A national Position Statement on adult end-of-life care in critical care

Patient death in critical care is not uncommon. Rather, the provision of end-of-life care is a core feature of critical care nursing, yet not all nurses feel adequately prepared for their role in the provision of end-of-life care. For this reason, the Australian College of Critical Care Nurses (ACCCN) supported the development of a Position Statement to provide nurses with clear practice recommendations to guide the provision of end-of-life care, which reflect the most relevant evidence and information associated with end-of-life care for adult patients in Australian critical care settings. A systematic literature search was conducted between June and July, 2020 in CINAHL Complete, Medline, and EMBASE databases to locate research evidence related to key elements of end-of-life care in critical care. Preference was given to the most recent Australian or Australasian research evidence, where available. Once the practice recommendations were drafted in accordance with the research evidence, a clinical expert review panel was established. The panel comprised clinically active ACCCN members with at least 12 months of clinical experience. The clinical expert review panel participated in an eDelphi process to provide face validity for practice recommendations and a subsequent online meeting to suggest additional refinements and ensure the final practice recommendations were meaningful and practical for critical care nursing practice in Australia. ACCCN Board members also provided independent review of the Position Statement. This Position Statement is intended to provide practical guidance to critical care nurses in the provision of adult end-of-life care in Australian critical care settings.     

A critical discourse analysis of provision of end-of-life care in key UK critical care documents

This article highlights certain practical and professional difficulties in providing end-of-life (EOL) care for patients in critical care units and explores discourses arising from guidelines for critical care services. BACKGROUND: A significant number of patients die in critical care after decisions to withdraw or withhold treatment. Guidelines for provision of critical care suggest, wherever possible, moving patients out of critical care at the EOL. This may not necessarily be conducive to a 'good death' for patients or their loved ones. There is a moral responsibility for both nurses and doctors to ensure that decision-making around EOL issues is sensitively implemented, that decisions about care includes families, patients when able, nurses and doctors, and that good EOL care is provided. METHODS: A critical discourse analysis (CDA) of four key UK critical care documents published since 1996. FINDINGS AND RECOMMENDATIONS: The key documents give little clear guidance about how to provide EOL care in critical care. Discourses include the power dynamic in critical care between professions, families and patients, and how this impacts on provision of EOL care. Difficulties encountered include dilemmas at discharge and paternalism in decision-making. The technological environment can act as a barrier to good EOL care, and critical care nurses are at risk of assuming the dominant medical model of care. Nurses, however, are in a prime position to ensure that decision-making is an inclusive process, patient needs are paramount, the practical aspects of withdrawal lead to a smooth transition in goals of care and that comfort measures are implemented.     

Talking about end-of-life care: Perspectives of nursing home residents

The purpose of the paper is to describe how residents express preferences for end-of-life (EOL) care. For this qualitative study, we conducted semi-structured interviews and completed conventional content analysis to describe how residents’ expressed their preferences for care at the end of life. Sixteen residents from four nursing homes (NH) in southeastern Pennsylvania participated in this study. Residents were on average 88 years old, primarily non White, and widowed. Three key domains emerged from the analyses: Preferences for Today, Anticipating the End of My Life, and Preferences for Final Days. Residents linked their everyday living and EOL preferences by using ‘if and then’ logic to convey anticipation and readiness related to EOL. These findings suggest new strategies to start discussions of EOL care preferences with NH residents.     

Spiritual care competence for contemporary nursing practice: A quantitative exploration of the guidance provided by fundamental nursing textbooks

Spirituality is receiving unprecedented attention in the nursing literature. Both the volume and scope of literature on the topic is expanding, and it is clear that this topic is of interest to nurses. There is consensus that the spiritual required by clients receiving health ought to be an integrated effort across the health care team. Although undergraduate nurses receive some education on the topic, this is ad hoc and inconsistent across universities. Textbooks are clearly a key resource in this area however the extent to which they form a comprehensive guide for nursing students and nurses is unclear. This study provides a hitherto unperformed analysis of core nursing textbooks to ascertain spirituality related content. 543 books were examined and this provides a range of useful information about inclusions and omissions in this field. Findings revealed that spirituality is not strongly portrayed as a component of holistic care and specific direction for the provision of spiritual care is lacking. Fundamental textbooks used by nurses and nursing students ought to inform and guide integrated spiritual care and reflect a more holistic approach to nursing care. The religious and/or spiritual needs of an increasingly diverse community need to be taken seriously within scholarly texts so that this commitment to individual clients' needs can be mirrored in practice.     

The clinical quandary of counseling the moribund critical care patient—a registry analysis of postsurgical outcomes

Purpose

To provide outcomes data to intensivists and surgeons for counseling patients and family members when considering a surgical intervention in a moribund patient.

Materials and Methods

Retrospective analysis of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database in moribund patients undergoing general surgical procedures.

Results

Out of 633,262 patients available in the national registry, 2063 (0.3%) were of moribund status. Post-operative mortality was 52.8% for moribund patients. Those who died had higher rates of compromised respiratory, renal and cognitive dysfunction, were older, less independent prior to surgery and had generally longer surgeries. 83% of patients experienced a major complication including mortality and 17 % of patients experienced minor complications.

Conclusion

The moribund patient is not as grave as once thought and surgery on these patients may not be futile given the 47% survival rate at 30 days. Postoperative complication rates are high. The data presented provide a meaningful tool for the clinicians in counseling patients and families on the expectations when considering a surgical intervention for moribund patients.     

Development of the nursing practice scale for end-of-life family conferences in critical care

ObjectivesThis study aimed to develop the Nursing Practice Scale for End-of-life Family conferences in critical care and to clarify the current status of nursing practice regarding family conferences.Research methodology/designWe conducted a cross-sectional, self-administered questionnaire survey with 955 critical care unit nurses in 97 hospitals. Content validity, factor validity and criterion-related validity, known-group validity, internal consistency and test–retest reliability were evaluated. Data were then analysed statistically.SettingAdult intensive care units or high dependency units in Japan.ResultsThree factors with 39 items were extracted through item analysis and confirmatory factor analysis as hypothesised (Factor 1: Preparation, Factor 2: Discussion and Factor 3: Follow-up), and the mean score per item for each factor was 3.57, 3.73 and 3.75, respectively. Nurses who had any certification or had worked in critical care unit for >5 years had a significantly greater score than the others. The Cronbach’s α were 0.86–0.96 and the intraclass correlation coefficients were 0.79–0.87.ConclusionThe Nursing Practice Scale for End-of-life Family conferences in critical care is a valid and reliable scale. This study could effectively facilitate communication among patients, their families and healthcare providers.     

EfCCNa survey: European intensive care nurses' attitudes and beliefs towards end-of-life care

Background: Available literature suggests that critical care nurses have varied experiences in relation to end‐of‐life (EOL) care. Few studies have examined the involvement of European intensive care nurses’ involvement in EOL care decisions and the extent to which their nursing practice is based on shared beliefs, experiences and attitudes. Aim: To investigate experiences and attitudes of European intensive care nurses regarding EOL care. Methods: Using a survey method, delegates (n = 419) attending an international critical care nursing conference were invited to complete a self‐administered questionnaire about their involvement with EOL care practices. The questionnaire composed of 45 items and was available in three European languages. Results: A total of 164 questionnaires were completed, yielding a response rate of 39%. The majority of respondents (91·8%) indicated direct involvement in EOL patient care, while 73·4% reported active involvement in decision‐making process. 78·6% of respondents expressed commitment to family involvement in EOL decisions, however only 59·3% of the participants said that this was routinely undertaken (p < 0·0005, Z = ?4·778). In decisions to withdraw or withhold therapy, 65% would decrease the flow of inspired oxygen, 98·8% provide continuous pain relief and 91·3% endorse open visiting. The majority (78%) disagreed that dying patients should be transferred to a single room. A division of views was observed in relation to 44% agreeing that patients should be kept deeply sedated and equal numbers contesting the continuation of nutritional support (41·6% versus 42·3%). Conclusions: The involvement of European intensive care nurses in EOL care discussions and decisions is reasonably consistent with many engaged in initiating dialogue with coworkers. In general, views and experiences of EOL care were similar, with the exception of the provision of nutrition and use of sedation. Relevance to practice: Use of formal guidelines and education may increase nurses’ involvement and confidence with EOL decisions.     

The end-of-life care practices of emergency care nurses and the factors that influence these practices: An integrative review

IntroductionDue to philosophical tensions between end-of-life care and emergency care, nurses in the emergency department face challenges in the provision of end-of-life care. The purpose of this integrative review was to synthesise evidence of the end-of-life care practices of emergency care nurses and the factors that influence these practices.MethodsFor this integrative review, CINAHL, Embase, and MEDLINE databases were systematically searched in April 2020. In total, 30 studies written in English and published between 2010 and 2020 investigating the experiences of nurses caring for a patient that died in the emergency department were included. A constant comparative method was used to analyse and synthesise data.ResultsEnd-of-life care practices prominent in the literature included modifying the environment for privacy, the provision of information to families and the management of symptoms. The culture of emergency care, the nurse’s personal characteristics, the trajectory of death and available resources are factors that appear to determine whether ED nurses immerse themselves in end-of-life care or display distancing behaviours.ConclusionThere is limited evidence articulating the frequency to which specific practices are undertaken and the magnitude to which various factors influence end-oflife care provision. The generation of such knowledge may facilitate the development of initiatives that can optimise end-of-life care in the emergency department.     

Contradictions and communication strategies during end-of-life decision making in the intensive care unit

PURPOSE: The aim of this study was to identify inherent tensions that arose during family conferences in the intensive care unit, and the communication strategies clinicians used in response. MATERIALS AND METHODS: We identified 51 clinician-family conferences in the intensive care unit from 4 hospitals in which the attending physician believed discussion of withdrawing life-sustaining treatments or delivery of bad news would occur. The communication between clinicians and family members was analyzed using a dialectic perspective. RESULTS: The tension of choosing whether to "let the patient die now" versus to "not let the patient die now" was the central contradiction within the conferences. Under this overriding theme were 5 categories: killing or allowing to die; death as a benefit or a burden; honoring the patient's wishes or following the family's wishes; weighing contradictory versions of the patient's wishes; and choosing an individual family member as decision maker or the family as a unit as decision maker. In response to these contradictions, clinicians used 2 clusters of communication strategies: decision-centered strategies and information-seeking strategies. CONCLUSIONS: This study offered insights into end-of-life decision making, prompting clinicians to be conscious of the contradictions that arise and to use specific strategies to address these contradictions in their communication with families.     

Intensive care unit cultures and end-of-life decision making

PURPOSE: Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM. MATERIALS AND METHODS: Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit. RESULTS: The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM. CONCLUSIONS: As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.     

Improving end-of-life care: gathering suggestions from family members

Tertiary care centers are criticized for not providing a peaceful death experience. This qualitative study was undertaken to ascertain suggestions family members (N = 29) might have to improve the situation. Family members made three major suggestions where the negative effects of the complex hospital system might be ameliorated when caring for dying patients: facilitate improved interaction between the dying patient and the family; improve interactions between caregivers and patients/families; and create a setting, or milieu, more conducive to these interactions. Further, family members related an overwhelming need to be close physically to their dying loved one; to be given permission, instruction, and opportunities to touch their loved one; to receive more information from caregivers; and to have their and their loved one's personhood acknowledged and respected. Thus, nurses should engage in respectful, personalized conversations with patients and families that allow them to define the dying experience they desire.     

Analysis of palliative care content in nursing textbooks

Overall, this study demonstrates significant deficiencies in end-of-life care content in nursing textbooks. Defining palliative care, quality of life at the end of life, and issues of policy, ethics, and law are the foundation of end-of-life care. Analysis of these topics revealed a need to clarify concepts and to apply them within the context of end-of-life care. The analysis also demonstrated a need to transfer findings from palliative care research and concepts from hospice into basic education. In March 1999 the investigators convened a conference in New York in collaboration with a group of medical investigators analyzing EOL content in medical textbooks. The conference was also attended by publishers, editors, and authors of textbooks. The investigators were very encouraged by their interest in and commitment to correcting any weaknesses in their books. The investigators provided them with specific recommendations for improvement and resources for locating both appropriate content and authors with palliative care expertise. These resources are also made available on the City of Hope Pain Resource Center Web site (http:@mayday.coh.org). Achieving the overall project goal of strengthened nursing education in end-of-life care will be reached through a variety of measures. Improving textbooks is but one important step. The various disciplines involved in palliative care can contribute to this project by working in collaboration with textbook publishers.     

Family involvement in end-of-life care in a paediatric intensive care unit

End-of-life care (ELC) on a paediatric intensive care unit (PICU) is a fundamental aspect of clinical practice and yet often remains a highly emotive and challenging issue. Every year, many children die in PICU often following the withdrawal of life-sustaining treatment, and as health professionals we have a duty to provide ELC that meets the needs of the dying child and their family. To achieve this, there is a growing emphasis on incorporating parental views on withdrawal of intensive care especially in time and place. Home care of the dying child enables the child to die at home in familiar surroundings and with the people who love them the most. This service is essentially child centred and acknowledges the unique and pivotal position that parents have in their child's life by empowering them to have control over the time and place of death. This is a vitally important aspect of end-of-life in PICU and underpins the ethos of this area of practice. We present a series of case reviews of patients cared for within a 12-month period, where intensive care was withdrawn distant from the PICU environment and address the challenges and considerations surrounding this area of practice.