A survey of nursing and medical staff views on the use of cardiopulmonary resuscitation in the hospice.

Research evidence suggests that cardiopulmonary resuscitation (CPR) would be indicated in very few hospice patients. However, with the increasing access and expansion of specialist palliative care services the question of CPR is becoming more important. In order to develop a policy in our unit we felt it was important to assess the understanding, attitudes and experience of the health care professionals involved. A semi-structured questionnaire regarding CPR issues, including case scenarios, was distributed to doctors and registered nurses in a palliative care unit. Thirty-seven (80%) of the questionnaires were returned. Ten per cent of respondents identified patients for whom they felt CPR would have been indicated in the event of an unexpected cardiac arrest. Thirty-two per cent could foresee the number of patients in this category increasing in the future. The majority of respondents indicated that CPR should be discussed in certain cases, however 86% had never done so. The success rate of CPR was frequently overestimated. Some respondents felt vulnerable as there was no existing written policy. Factors thought important in making decisions regarding CPR orders included: prognosis; patient's wishes; quality of life; and legal issues. CPR in palliative care units raises many practical and ethical concerns. Our survey shows that staff are aware of the small, but increasing, need for its consideration in certain cases. There was a wide range of views regarding the role of CPR with an overestimation of the chances of success and concerns regarding discussion of the issue with patients. When introducing a CPR policy in a palliative care unit, adequate education and a framework for decision making is required.     

A survey of methicillin-resistant Staphylococcus aureus (MRSA) management in hospices/palliative care units

A questionnaire-based survey was performed of the protocols adopted by specialist palliative care in-patient units in southern England for the management of methicillin-resistant Staphylococcus aureus (MRSA). An 87% response rate was obtained from a total of 63 units. Ninety-five percent of the responding units had a protocol for MRSA management, but staff training in its contents was provided in only 59%. Some form of screening for MRSA was carried out by 13% of units. Infection control precautions taken varied between units and according to whether a patient was colonized or infected with MRSA. Although 86% carried out some form of isolation of patients with known or suspected MRSA infection, only 46% restricted their activity within the unit. However, 41 % of respondents felt that protocols to eradicate MRSA colonization were not relevant to hospices. The impact of MRSA infection or colonization on a palliative care population in terms of quality of life and morbidity remains unknown.     

Entwicklung und Stand der stationären palliativmedizinischen Einrichtungen in Deutschland

In April 1999 altogether 114 inpatient units providing palliative care (50 palliative care units, 64 inpatient-hospices) offered a total of 989 beds. Compared to 1993 this has been an increase of 256%, compared to 1997 of 60%. The number of available beds, compared to 1997, increased markedly (58%), with a availability of 12 beds per one million residents. However, there are still major deficits: the distribution of the units is very irregular and the number of available beds is still to low, compared to the estimated need of 50 inpatient beds per one million residents. The quality of palliative care shows significant deficits (e. g. the availability of nursing staff, cooperation with pain clinics, standardised documentation, education). Differences between palliative care wards and hospices were huge. According to the definition of the German Society for Palliative Care, a palliative care ward should provide a ratio of at least 1.4 nursing staff per bed, however, only 18% of the palliative care units fulfil this definition. Only few hospices and half of the palliative care units worked in close cooperation with pain clinics. Despite a significant increase in units and inpatient beds providing palliative care, there still is a major deficit in the overall number of beds and the quality of palliative care.     

How many inpatients at an acute hospital have palliative care needs? Comparing the perspectives of medical and nursing staff

The primary aim of this prospective face-to-face interview survey was to identify the proportion of inpatients at an acute hospital (Royal Hallamshire Hospital, Sheffield, UK) considered to have palliative care needs by medical and nursing staff directly responsible for their care. During the 1-week period of the survey (6-10 September 1999), 452 inpatients were present in the hospital. Nursing staff were interviewed for 99% of patients; medical staff for 81%. Staff interview data were supplemented by case note review. Overall, 23% of the total inpatient population were identified as having palliative care needs and/or being terminally ill by staff and 11% were considered suitable for referral to a specialist palliative care bed. However, there was a low level of concurrence between medical and nursing staff as to which individual patients had palliative care needs (although this increased with perceived increased proximity to death), including which would be suitable for referral to a specialist palliative care bed. A need for further palliative care education for medical and nursing staff working within acute hospital settings was identified to ensure that the best use is made of hospital-based specialist palliative care services.     

A national survey of health professionals and volunteers working in voluntary hospice services in the UK. I. Attitudes to current issues affecting hospices and palliative care

This paper reports results from a national survey in 1999 of voluntary hospice services in the UK. It focuses on volunteer and staff views of the purposes of hospice care, and on current debates within palliative care. Twenty-five hospice services, stratified by region, services provided (inpatient care, day care and/or home care) and number of beds were randomly sampled from amongst 175 voluntary hospices in the UK. Nineteen participated. Seventy per cent of a random sample of professional and voluntary staff within these hospices returned a postal questionnaire. Both volunteers and professionals considered care of the whole person, pain and symptom control, quality of life and dying peacefully to be important aspects of hospice care. Most doctors chose care of the whole person as the most important aspect, and they were more likely to choose this option than other staff. Hospice volunteers were less positive than hospice staff (particularly doctors and nurses) in their attitudes to extending hospice care to noncancer patients (where many volunteers held no strong view), to restricting care to patients with specialist palliative care needs, and less negative about euthanasia. These findings illustrate the importance of including hospice volunteers and the general public, as well as hospice staff, in debates about the future of hospice and palliative care in the UK. Further research is needed into lay and professional views of the role of hospices and palliative care services.     

Specialist palliative care in nonmalignant disease

The objective of this study was to investigate how many patients who die from causes other than cancer might benefit from specialist palliative care. This was achieved by secondary analysis of data from the Regional Study of Care for the Dying, a retrospective national population-based interview survey. The investigation involved 20 self-selected English health districts, nationally representative in terms of social deprivation and most aspects of health services provision. A total of 3696 patients were randomly selected from death registrations in the last quarter of 1990; an interview concerning the patient was completed 10 months after the death by bereaved family, friends or officials. The results show that a third (243/720) of cancer patients who were admitted to hospices or had domiciliary palliative care scored at or above the median on three measures of reported symptom experience in the last year of life. That is the number of symptoms (eight or more), the number of distressing symptoms (three or more) and the number of symptoms lasting more than six months (three or more). A total of 269 out of 1605 noncancer patients (16.8%) fulfilled these criteria. On this basis, it is estimated that 71,744 people who die from nonmalignant disease in England and Wales each year may require specialist palliative care. An increase of at least 79% in caseload would, therefore, be expected if specialist palliative care services were made fully available to noncancer patients. This is a conservative estimate, as non-cancer patients were matched to only one-third of cancer patients who had specialist palliative care. It is concluded that clinicians and patient groups caring for patients with advanced nonmalignant disease must work together with specialist palliative care services and with health commissioners to develop, fund and evaluate appropriate, cost-effective services which meet patient and family needs for symptom control and psychosocial support.     

Barriers and facilitators to the receipt of palliative care for people with dementia: The views of medical and nursing staff

Background: The global prevalence of dementia is set to rise to almost 65 million people by 2030, providing policy makers and practitioners with significant challenges, not least within the realms of end-of-life care. The international literature would suggest that people with dementia may benefit from palliative forms of care, but evidence indicates that many fail to access such provision at the end of life. The role of the health care team is pivotal if people with dementia are to benefit from the transition to palliative care. Aim: This paper reports on qualitative research conducted in the UK that sought to explore the experiences of health care practitioners working in palliative care and sought to establish the issues relating to end-of-life care for people with dementia. Design: Eight focus groups and four individual interviews were held. Data were analysed using a thematic approach. Setting/participants: The study included palliative care practitioners (n = 58) including medical, nursing and allied health professionals. Participants were recruited from acute hospitals, general practice, hospices and specialist palliative care units in the UK. Results: Four themes were identified: Making the transition; Competence challenged; 'The long view' and Working together. Whilst there exists good practice in this area, the barriers to timely and appropriate transitions to palliative care for people with dementia and their families continue to exist. The paper concludes with recommendations for policy and practice development.     

Is the public equipped to act in out of hospital cardiac emergencies?

Methods: A cross sectional telephone survey, which contained sections regarding participant demographics, cardiopulmonary resuscitation (CPR) training, knowledge of CPR, and the emergency contact number and potential barriers to performing chest compressions and mouth to mouth.

Results: A total of 1489 people completed the questionnaire. Only 11% of the population had recently (<12 months) trained in CPR. When presented with a cardiac arrest scenario most participants stated that they would telephone 000. Significantly more respondents believed that they would give mouth to mouth to a family member compared with a stranger. A bleeding victim and fear of not having the skills were the most common barriers that reduced the participants perceived willingness to perform chest compressions and mouth to mouth.

Conclusion: This study suggests that a low percentage of the public is currently trained in CPR and also that they are unprepared to act in a cardiac emergency.

     

Visiting hours policies in New England intensive care units: strategies for improvement

OBJECTIVE: Dying patients often feel isolated and alone, and restricted visiting hours in the intensive care unit (ICU) has been shown to increase anxiety and dissatisfaction in both critically ill patients and their families. Unrestricted visiting has been identified as a top-ten need by families of patients in the ICU. Because emotional distress experienced by patients and families may persist well beyond the ICU stay, an open visiting policy, by meeting the needs of patients and families, may improve the quality of end-of-life care in the ICU. This two-part study included a survey to determine the visiting hours policies of New England-area hospital ICUs, and nursing focus groups to describe challenges and barriers that nursing staff working in an open ICU have experienced and to provide solutions that will facilitate implementation of an open visiting hours policy. DESIGN: Two-part study: survey and focus groups. SETTING: ICUs in New England and one medical ICU in a tertiary care hospital. SUBJECTS: Registered nurses employed in medical ICUs. INTERVENTIONS: Adult ICUs in the six New England states were located using a library listing of all regional hospitals. A telephone questionnaire interview was used to ascertain visiting hours policies in each ICU. Six focus-group sessions were conducted with nursing staff who work in an urban, northeastern ICU with 8 yrs of experience with an unrestricted visiting hours policy. MEASUREMENTS AND MAIN RESULTS: A total of 171 hospitals completed the questionnaire (96%). From all ICUs surveyed, 62 (32%) had unrestricted, open visiting hours. Out of these, 57 (92%) were medical ICUs or mixed medical/surgical ICUs. Nursing staff identified three major areas of concern with an open visiting hours policy: space, conflict, and burden. Strategies for resolution that are either employed or advocated by nursing staff are described. CONCLUSIONS: The majority of ICUs in New England have restricted visiting hours. Only one third of ICUs have open visiting policies. Nursing concerns with an unrestricted ICU were identified and solutions were offered that may provide guidance for other ICUs considering adopting an open visiting hours policy.     

The acceptability of an information leaflet explaining cardiopulmonary resuscitation policy in the hospice setting: a qualitative study exploring patients' views

BACKGROUND: Guidelines advise that patients receiving palliative care should be given realistic information about cardiopulmonary resuscitation (CPR) and encouraged to participate in decisions about this. For many patients attending a hospice, CPR is unlikely to be successful because of advanced disease. It is difficult to predict which patients would like to discuss CPR and whether such discussion might cause distress. AIM: This research set out to determine the acceptability and understanding of a patient information leaflet about CPR given to inpatients and day-unit patients in one hospice, and to seek patients' views on communication about resuscitation. METHODS: Semi-structured interviews were carried out with five hospice inpatients and one day-unit patient and analysed using interpretative phenomenological analysis for emergent themes. Results and conclusions: The leaflet was acceptable to the participants but was interpreted in the context of their understanding of their illness and prognosis. The leaflet alone is not a reliable method of communicating resuscitation policy and should be followed up by the opportunity to ask questions, if the patient wishes. Many factors influence patient choices about CPR. Realistic information about prognosis and about the risks and harms of CPR would allow patients to make a better-informed decision. However, if a patient prefers not to talk about their prognosis and end-of-life issues, then this should be respected.     

Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses.

BACKGROUND: Increasingly, patients' families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. OBJECTIVE: To identify the policies, preferences, and practices of critical care and emergency nurses for having patients' families present during resuscitation and invasive procedures. METHODS: A 30-item survey was mailed to a random sample of 1500 members of the American Association Of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. RESULTS: Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedures) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures). CONCLUSIONS: Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.     

Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses.

BACKGROUND: Increasingly, patients' families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. OBJECTIVE: To identify the policies, preferences, and practices of critical care and emergency nurses for having patients' families present during resuscitation and invasive procedures. METHODS: A 30-item survey was mailed to a random sample of 1500 members of the American Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. RESULTS: Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures), Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedure) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures). CONCLUSIONS: Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.     

Staff awareness of a 'Do Not Attempt Resuscitation' policy in a District General Hospital

UK hospitals have been instructed to ensure that all staff understand the institution's resuscitation policy. Using a questionnaire, we determined the level of knowledge about the hospital's 'do not attempt resuscitation' (DNAR) policy amongst a range of staff. Six hundred and seventy-seven questionnaires were returned. 91.4% of responders did not know the correct overall percentage survival to hospital discharge following an in-hospital cardiac arrest. 19.3% of doctors, 10.6% of nurses, and 8.9% of health care support workers (HCSW) gave answers in the correct range (i.e., 15-25%). Most doctors (93.5%), nurses (93.5%), and HCSW (78.9%) correctly identified that cardiopulmonary resuscitation (CPR) should be the default position, when a DNAR decision does not exist. The majority of doctors (78.5%), nurses (73.2%) and HCSW (65.8%) appreciated that the hospital policy allowed a senior trainee doctor (specialist registrar; SpR) to make the initial decision without consultation with more senior medical staff. Knowledge of who was ultimately responsible for the DNAR decision was also good, with 100% of doctors, 100% of midwives, 98.3% of nurses and 78.9% of HCSW responding correctly. Ten percent of doctors, 15% of nurses and 10.5% of HCSW believed that the next of kin could demand resuscitation or a DNAR status. There was inconsistency about what information staff felt should be included in DNAR documentation and what, if any, continuing care should be given to patients who are not for resuscitation. Our study demonstrates that there is room for improvement in the awareness of staff about the DNAR process. The local DNAR policy is being reviewed to ensure that its messages are clear and a specific DNAR educational programme has been commenced.     

Palliative care in children in Wales: a study of provision and need

AIM: To establish incidence and prevalence of children needing palliative care in Wales. PATIENTS AND METHODS: Children were identified in three ways: (1) from paediatricians using the Welsh Paediatric Surveillance Unit (WPSU); (2) referrals to the specialist palliative medicine service based in Cardiff; and (3) children under the care of the two principal children's hospices serving Wales. All children referred or reported between January 2001 and December 2002 were included. RESULTS: A total of 226 children were identified. Fifty (22%) were identified by paediatricians, 58 (26%) were referred to the specialist paediatric palliative medicine service, 158 (70%) had been under the care of a children's hospice, and 34 (15%) were identified by more than one source. This study identified approximately 3.75 per 10000 children. This is about half the prevalence figures quoted in the ACT/ RCPCH document in 1997. CONCLUSIONS: The study may underestimate prevalence. Children needing palliative medicine are still under-recognized in Wales. The overlap between children's hospice care and specialist paediatric palliative medicine is relatively small.