Aims and objectives
To explore how nurses navigate communication with families during withdrawal of life‐sustaining treatment in intensive care.
Background
Death in the intensive care unit is seldom ...unexpected and often happens following the withdrawal of life‐sustaining treatment. A family‐centred approach to care relies on the development of a therapeutic relationship and understanding of what is happening to the patient. Whilst previous research has focused on the transition from cure to palliation and the nurse's role in supporting families, less is known about how nurses navigate communication with families during treatment withdrawal.
Design
A qualitative descriptive approach was used. Semi‐structured focus groups were conducted with adult critical care nurses from four intensive care units, two in Australia and two in New Zealand.
Results
Twenty‐one nurses participated in the study. Inductive content analysis revealed five key themes relating to how nurses navigate family communication: (1) establishing the WHO; (2) working out HOW; (3) judging WHEN; (4) assessing the WHAT; and (5) WHERE these skills were learnt.
Conclusions
Navigating an approach to family communication during treatment withdrawal is a complex and multifaceted nursing activity that is known to contribute to family satisfaction with care. There is need for support and ongoing education opportunities that develop the art of communication in this frequently encountered aspect of end‐of‐life care.
Relevance to clinical practice
How nurses navigate communication with families during treatment withdrawal is just as important as what is communicated. Nurses need access to supports and education opportunities in order to be able to perform this vital role.
Aim
The aim of this study was to conduct an integrative review on how nurses prepare families for and support families during withdrawal of life‐sustaining treatments in intensive care.
Background
...End‐of‐life care is widely acknowledged as integral to the practice of intensive care. However, little is known about what happens after the decision to withdraw life‐sustaining treatments has been made and how families are prepared for death and the dying process.
Design
Integrative literature review.
Data sources
MEDLINE, CINAHL Plus, PsychINFO, PUBMED, Scopus, EMBASE and Web of Knowledge were searched for papers published between 2000–May 2015.
Review methods
A five stage review process, informed by Whittemore and Knafl's methodology was conducted. All papers were reviewed and quality assessment performed. Data were extracted, organized and analysed. Convergent qualitative thematic synthesis was used.
Results
From an identified 479 papers, 24 papers were included in this review with a range of research approaches: qualitative (n = 15); quantitative (n = 4); mixed methods (n = 2); case study (n = 2) and discourse analysis (n = 1). Thematic analysis revealed the nurses: equipped families for end of life through information provision and communication; managed the withdrawal of life‐sustaining treatments to meet family need; and continued care to build memories.
Conclusion
Greater understanding is needed of the language that can be used with families to describe death and dying in intensive care. Clearer conceptualization of the relationship between the medically focussed withdrawal of life‐sustaining treatments and patient/family‐centred end‐of‐life care is required making the nursing contribution at this time more visible.
Background:
Increasing importance is being placed on the coordination of services at the end of life.
Aim:
To describe decision-making processes that influence transitions in care when approaching ...the end of life.
Design:
Qualitative study using field observations and longitudinal semi-structured interviews.
Setting/participants:
Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3–4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken.
Findings:
Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making ‘safe’ discharge options informed hospital discharge decisions.
Conclusion:
While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life.
Providing quality end of life care is a challenging area in intensive care practice. The most demanding aspect for doctors and nurses in this setting is not the management of care at end of life per ...se, but facilitating the transition from active intervention to palliation and finally, end of life care. Whilst there is understanding about some aspects of this transition, recognition of the complex and inter-related processes that work to shift the patient's trajectory from cure to end of life care is required. This is important in order to work towards solutions for issues that continue to pose problems for health care professionals.
To identify the challenges for health care professionals when moving from a recovery trajectory to an end of life trajectory in intensive care.
Qualitative methods of enquiry.
Single semi-structured interviews with 13 medical staff and 13 nurses associated with 17 decedents who underwent treatment withdrawal in intensive care were carried out. Participants were drawn from two Intensive Care Units in a large university-affiliated hospital in England.
Patients who died in intensive care appeared to follow a three-stage end of life trajectory: admission with hope of recovery; transition from intervention to end of life care; a controlled death. The transition from intervention to end of life care was reported as being the most problematic and ambiguous stage in the end of life trajectory, with potential for conflict between medical teams, as well as between doctors and nurses.
End of life care policy emphasises the importance of end of life care for all patients regardless of setting. These findings demonstrate that in intensive care, there is need to focus on transition from curative intervention to end of life care, rather than end of life care itself so that effective and timely decision making underpins the care of the 20% of intensive care patients who die in this setting each year.
Pneumococcal pneumonia is the leading cause of community-acquired pneumonia. Obesity is a risk factor for pneumonia. Host factors play a critical role in susceptibility to pulmonary pathogens and ...outcome from pulmonary infections. Obesity impairs innate and adaptive immune responses, important in the host defence against pneumococcal disease. One area of emerging interest in understanding the complex relationship between obesity and pulmonary infections is the role of the hormone leptin. There is a substantive evidence base supporting the associations between obesity, leptin, pulmonary infections and host defence mechanisms. Despite this, there is a paucity of research that specifically focuses on
(pneumococcal) infections, which are the leading cause of community-acquired pneumonia hospitalisations and mortality worldwide. Much of the evidence examining the role of leptin in relation to
infections has used genetically mutated mice. The purpose of this mini review is to explore the role leptin plays in the host defence of
in subjects with obesity and posit an argument for the need for more human research.
OBJECTIVES:To explore the importance, challenges, and opportunities using qualitative research to enhance development of clinical practice guidelines, using recent guidelines for family-centered care ...in the ICU as an example.
METHODS:In developing the Society of Critical Care Medicine guidelines for family-centered care in the neonatal ICU, PICU, and adult ICU, we developed an innovative adaptation of the Grading of Recommendations, Assessments, Development and Evaluations approach to explicitly incorporate qualitative research. Using Grading of Recommendations, Assessments, Development and Evaluations and the Council of Medical Specialty Societies principles, we conducted a systematic review of qualitative research to establish family-centered domains and outcomes. Thematic analyses were undertaken on study findings and used to support Population, Intervention, Comparison, Outcome question development.
RESULTS:We identified and employed three approaches using qualitative research in these guidelines. First, previously published qualitative research was used to identify important domains for the Population, Intervention, Comparison, Outcome questions. Second, this qualitative research was used to identify and prioritize key outcomes to be evaluated. Finally, we used qualitative methods, member checking with patients and families, to validate the process and outcome of the guideline development.
CONCLUSIONS:In this, a novel report, we provide direction for standardizing the use of qualitative evidence in future guidelines. Recommendations are made to incorporate qualitative literature review and appraisal, include qualitative methodologists in guideline taskforce teams, and develop training for evaluation of qualitative research into guideline development procedures. Effective methods of involving patients and families as members of guideline development represent opportunities for future work.
Background. Health care policy in the United Kingdom identifies the need for health professsionals to find new ways of working to deliver patient‐focussed and economic care. Much debate has followed ...on the nature of working relationships within the health care team.
Aim. This paper reports on an ethnographic study that examined the nursing role in clinical decision‐making in intensive care units. This was chosen as a case for analysis due to the close doctor–nurse relationships that are essential in this acute and complex care setting.
Methods. Data were collected during two‐stages of fieldwork using participant observation, in‐depth ethnographic interviews and documentation across three clinical sites.
Findings. The findings revealed the different types of knowledge used for, divergence of roles involved in and degree of authority in clinical decision‐making. Furthermore, conflict arose between doctors and nurses due to these differences and in particular because medicine dominated the decision‐making process.
Conclusions. The nursing role, whilst pivotal to implementing clinical decisions, remained unacknowledged and devalued. Medical hegemony continues to render nurses unable to influence substantially the decision‐making process. This has fundamental ramifications for the quality of team decision‐making and the effectiveness of new ways of inter‐professional working in intensive care.
Background:
Transferring critically ill patients home to die is poorly explored in the literature to date. This practice is rare, and there is a need to understand health care professionals’ (HCP) ...experience and views.
Objectives:
To examine (1) HCPs’ experience of transferring patients home to die from critical care, (2) HCPs’ views about transfer and (3) characteristics of patients, HCPs would hypothetically consider transferring home to die.
Design:
A national study developing a web-based survey, which was sent to the lead doctors and nurses in critical care units.
Setting/participants:
Lead doctors and senior nurses (756 individuals) working in 409 critical care units across the United Kingdom were invited to participate in the survey.
Results:
In total, 180 (23.8%) completed surveys were received. A total of 65 (36.1%) respondents had been actively involved in transferring patients home to die and 28 (15.5%) had been involved in discussions that did not lead to transfer. Respondents were supportive of the idea of transfer home to die (88.8%). Patients identified by respondents as unsuitable for transfer included unstable patients (61.8%), intubated and ventilated patients (68.5%) and patients receiving inotropes (65.7%). There were statistically significant differences in views between those with and without experience and between doctors and nurses. Nurses and those with experience tended to have more positive views.
Conclusion:
While transferring patients home to die is supported in critical care, its frequency in practice remains low. Patient stability and level of intervention are important factors in decision-making in this area. Views held about this practice are influenced by previous experience and the professional role held.
While the patient-carer dyad has been broadly described, there is little exploration of patient-carer models in use.
To explore types of patient-carer models in use for those with advanced and ...progressive disease.
Qualitative interviews were undertaken with patients at risk of dying in the next year and their carers across three sites (residential care home, medical assessment unit, general medical unit). Thematic analysis was undertaken.
Four patient-carer models were identified. In these, the provision of care and of coordination of care services were important areas and organised differently across the patient, the carer, and alternative sources of support.
A 'one size fits all' patient-carer model is outdated and a new understanding of different types of patient-carer models are required to fully inform care delivered at end of life.
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