruent, especially when made by family members. The strong gender effect should be further investigated. We suggest that the COPD decision aid be further tested in a community clinical setting.

Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents

STUDY OBJECTIVES

No large study has addressed whether parents want to be present when invasive procedures are performed on their children in the emergency department. We conducted a survey to address this question.

METHODS

The study used a self-administered, written survey consisting of 5 pediatric scenarios with increasing level of procedural invasiveness. Parents in an urban, teaching hospital ED waiting area were asked to participate.

RESULTS

Of 407 persons asked to participate, 400 (98%) completed the survey. The number of parents expressing a desire to be present during a procedure performed on their child was 387 (97.5%) for venipuncture of the extremity, 375 (94.0%) for laceration repair, 341 (86.5%) for lumbar puncture, and 317 (80.9%) for endotracheal intubation. For a major resuscitation scenario, 316 (80.7%) wished to be present if their child were conscious during the resuscitation, 277 (71.4%) wanted to be present if their child were unconscious during the resuscitation, whereas 322 (83.4%) indicated a desire to be present if their child were likely to die during the resuscitation. Of the 400, 261 (65.3%) wished to be present for all 5 scenarios. Only 26 (6.5%) wanted the physician to determine parental presence in all 5 scenarios.

CONCLUSION

Most parents surveyed would want to be present when invasive procedures are performed on their children. With increasing procedural invasiveness, parental desire to be present decreased. However, most parents would want to be in attendance if their child were likely to die, and nearly all parents want to participate in the decision about their presence.

Normal saline instillation with endotracheal suctioning: primum non nocere (first do no harm)

Normal saline instillation, in conjunction with endotracheal suctioning, is purported to be beneficial in removing thick and tenacious secretions for patients receiving mechanical ventilation. Guidelines for this routine procedure are inconsistent and its efficacy is unsupported by research-based evidence. This discussion paper highlights that the procedure produces no physiological benefits for the patient and, indeed, may have detrimental effects on the patient's psychological wellbeing. It is proposed that after 25 years of inconsistent practice in trying to remove thick and tenacious secretions, it is time to focus on techniques to prevent thick and tenacious secretions.

Ventilated patients' self-esteem during intubation and after extubation

The primary purpose of this study was to determine if there was a difference in patients' self-esteem during intubation and after extubation, when differences in acuity were controlled. A secondary purpose was to examine and compare the self-esteem of subjects intubated for medical or surgical reasons. A descriptive longitudinal design compared the self-esteem of 29 subjects during intubation and after extubation. A repeated measures analysis of covariance found self-esteem to be significantly higher after extubation in subjects as a whole, when acuity at extubation was controlled. A repeated measures multivariate analysis of variance revealed a significant interaction effect for reason of intubation. Only medical patients experienced an increase in self-esteem over time. Their self-esteem was also lower when they were intubated. The findings support the dynamic nature of self-esteem in hospitalized patients. The implications of the study for research and practice are discussed.

Factors related to the emotional responses of intubated patients to being unable to speak

OBJECTIVES

The purpose of the study was to examine the relationships among the intensity of intubated patients' negative emotional responses to being unable to speak and selected personal and situational variables.

DESIGN

Prospective correlational.

SETTING

Four intensive care units in a midwestern, university-affiliated medical center.

PATIENTS

A convenience sample of 48 patients intubated for 24 or more hours, alert and oriented to person, place, and situation.

OUTCOME MEASURES

Emotional responses (anger and worry/fear) to being unable to speak.

RESULTS

Multiple regression showed that self-esteem, severity of illness, difficulty with communication, and the number of days intubated at data collection were significantly associated with patients' emotional responses.

CONCLUSIONS

Results from this study extend prior research and support the need for nurses to facilitate communication and to support self-esteem in patients receiving ventilatory assistance, particularly in the early days of intubation. Implications for future research are discussed.

Impaired verbal communication during short-term oral intubation

PURPOSE

To describe the experience of impaired verbal communication during short-term oral intubation in surgical critical care patients.

METHODS

Semi-structured interviews (N = 10)

FINDINGS

Patients identified feelings related to discomfort, fear, and frustration. Patients desired to communicate messages regarding pain and discomfort, difficulty breathing, length of intubation, use of restraints, family, physical status, and suctioning.

CONCLUSION

Findings can be used to educate patients and families and develop patient-driven communication tools.

Posttraumatic distress in children and families after intubation

BACKGROUND

Posttraumatic stress disorder symptoms are seen in children who have experienced significant trauma. Respiratory arrest with subsequent intubation can be associated with terror, helplessness, and the threat of death.

METHODS

Three case reports are presented where emergency intubation was followed by symptoms of psychologic distress in the intubated child and his or her family members.

RESULTS

Although the medical literature documents posttraumatic distress symptoms after other medical procedures, this is the first account of symptoms following intubation. Children and other family members were found to have symptoms of reexperiencing the traumatic event, avoidance of thoughts or feelings related to the intubation, and hyperarousal. Issues around diagnosis and treatment are discussed.

CONCLUSIONS

Children with a history of emergency intubation should be evaluated for possible posttraumatic stress disorder symptoms.

Quality of life in COPD patients using transtracheal oxygen

Transtracheal oxygen offers patients with chronic obstructive pulmonary disease many benefits. A qualitative study was conducted to examine patients' perceptions of how the technology affects quality of life. This study has several implications for nurses working in hospital and home settings.

Improving patient tolerance of mechanical ventilation. Challenges ahead

The development of psychopharmacology and anesthesia practice in the ICU has lagged well behind the development of similar practices in other settings, notably the operating room. Because of important differences in the severity of organ dysfunction and the duration of treatment, however, lessons learned in other settings cannot be applied directly to the ICU. A fresh conceptual framework is needed to identify indications for sedating drugs and muscle relaxants in the ICU. New assessment tools are needed, both for clinical research and for clinical practice. More information is needed on the pharmacokinetics, adverse effects, and comparative costs of psychoactive drug use in the ICU. Practice guidelines are needed to improve efficacy and reduce errors associated with these drugs. The challenge is considerable. The reward is a more humane ICU experience for critically ill patients.

Nonpharmacologic management of patient distress during mechanical ventilation

Patients on mechanical ventilators experience distress related to the endotracheal tube, the critical care environment, and the critical illness. The strategies suggested here to limit distress--therapeutic relationship building and communication, cognitive-behavioral therapies, and contracted family visiting--all can be implemented by critical care providers. A growing research base documents the success of these interventions in intubated patients.

Communication and socialisation (1): An exploratory study and explanation for nurse-patient communication in an ITU

This exploratory study was designed to determine the state of communication between conscious, intubated and orientated patients, and nurses in an intensive therapy unit (ITU) and the factors that influence this communication. The aim was to determine whether nurses are able to identify the needs and problems of their patients. This was done by examining characteristics of nurse-patient interactions through participant observation, and exploring nurses' attitudes and knowledge of communication and the nursing process. Dissatisfaction with the nursing process and continual difficulty in communicating with conscious intubated patients by ITU colleagues was the stimulus to investigate the state of nurse-patient communication in the unit where the researcher works. In this paper critical evaluation of previous studies of nurse-patient communication in ITUs is followed by presentation of results of the observations and interviews in this study. The discussion that follows focuses on the socialisation of nurses in 'becoming' ITU nurses related to Bradby's (1990) interpretation of status passage, and the effect that this has on the way in which they communicate.

Enalapril premedication attenuates the blood pressure response to tracheal intubation and stabilizes postoperative blood pressure after controlled hypotension with sodium nitroprusside in neurovascular patients

Oral premedication with enalapril, 0.1 mg/kg was compared with placebo in 22 patients subjected to craniotomy and ligation of an intracranial aneurysm or extirpation of an arteriovenous malformation. Balanced hypotensive anesthesia was used with sodium nitroprusside (SNP) as the main hypotensive agent. The hypertensive response to laryngoscopy and tracheal intubation was significantly attenuated by enalapril (p = 0.020). The mean blood pressure was lower and more stable in the intensive care unit after enalapril than after placebo (p = 0.044). The median SNP dose rate tended to be lower in the enalapril-pretreated patients [0.6 (range of 0-3.5) micrograms/kg/min] compared to the placebo group [1.4 (0.4-5.8) micrograms/kg/min] (p = 0.12). Concentrations of plasma catecholamines, vasopressin, and endothelin as well as serum osmolality, arterial blood gases, and plasma electrolytes and level of consciousness were repeatedly measured. Enalapril had no significant effects on these variables. Plasma renin activity was increased and serum angiotensin converting enzyme (ACE) activity was reduced in the expected manner by enalapril. We found premedication with an ACE inhibitor favorable for hypotensive anesthesia in neurovascular patients as assessed by the circulatory responses.

A review of communication with intubated patients and those with tracheostomies within an intensive care environment

A major aspect of nursing care within intensive care environments is communication. If nursing communication with patients is to be both effective and therapeutic nurses need to understand the principles of communication and identify the purposes of nurse-patient interactions. The main purpose of this article is to review and examine normal communication channels and the actual and potential barriers to communication between nurses and patients who are intubated or have tracheostomies. The assessment of these patients' needs for communication, planning, implementation and evaluation of nursing to meet them are discussed, and also implications for the future.

[The stress reaction in the recovery phase from halothane and isoflurane anesthesia]

This study was undertaken to investigate the influences of halothane and isoflurane as well as different extubation techniques on the endocrine stress response during recovery from general anesthesia. Forty patients scheduled for herniorrhaphy and cholecystectomy were randomly allocated to 4 groups: 20 received halothane and 20 received isoflurane anesthesia. Within the halothane and isoflurane groups, 10 patients each were extubated during anesthesia (1/2 MAC) and a further 10 had awake extubation. Premedication, induction of anesthesia, and intraoperative anesthetic management were standardized in all groups. Plasma levels of endocrine stress parameters as well as mean arterial pressure (MAP), heart rate (HR), and arterial oxygen saturation (SaO2) were measured at nine time points up to 60 min after extubation. Biometric data and duration of operation and anesthesia were comparable in all groups. In the recovery period, epinephrine levels were higher in the isoflurane groups than in the halothane groups (P = 0.02). With respect to time course, earlier and more marked increases of epinephrine, norepinephrine, and antidiuretic hormone (ADH) levels were observed in the isoflurane groups compared to the halothane groups (P less than 0.01), representing the more rapid elimination of isoflurane. The sympathoadrenergic stress response was more pronounced in patients with extubation during anesthesia than in those with awake extubation: epinephrine levels were slightly higher and group levels of norepinephrine were significantly increased (P = 0.02). No influence of the extubation techniques was observed on ADH, ACTH, and cortisol levels or on MAP, HR, or SaO2. In summary, extubation during anesthesia did not reduce the endocrine stress response. It is concluded that awake extubation should be preferred unless the operation or the patient's condition requires extubation during anesthesia.

Estimating anesthetic depth by electroencephalography during anesthetic induction and intubation in patients undergoing cardiac surgery

Intravenous (IV) anesthesia titrated to continuous computer-processed electroencephalograms (EEGs) was studied in 32 consecutive patients undergoing cardiac surgery. Anesthesia was induced with fentanyl 50 micrograms/kg with no EEG monitoring (n = 16) or 25 to 50 micrograms depending on changes in EEG (n = 16). EEG, oxygen saturation by pulse oximeter, intra-arterial blood pressure (BP), central venous pressure (CVP), and pulmonary artery pressure (PAP) (n = 18) were monitored continuously. Cardiac output (CO), CVP, PAP, spectral-edge frequency for each hemisphere, and BP were recorded before induction, immediately before intubation, and 1 and 5 minutes after intubation. With EEG monitoring, intubation was performed when spectral-edge frequency decreased to 10 Hz or less. Recall and pain were investigated 2 to 12 weeks postoperatively. With EEG, the amount of fentanyl used before intubation was significantly lower (39.7 +/- 2 micrograms/kg; p less than 0.005) than without EEG (50 micrograms/kg). The decrease in BP (% change) was less with than without EEG; mean changes in BP between preinduction and preintubation were -7.4% +/- 3.8% and -16.5% +/- 3.1% and between preinduction and 1 minute after intubation 0.3% +/- 3.4% and -12.5% +/- 3.5%, respectively. Percent changes in mean BP between intubation and 1 minute after were 9.6% +/- 4.0% with EEG and 5.2% +/- 3.0% without EEG. No patient in either group had recall. The authors conclude that using EEG monitoring to estimate depth of anesthesia during induction and laryngoscopy may increase safety in high-risk patients undergoing cardiac surgery.

Communication options for intubated patients

The number of communication options available to intubated patients is rapidly increasing. Selection of an appropriate augmentative communication approach depends on the decision-making practices of a team of experts. A series of oral and nonoral augmentative communication options is reviewed here, with particular emphasis on patients who are candidates for each approach.

Surgical treatment of acquired subglottic stenosis

Seven patients with severe acquired glottic-subglottic stenosis were treated surgically, some of them by the augmentation principle and other by resection. The surgical results are reported and although only 50 per cent could be decannulated it was evident, at the end of a minimum follow-up period of 4 years, that the physical, mental, and social handicaps suffered by a child permanently wearing a cannula are so great that a very active surgical attitude to the problems of laryngeal stenosis is required.

Tracheal suctioning: a tool for evaluation and learning needs assessment

A 21-item observation tool developed by one of the authors was used to assess learning needs of 30 registered nurses who regularly suction intubated patients. Of the nurses observed, 97 percent had excellent regard for proper equipment utilization and 91 percent for maintenance of sterile environment. These high percentages were responsible for pulling the overall average scores to 65 percent, thus partially disguising the acute need for patient assessment (38 percent), psychological support (57 percent), and procedure (62 percent). Scores for subgroups of nurses--associate degree (group 1), diploma (group II), And baccalaureate (group III)--were 72, 69, and 65, respectively. Of particular concern were low scores in the assessment and psychological support categories. Despite increased emphasis on both of these areas in nursing programs in the last decade, AD graduates received scores of 52 and 57 percent while diploma graduates received scores of 38 and 58 percent and baccalaureate graduates received scores of 26 and 55 percent.