Meeting the needs of intensive care unit patient families: a multicenter study

Intensive care unit (ICU) caregivers should seek to develop collaborative relationships with their patients' family members, based on an open exchange of information and aimed at helping family members cope with their distress and allowing them to speak for the patient if necessary. We conducted a prospective multicenter study of family member satisfaction evaluated using the Critical Care Family Needs Inventory. Forty-three French ICUs participated in the study. ICU characteristics, patient and family member demographics, and data on satisfaction were collected. Factors associated with satisfaction were identified using a Poisson regression model. A total of 637 patients were included in the study, and 920 family members completed the questionnaire. Seven predictors of family satisfaction were found: one family-related factor, namely, family of French descent and six caregiver-related factors, namely, no perceived contradictions in information given by caregivers; information provided by a junior physician; patient to nurse ratio 相似文献   

Dying in the ICU: perspectives of family members

OBJECTIVE: To describe the perspectives of family members to the care provided to critically ill patients who died in the ICU. DESIGN: Multicenter, prospective, observational study. SETTING: Six university-affiliated ICUs across Canada. METHODS: Patients who received mechanical ventilation for > 48 h and who died in the ICU were eligible for this study. Three to four weeks after the patient's death, we mailed a validated questionnaire to one selected family member who made at least one visit to the patient in the ICU. We obtained self-rated levels of satisfaction with key aspects of end-of-life care, communication, and decision making, and the overall ICU experience. Main results: Questionnaires were mailed to 413 family members; 256 completed surveys were returned (response rate, 62.0%). In the final hours before the death of the patient, family members reported that patients were "totally comfortable" (34.8%), "very comfortable" (23.8%), or "mostly comfortable" (32.0%). Family members felt "very supported" (57.0%) and "supported" (30.7%) by the health-care team. Most (82.0%) believed that the patient's life was neither prolonged nor shortened unnecessarily. Most family members (90.4%) preferred some form of shared decision making. Overall, 52% of families rated their satisfaction with care as "excellent," 31% rated care as "very good," 10% as "good," 4% as "fair," and 2% as "poor." Overall satisfaction with end-of-life care was significantly associated with completeness of information received by the family member, respect and compassion shown to patient and family member, and satisfaction with amount or level of health care received. CONCLUSIONS: The majority of families of patients who died in participating ICUs were satisfied with the end-of-life care provided. Adequate communication, good decision making, and respect and compassion shown to both the dying patient and their family are key determinants to family satisfaction.     

Communication of prognostic information for critically ill patients

STUDY OBJECTIVES: The purpose of this study was to determine whether the timing of prognostic information delivery by physicians is associated with caregiver satisfaction with communication or decision making in the ICU. DESIGN: Multicenter, prospective, longitudinal observational study. SETTING: Medical and surgical ICUs in a community and university hospital. PARTICIPANTS: Decision makers for critically ill patients. MEASUREMENTS AND RESULTS: Longitudinal surveys assessed both actual and desired frequency of communication with physicians, timing and content of physician prognosis, and subject satisfaction with physician communication and subject's role in decision making. Seventy subjects were enrolled and completed 216 surveys. Fifty-seven caregivers (81%) received prognostic information during the ICU stay, with a mean time between ICU admission and provision of prognostic information (prognostic interval) of 1.7 +/- 2.8 days (median, 1 day). This interval was not associated with patient age, severity of illness, clinical service, hospital, socioeconomic status, or prior patient ICU admission. A shorter prognostic interval was associated with increased satisfaction with communication, with a trend toward statistical significance (p = 0.06). Both the measured communication rate (p < 0.001) and subjects' desired communication rate with physicians decreased over time in the ICU (p < 0.001). Although 78% of subjects rated their overall satisfaction with frequency of communication as "good," "very good," or "excellent," their satisfaction with communication frequency decreased with time in the ICU (p = 0.006). CONCLUSIONS: Families of critically ill patients were generally satisfied with communication in the ICU; however, 19% were unable to recall receiving any prognostic information from physicians. Providing all decision makers with some prognostic information, even if it consists of a statement of uncertainty (as was commonly done in this study), may further improve satisfaction with ICU care. A widening gap between the actual and desired communication rate may result in a decline in communication satisfaction over the course of the ICU stay. This suggests that the capacity of physicians and other ICU personnel to manage families' communication expectations may positively influence caregiver satisfaction.     

Quality of dying and death in two medical ICUs: perceptions of family and clinicians

OBJECTIVE: We compared perceptions of the quality of dying and death in the ICU across nurses, resident physicians, attending physicians, and family members. The aim was to obtain a surrogate assessment of the quality of the dying process and examine differences in the perceptions of different types of raters. DESIGN: Cross-sectional survey of family members and ICU clinicians conducted following the death of enrolled patients. SETTING: Two medical ICUs at academic tertiary care medical centers. PATIENTS: Patients dying in the ICU (n = 68). MEASUREMENTS AND RESULTS: The previously validated Quality of Dying and Death (QODD) instrument was modified for use in the ICU. Within 48 h of the time of death, the nurse, resident, and attending physician caring for the patient were asked to complete the QODD. One month following the death, a designated family member was contacted and the QODD was administered on the telephone. Family members and attending physicians gave the most favorable ratings of death, while nurses and residents provided less favorable ratings. Significant differences between these groups were notable (p < 0.01) on items related to patient autonomy: maintaining dignity, being touched by loved ones, and the overall quality of death. CONCLUSIONS: The perception of dying and death in the ICU varies considerably between nurses, attending physicians, resident physicians, and family members. Further studies are needed to explain these differences and determine the utility of the ICU QODD instrument for assessing and improving the quality of end-of-life care in the ICU.     

Factors affecting subjective satisfaction with verbal communication among the disabled elderly and their family caregivers

The aims of the present study were to investigate satisfaction with verbal communication among the disabled elderly and their family caregivers; and to find the significantly influential factors of satisfaction with verbal communication. The subjects were 85 disabled elderly and 85 family caregivers. For the disabled elderly, satisfaction with verbal communication, demographic, and physical factors were examined using an interview survey. For the caregivers, satisfaction with verbal communication, demographic factors, and some factors related caregiving were examined using a self-administered questionnaire. In the disabled elderly, 82.4% were satisfied with their verbal communication while 55.3% of family caregivers were satisfied. Satisfaction with verbal communication between the disabled elderly and their caregivers showed low agreement (kappa = 0.17). Bivariate analysis revealed that satisfaction with verbal communication of the disabled elderly was significantly related to ADL (p < 0.01), dysphagia risk (p < 0.05), and ability of comprehension (p < 0.05) while satisfaction with verbal communication of caregivers was significantly related to the gender of the disabled elderly and caregivers' burden. Furthermore, multiple regression analysis showed that the factor most related to satisfaction with verbal communication for the disabled elderly was ability of comprehension (p value = 0.032, odds ratio = 2.960), and the most related factor for their caregivers was the burden evaluated by J-ZBI_8 (p value = 0.004, odds ratio = 0.842). These results suggest that satisfaction with verbal communication of the disabled elderly disagrees with that of the family caregivers, and that some related factors for the disabled elderly are different from those in their family caregivers.     

Actor and partner effects of self-rated health on life satisfaction among family caregiver couples

ObjectivesThis study examined the dyadic effects of self-rated health on the life satisfaction of family caregivers. The effects of the use of long-term care services were also explored to investigate whether support through care services is associated with the life satisfaction of family caregivers.MethodsThe data were drawn from the sixth wave (2016) of the Korean Longitudinal Study of Aging. Caregivers who used long-term care services for older family members, and spouses of the caregivers, were identified. A total of 81 married caregiver couples were analyzed using the actor-partner interdependence model.ResultsThe study showed that better self-rated health of caregivers was associated with higher levels of life satisfaction (B = 8.87, p < 0.001). Better self-rated health of the caregivers was also associated with higher life satisfaction of their spouses (B = 6.01, p < 0.05). In addition, the results suggested that the use of long-term care services for patients was associated with the life satisfaction of both caregivers (B = 14.57, p < 0.01) and their spouses (B = 12.51, p < 0.05).DiscussionOur findings suggested mutual influences among family caregivers on their life satisfaction. In addition, long-term care services for patients may improve the life satisfaction of other family members. More support through long-term care services for people with care needs is required to increase the life satisfaction of family caregivers. The diverse relationships among family caregivers should be taken into consideration when developing policies and interventions.     

Quality of dying in the ICU: ratings by family members

STUDY OBJECTIVES: To explore the quality of the dying experience and associations to higher quality ratings for people who died in an ICU. DESIGN: Retrospective study using medical record review and surveys of family members with the Quality of Dying and Death (QODD) instrument. SETTING: Four ICUs affiliated with a university and a Veterans Affairs Medical Center. PARTICIPANTS: Ninety-four family members of 38 ICU decedents. MEASUREMENTS AND RESULTS: We explored associations between components of the ICU experience and the overall rating of the quality of the dying experience. Overall, family members reported that symptoms were poorly controlled: pain under control most or all of the time in 47%, and breathing comfortably most or all of the time in 3% of patients. Families expressed a moderate and variable view of the quality of dying resulting in an overall ICU QODD score of 60 +/- 14 (on a scale of 0 to 100) [mean +/- SD]. Higher ICU QODD scores were associated with control of pain (r = 0.42, p = 0.009), control of events (r = 0.62, p < 0.001), a "preparation for death" aspect of the dying experience--feeling at peace with dying (r = 0.69, p < 0.001), and a "whole-person concern"--keeping one's dignity and self-respect (r = 0.50, p < 0.001). CONCLUSIONS: After adjusting for symptom and personal care scores, certain whole-person and preparation-for-death aspects of the dying process, and not aggressiveness of end-of-life care, remained the most associated to quality ratings. While future research should explore the important predictors of quality of dying in the ICU, this study suggests that care at the end of life in the ICU include not only managing pain, but also supporting dignity, respect, and peace, and maximizing patient control.     

Family satisfaction in the ICU: differences between families of survivors and nonsurvivors

BACKGROUND: We previously noted that the families of patients dying in the ICU reported higher satisfaction with their ICU experience than the families of survivors. However, the reasons for this finding were unclear. In the current study, we sought to confirm these findings and identify specific aspects of care that were rated more highly by the family members of patients dying in the ICU compared to family members of ICU survivors. METHODS: A total of 539 family members with a patient in the ICU were surveyed. Family satisfaction was measured using the 24-item family satisfaction in the ICU questionnaire. Ordinal logistic regression identified which components of family satisfaction were associated with the patient's outcome (ie, whether the patient lived or died). RESULTS: A total of 51% of respondents had a loved one die in the ICU. Overall, the families of patients dying in the ICU were more satisfied with their ICU experience than were families of ICU survivors, and the largest differences were noted for care aspects directly affecting family members. Significant differences were found for inclusion in decision making, communication, emotional support, respect and compassion shown to family, and consideration of family needs (p<0.01). CONCLUSIONS: The families of patients dying in the ICU were more satisfied with their ICU experience than were the families of ICU survivors. The reasons for this difference were higher ratings on family-centered aspects of care. These findings suggest that efforts to improve the support of ICU family members should focus not only on the families of dying patients but also on the families of patients who survive their ICU stay.     

Risk of post-traumatic stress symptoms in family members of intensive care unit patients

RATIONALE: Intensive care unit (ICU) admission of a relative is a stressful event that may cause symptoms of post-traumatic stress disorder (PTSD). OBJECTIVES: Factors associated with these symptoms need to be identified. METHODS: For patients admitted to 21 ICUs between March and November 2003, we studied the family member with the main potential decision-making role. MEASUREMENTS: Ninety days after ICU discharge or death, family members completed the Impact of Event Scale (which evaluates the severity of post-traumatic stress reactions), Hospital Anxiety and Depression Scale, and 36-item Short-Form General Health Survey during a telephone interview. Linear regression was used to identify factors associated with the risk of post-traumatic stress symptoms. MAIN RESULTS: Interviews were obtained for family members of 284 (62%) of the 459 eligible patients. Post-traumatic stress symptoms consistent with a moderate to major risk of PTSD were found in 94 (33.1%) family members. Higher rates were noted among family members who felt information was incomplete in the ICU (48.4%), who shared in decision making (47.8%), whose relative died in the ICU (50%), whose relative died after end-of-life decisions (60%), and who shared in end-of-life decisions (81.8%). Severe post-traumatic stress reaction was associated with increased rates of anxiety and depression and decreased quality of life. CONCLUSION: Post-traumatic stress reaction consistent with a high risk of PTSD is common in family members of ICU patients and is the rule among those who share in end-of-life decisions. Research is needed to investigate PTSD rates and to devise preventive and early-detection strategies.     

Junior versus senior physicians for informing families of intensive care unit patients

To compare the effectiveness of information delivered to family members of critically ill patients by junior and senior physicians, we performed a prospective randomized multicenter trial in 11 French intensive care units. Patients (n = 220) were allocated at random to having their family members receive information by only junior or only senior physicians throughout the intensive care unit stay; there were 92 and 93 evaluable cases in the junior and senior groups, respectively, with no significant differences in baseline characteristics. Between Days 3 and 5, one family representative per patient was evaluated for comprehension of the diagnosis, prognosis, and treatment in the patient; satisfaction with information and care; and presence of symptoms of anxiety and depression. No significant differences were found between the two groups for any of these three criteria. Family members informed by a junior physician were more likely to feel they had not been given enough information time (additional time wanted: 3 [0-6.5] vs. 0 [0-5] minutes, p = 0.01) and to have sought additional explanations from their usual doctor (48.9 vs. 34.4%, p = 0.004). Specialty residents, if given opportunities for acquiring experience, can become proficient in communicating with families and share this task with senior physicians.     

A randomized, controlled trial of interactive, multimedia software for patient colonoscopy education

The purpose of our study was to assess the effectiveness of computer-assisted instruction (CAI) in patients having colonoscopies. We conducted a randomized, controlled trial in large, multispecialty clinic. Eighty-six patients were referred for colonoscopies. The interventions were standard education versus standard education plus CAI, and the outcome measures were anxiety, comprehension, and satisfaction. Computer-assisted instruction had no effect on patients' anxiety. The group receiving CAI demonstrated better overall comprehension (p < 0.001). However, Comprehension of certain aspects of serious complications and appropriate postsedation behavior were unaffected by educational method. Patients in the CAI group were more likely to indicate satisfaction with the amount of information provided when compared with the standard education counterparts (p = 0.001). Overall satisfaction was unaffected by educational method. Computer-assisted instruction for colonoscopy provided better comprehension and greater satisfaction with the adequacy of education than standard education. Computer-assisted instruction helps physicians meet their educational responsibilities with no decrement to the interpersonal aspects of the patient-physician relationship.     

Critical care family needs: nurse-family member confederate pairs

In this study we explored the relationship between critical care family members' perceived needs and the assessment of these needs by a confederate sample of intensive care unit (ICU) nurses. Family needs were measured by using Molter's revised Critical Care Family Needs Inventory. Data consisted of 92 confederate pairs of Critical Care Family Needs Inventory responses obtained from 92 family members of adult patients hospitalized in a variety of ICUs and 49 ICU nurses providing direct care for these patients. Paired t tests (two tailed) were calculated to detect significant differences between confederate pairs of family members' perceptions and ICU nurses' assessments of the importance of the needs studied. Family members' perceptions and ICU nurses' assessments of the most and least important critical care family needs were identified. Significant (p less than 0.001 to p less than 0.05) differences were detected between confederate pairs of family members' perceptions and ICU nurses' assessments of the importance of 15 (50%) of the critical care family needs studied. Therefore, it appears that these nurses were only moderately accurate in their assessments of critical care family needs. Implications for nursing practice, education, and research were identified and discussed.     

Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury

RATIONALE: Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients. OBJECTIVES: To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA). METHODS: Cohort study of patients with acute lung injury (ALI). MEASUREMENTS AND MAIN RESULTS: ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition. CONCLUSIONS: Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.     

A prospective, multicenter study of the epidemiology, management, and outcome of severe acute renal failure in a "closed" ICU system

The safety and effectiveness of "closed" intensive care units (ICUs) are highly controversial. The epidemiology and outcome of acute renal failure (ARF) requiring replacement therapy (severe ARF) within a "closed" ICU system are unknown. Accordingly, we performed a prospective 3-mo multicenter observational study of all Nephrology Units and ICUs in the State of Victoria (all "closed" ICUs), Australia, and focused on the epidemiology, treatment, and outcome of patients with severe ARF. We collected demographic, clinical, and outcome data using standardized case report forms. Nineteen ward patients and 116 adult ICU patients had severe ARF (13.4 cases/100, 000 adults/yr). Among the ICU patients with severe ARF, 37 had impaired baseline renal function, 91 needed ventilation, and 95 needed vasoactive drugs. Intensivists controlled patient care in all cases. Continuous renal replacement therapy (CRRT) was used in 111 of the ICU patients. Nephrological opinion was sought in only 30 cases. Predicted mortality was 59.6%. Actual mortality was 49.2%. Only 11 ICU survivors were dialysis dependent at hospital discharge. In the state of Victoria, Australia, intensivists manage severe ARF within a "closed" ICU system. Renal replacement is typically continuous and outcomes compare favorably with those predicted by illness severity scores. Our findings support the safety and efficacy of a "closed" ICU model of care.     

Emotional support from family members and subjective health in caregivers of the frail elderly at home in Japan

This study sought to determine the factors associated with subjective health in caregivers of the frail elderly living at home, using multivariate regression analysis. Data were collected from 130 caregivers of frail elderly persons listed on a roster for utilization of day service or short stay service from two Home Visit Nursing Care Stations, using self-administered questionnaire from January to February of 2005. Family caregivers were defined as co-residents family members who provided a minimum of 1 h of daily care for at least 3 months. Multiple logistic regression analysis was performed to examine the factors associated with subjective health in caregivers of the frail elderly at home. Subjects with good health had less depressive symptom (p=0.001), much emotional support (p=0.003) and low caregiver burden (p=0.03). Multivariate logistic regression analysis showed good health had a significantly positive association with only much emotional support after adjustment for confounders. Of the total effect of emotional support on subjective health, the direct effect (84.7%) was much greater than the indirect effect (15.3%). Results indicate that much emotional support from family member for caregiver is essential for better subjective health in caregivers.     

Dementia family caregiver training: affecting beliefs about caregiving and caregiver outcomes

OBJECTIVES: Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimer's disease. This study tested role-training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving. DESIGN: Training effectiveness was tested in a trial in which family care receiver dyads were randomly assigned to training beginning immediately or were placed in a wait-list control group and assigned to receive training in 5 to 6 months, following completion of data collection. SETTING: A community-based 14-hour training program provided in seven weekly 2-hour sessions. The training program curriculum was built on a stress and coping theory base. Recruitment and randomization were ongoing. Programs were begun every 2 months over a two and one half-year period for a total of 16 programs. PARTICIPANTS: Community health and social service agencies referred primary caregivers and at least one other family member of community-dwelling persons with dementia to participate. MEASUREMENTS: Data reported in this paper were gathered from each participating family at entry to the study and 5 months later. Standard measures of beliefs about caregiving, burden, depression, and reaction to care receiver behavior were administered to caregivers. A standard measure of mental status was administered to the person with dementia and standardized instruments were used to gather information from caregivers concerning care receivers' behavior and abilities to perform activities of daily living (ADLs). RESULTS: Data were analyzed from 94 caregiver/care receiver dyads with complete sets of data. Treatment and control caregivers and care receivers were similar at baseline, and care receivers in both groups declined similarly over the 5-month period. Significant within-group improvements occurred with treatment group caregivers on measures of beliefs about caregiving (P = .044) and reaction to behavior (P = .001). When outcomes were compared, treatment group caregivers were significantly different (in the expected direction) from those in the control group on measures of the stress mediator, beliefs (P = .025), and key outcomes, response to behavior (P = .019), depression (P = .040), and burden (P = .051). There was a significant positive association between the strengthened mediator, the caregivers' having less-emotionally enmeshed beliefs about caregiving roles and responsibilities, and the outcome, namely improvements in burden (P = .019) and depression (P = .007). CONCLUSION: A caregiver training intervention focused on the work of caregiving and targeted at knowledge, skills, and beliefs benefits caregivers in important outcome dimensions. The results suggest the benefits of providing information, linkage, and role coaching to dementia family caregivers.     

Dyadic relationship scale: a measure of the impact of the provision and receipt of family care

PURPOSE: This study evaluated the psychometric properties of the Dyadic Relationship Scale (DRS), which measures negative and positive dyadic interactions from the perspective of both the patient and the family caregiver. An important aspect of evaluating the DRS was that it be statistically sound and meaningful for both members of the dyad. DESIGN AND METHODS: The study used a cross-sectional design. Survey packages were mailed to home health care patients and their family caregivers. The unit of analysis was the dyad, and exploratory and confirmatory factor analyses were conducted. We examined the reliability, discriminant, and concurrent validities of the instrument. RESULTS: The data supported a two-factor DRS that included negative dyadic strain (patient alpha =.84; caregiver alpha =.89) and positive dyadic interaction (patient alpha =.86; caregiver alpha =.85). The analysis supported the DRS's construct, discriminant, and concurrent validity, as well as its reliability for both patients and family caregivers. IMPLICATIONS: Using the DRS to measure the impact of family care on positive and negative interactions inclusive of patients and caregivers can assist in identifying areas of difficulty and guide interventions to improve outcomes for both members of the dyad.     

A model telephone information and support program for caregivers of Alzheimer's patients

A model telephone support program involved setting up peer networks of four or five caregivers for regular telephone conversations. A randomized comparison was made of participants in networks (n = 31) and participants listening to an informational mini-lecture series assessed over the telephone (n = 35). Results indicated information gain, increased perceived social supports, and increased satisfaction with social supports regardless of program component. Greater information gain and more frequent emotional support from family and friends was shown for those listening to lectures. Less frequent emotional support from family and friends was found for peer network participants, suggesting support substitution.     

A survey on the view of end-of-life care in the elderly -a comparison among elderly patients, family members. physicians, nurses, and other caregivers

AIM: The purpose of this study was to investigate the role of geriatric physicians in end-of-life care through surveying elderly patients, their families, and health-care providers including physicians, nurses, and other caregivers, in order to determine what comprises good end-of-life care. METHODS: The survey respondents comprised 148 elderly patients, 76 members of their families, 105 physicians, 784 nurses, and 193 other caregivers. The survey asked respondents to rate the importance of (a) indicators of end-of-life in the elderly and (b) 17 aspects of quality of end-of-life care. RESULTS: With respect to indicators of end-of-life in the elderly, a patient being consistently critically ill was rated highly by all health-care providers (>70% responded that this indicated end-of-life). Being unable to perform the activities of daily life was considered an indicator of end-of-life by 36% of patients and 45% of their family members, but only by 23% of physicians, 8% of nurses, and 24% of other caregivers. For quality of end-of-life care, four items were rated as being important by all groups (>70% in each group): palliation of pain, freedom from anxiety regarding death, ability to spend time with close friends or family, and being respected. However, respecting the patient's principles and lifestyle was thought to be less important by patients (16.1%) and family members (28.2%) than it was by physicians (63.8%). Death at home was also thought to be less important by patients (21.0%) and family members (7.1%) than by physicians (37.5%). CONCLUSION: Elderly patients and their families have different views from their health-care providers on matters related to good end-of-life care. Geriatric physicians should pay attention to not only the care of patients' physical needs, but also other needs of the patients and their families.