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Yuan L, Chaudhari V, Rabin S, McClintic M, Desai P, Beck T, Chen E, Rojas JC. Discussing End-of-Life in the Intensive Care Unit: Education Practices in Pulmonary and Critical Care Medicine Fellowship Programs. Am J Hosp Palliat Care 2025:10499091251333401. [PMID: 40235163 DOI: 10.1177/10499091251333401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2025] Open
Abstract
IntroductionEnd-of-life care (EOLC) is an important aspect of patient management in the Intensive Care Unit (ICU). Poor communication during this time can lead to unnecessary suffering for patients and their families. Although palliative training is required in Pulmonary and Critical Care Medicine (PCCM) fellowship programs, there is significant variability in its delivery, and data on its effectiveness are limited. This study evaluates the implementation and impact of EOLC communication instruction in PCCM fellowship programs.MethodsA web-based survey was administered to PCCM fellows in the United States from December 2023 to February 2024. Statistical analyses were conducted to assess factors influencing fellow confidence in leading EOLC discussions in the ICU.ResultsA total of 167 fellows completed the survey (response rate: 7.4%). Most respondents (61%) reported one or two types of EOLC training in their programs. Nearly half (53%) felt their training was adequate. Fellows who led more EOLC discussions were significantly more confident in doing so (P < 0.001). Greater confidence was also associated with smaller ICU census and stronger faculty mentorship (P < 0.05).ConclusionsPCCM fellows feel more confident in leading EOLC discussions when they have supportive faculty mentors, manageable ICU workloads, and ample experience with these conversations. As nearly half of fellows report insufficient training, integrating these strategies into fellowship curricula is essential for improving EOLC communication.
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Affiliation(s)
- Leah Yuan
- Department of Internal Medicine, Rush University, Chicago, IL, USA
| | - Vaishvik Chaudhari
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush University, Chicago, IL, USA
| | - Sydney Rabin
- Department of Internal Medicine, Rush University, Chicago, IL, USA
| | - Mia McClintic
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush University, Chicago, IL, USA
| | - Pankaja Desai
- Department of Internal Medicine, Rush University, Chicago, IL, USA
| | - Todd Beck
- Department of Internal Medicine, Rush University, Chicago, IL, USA
| | - Elaine Chen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush University, Chicago, IL, USA
| | - Juan C Rojas
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush University, Chicago, IL, USA
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Feng X, Liang S, Dai X, Du J, Yang Z. Gender differences in quality of dying and death among older adults: a cross-sectional study in China. Front Public Health 2025; 13:1542918. [PMID: 40109418 PMCID: PMC11919661 DOI: 10.3389/fpubh.2025.1542918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Accepted: 02/19/2025] [Indexed: 03/22/2025] Open
Abstract
Background The aging of China is deepening year by year, and improving the quality of dying and death (QODD) is increasingly becoming an urgent and realistic need. This study explores the gender differences in the quality of dying and death and its influencing factors among Chinese older adults, aiming to provide assistance to the relevant authorities in formulating end-of-life care policies for the older adults, and to adapt to the needs of an aging society. Methods Based on the data of the Chinese Longitudinal Health Longevity Survey (CLHLS) during 2008-2018, a total of 7,341 respondents were included. Chi-square test and logistic regression analysis were used to analyze the quality of dying and death among Chinese older adults and its influencing factors. In addition, A Fairlie decomposition analysis (FDA) was conducted to ascertain the degree of influence exerted by various contributing factors. Results The proportion of high QODD among female older adults (63.80%) was significantly higher than male older adults (56.00%), which was statistically significant. Logistic regression showed that age, residence, home facilities score, place of death, medical costs, got timely treatment, number of chronic diseases and unconsciousness were the factors influencing QODD among male older adults. Meanwhile, residence, marital status, home facilities score, place of death, got timely treatment, bedridden, suffered from serious illness, unconsciousness and drinking were the factors influencing QODD among female older adults. FDA showed that 47.89% of the differences in QODD were caused by the observed variables, while 52.11% of the differences were caused by gender differences and unmeasured variables. Conclusion Chinese men have a poorer QODD compared to women. The main factors contributing to this difference were age, the number of chronic diseases, suffered from serious illness, unconsciousness, place of death, residence and home facilities scores. To ensure successful aging, the relevant departments should focus on these factors and work toward reducing the gender differences in QODD.
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Affiliation(s)
| | | | | | | | - Zheng Yang
- School of Public Health, Guangdong Medical University, Dongguan, China
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3
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Danyalian AM, Iguina MM, Malhi M, Shaikh U, Kashan SB, Morgan D, Heller D, Danckers M. Impact of a Comprehensive Palliative Quality Improvement Initiative (ICU-PAL) in a Medical-Surgical Intensive Care Unit. HCA HEALTHCARE JOURNAL OF MEDICINE 2025; 6:31-42. [PMID: 40071180 PMCID: PMC11892402 DOI: 10.36518/2689-0216.1751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2025]
Abstract
Background Early palliative care practice implementation in the intensive care unit (ICU) improves advance care planning, promotes patient and family satisfaction, and decreases health care costs. The consensus for protocolized palliative care delivery is unknown. We assessed the impact of a qualitive improvement educational intervention that promotes the identification of critically ill patients who will benefit from early expert palliative care interventions. Methods In this observational study, we examined the impact of an educational intervention that promoted (1) early detection of palliative care triggers (PCT) during ICU multidisciplinary rounds (MDRs), (2) admission and 48-hour pain assessment, and (3) family meetings within the first 72 hours of ICU admission among critically-ill patients in a mixed adult community ICU. The primary outcome was the monthly number of hospital-wide palliative care consultations pre- and post-intervention. Secondary outcomes included trends in the rate of PCT detection by the MDR team, pain assessment, and family meetings within 72 hours in ICU patients after the implementation of the education intervention. Results The median monthly palliative care consultations progressively increased after the ICU-PAL implementation (preceding year: median 49 [45.5-54], first year: 70 [57.25-78.5], second year: 90 [79-105.25], P < .05 for all comparisons). Family meeting documentation within 72 hours among critically ill patients progressively became more frequent after implementation without changes in PCT detection in MDRs nor pain assessment frequency. Conclusion Implementing the ICU-PAL qualitive improvement initiative was associated with a consistent increase in the median average hospital-wide palliative care consultations over several years and a progressively increased rate of early family meetings in critically ill patients after its deployment.
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Affiliation(s)
| | | | - Manjot Malhi
- HCA Florida Aventura Hospital, Aventura, Florida
| | - Umair Shaikh
- Piedmont Eastside Medical Center, Snellville, Georgia
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Kesecioglu J, Rusinova K, Alampi D, Arabi YM, Benbenishty J, Benoit D, Boulanger C, Cecconi M, Cox C, van Dam M, van Dijk D, Downar J, Efstathiou N, Endacott R, Galazzi A, van Gelder F, Gerritsen RT, Girbes A, Hawyrluck L, Herridge M, Hudec J, Kentish-Barnes N, Kerckhoffs M, Latour JM, Malaska J, Marra A, Meddick-Dyson S, Mentzelopoulos S, Mer M, Metaxa V, Michalsen A, Mishra R, Mistraletti G, van Mol M, Moreno R, Nelson J, Suñer AO, Pattison N, Prokopova T, Puntillo K, Puxty K, Qahtani SA, Radbruch L, Rodriguez-Ruiz E, Sabar R, Schaller SJ, Siddiqui S, Sprung CL, Umbrello M, Vergano M, Zambon M, Zegers M, Darmon M, Azoulay E. European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit. Intensive Care Med 2024; 50:1740-1766. [PMID: 39361081 PMCID: PMC11541285 DOI: 10.1007/s00134-024-07579-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/28/2024] [Indexed: 11/07/2024]
Abstract
The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.
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Affiliation(s)
- Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Katerina Rusinova
- Department of Palliative Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Daniela Alampi
- Sapienza University of Rome, A.O.U. Sant'Andrea, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Julie Benbenishty
- Faculty of Medicine, School of Nursing, Hebrew University, Jerusalem, Israel
| | - Dominique Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | | | - Maurizio Cecconi
- Biomedical Sciences Department, Humanitas University, Milan, Italy
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Christopher Cox
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, NC, USA
| | - Marjel van Dam
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Diederik van Dijk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Bruyere Research Institute, Ottawa, Canada
| | - Nikolas Efstathiou
- School of Nursing and Midwifery, University of Birmingham, Birmingham, UK
| | - Ruth Endacott
- National Institute for Health and Care Research, London, UK
| | | | | | - Rik T Gerritsen
- Centrum Voor Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Armand Girbes
- Department of Critical Care, AmsterdamUMC Location VUmc, Amsterdam, The Netherlands
| | - Laura Hawyrluck
- Interdepartmental Division Critical Care Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Margaret Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Toronto, Canada
- Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jan Hudec
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Nancy Kentish-Barnes
- Famiréa Research Group, APHP Nord, Saint Louis Hospital, Intensive Care Unit, Paris, France
| | - Monika Kerckhoffs
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Curtin School of Nursing, Curtin University, Perth, Australia
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jan Malaska
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
- Second Department of Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czechia
| | - Annachiara Marra
- Department of Neuroscience, Reproductive Science and Dentistry, University of Naples, Naples, Italy
| | - Stephanie Meddick-Dyson
- Wolfson Palliative Care Research Centre, Hull York, Medical School, University of Hull, Hull, UK
| | - Spyridon Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Konstanz Hospital, Constance, Germany
| | - Rajesh Mishra
- Ahmedabad Shaibya Comprehensive Care Clinic, Ahmedabad, India
| | - Giovanni Mistraletti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- S.C. Anesthesia and Intensive Care, Legnano Hospital, ASST Ovest Milanese, Milan, Italy
| | - Margo van Mol
- Department of Intensive Care Adults, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Rui Moreno
- Hospital de São José, Unidade Local de Saúde São José, Lisbon, Portugal
- Faculdade de Ciências Médicas de Lisboa, Nova Medical School, Centro Clínico Académico de Lisboa, Lisbon, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Judith Nelson
- Memorial Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Andrea Ortiz Suñer
- Hospital Arnau de Vilanova-Lliria, Valencia, Spain
- Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | - Natalie Pattison
- University of Hertfordshire, East and North Hertfordshire NHS Trust, Hatfield, UK
- Imperial Healthcare NHS Trust, Imperial College, London, UK
| | - Tereza Prokopova
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Kathleen Puntillo
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn Puxty
- Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Samah Al Qahtani
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Emilio Rodriguez-Ruiz
- Department of Intensive Care Medicine, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
- Simulation, Life Support and Intensive Care Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Shahla Siddiqui
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care Medicine and Pain, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michele Umbrello
- S.C. Anesthesia and Intensive Care, Legnano Hospital, ASST Ovest Milanese, Milan, Italy
| | - Marco Vergano
- Department of Anesthesia, Intensive Care and Emergency, San Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Zambon
- Anesthesia and Intensive Care Ospedale "Uboldo", Cernusco sul Naviglio, Milan, Italy
| | - Marieke Zegers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Darmon
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, Paris, France
- Université Paris Cité, Paris, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, Paris, France
- Université Paris Cité, Paris, France
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Godfrey S, Barnes A, Gao J, Sulistio MS, Katz JN, Chuzi S. Shared Decision-making in Palliative and End-of-life Care in the Cardiac Intensive Care Unit. US CARDIOLOGY REVIEW 2024; 18:e13. [PMID: 39494405 PMCID: PMC11526488 DOI: 10.15420/usc.2024.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/29/2024] [Indexed: 11/05/2024] Open
Abstract
Patients and clinicians in the cardiac intensive care unit (CICU) are often tasked with making high-stakes decisions about aggressive or life- sustaining therapies. Shared decision-making (SDM), a collaborative process where patients and clinicians work together to make medical decisions that are aligned with a patient's goals and values, is therefore highly relevant in the CICU, especially in the context of palliative or end-of-life decisions. Despite its importance, there are barriers to optimal integration and implementation of SDM. This review describes the fundamentals and models of SDM, the role of SDM in the CICU, and evidence-based strategies to promote SDM in the CICU.
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Affiliation(s)
- Sarah Godfrey
- Division of Cardiology, University of Texas Southwestern Medical CenterDallas, TX
| | - Alexis Barnes
- Division of Cardiology, University of Pittsburgh Medical CenterPittsburgh, PA
| | - Jing Gao
- Department of Internal Medicine, Northwestern University Feinberg School of MedicineChicago, IL
| | - Melanie S Sulistio
- Division of Cardiology, University of Texas Southwestern Medical CenterDallas, TX
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of MedicineNew York, NY
| | - Sarah Chuzi
- Division of Cardiology, Northwestern University Feinberg School of MedicineChicago, IL
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Naya K, Sakuramoto H, Aikawa G, Ouchi A, Oyama Y, Tanaka Y, Kaneko K, Fukushima A, Ota Y. Intensive care unit interventions to improve quality of dying and death: scoping review. BMJ Support Palliat Care 2024:spcare-2024-004967. [PMID: 39089724 DOI: 10.1136/spcare-2024-004967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/12/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Intensive care units (ICUs) have mortality rates of 10%-29% owing to illness severity. Postintensive care syndrome-family affects bereaved relatives, with a prevalence of 26% at 3 months after bereavement, increasing the risk for anxiety and depression. Complicated grief highlights issues such as family presence at death, inadequate physician communication and urgent improvement needs in end-of-life care. However, no study has comprehensively reviewed strategies and components of interventions to improve end-of-life care in ICUs. AIM This scoping review aimed to analyse studies on improvement of the quality of dying and death in ICUs and identify interventions and their evaluation measures and effects on patients. METHODS MEDLINE, CINAHL, PsycINFO and Central Journal of Medicine databases were searched for relevant studies published until December 2023, and their characteristics and details were extracted and categorised based on the Joanna Briggs model. RESULTS A total of 24 articles were analysed and 10 intervention strategies were identified: communication skills, brochure/leaflet/pamphlet, symptom management, intervention by an expert team, surrogate decision-making, family meeting/conference, family participation in bedside rounds, psychosocial assessment and support for family members, bereavement care and feedback on end-on-life care for healthcare workers. Some studies included alternative assessment by family members and none used patient assessment of the intervention effects. CONCLUSION This review identified 10 intervention strategies to improve the quality of dying and death in ICUs. Many studies aimed to enhance the quality by evaluating the outcomes through proxy assessments. Future studies should directly assess the quality of dying process, including symptom evaluation of the patients.
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Affiliation(s)
- Kazuaki Naya
- Wakayama Faculty of Nursing, Tokyo Healthcare University, Wakayama, Japan
| | - Hideaki Sakuramoto
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Fukuoka, Japan
| | - Gen Aikawa
- College of Nursing, Kanto Gakuin University, Kanagawa, Japan
| | - Akira Ouchi
- Department of Adult Health Nursing, Ibaraki Christian University, Ibaraki, Japan
| | - Yusuke Oyama
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yuta Tanaka
- Department of Nursing, Akita University Graduate School of Health Sciences, Akita, Japan
| | | | - Ayako Fukushima
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Fukuoka, Japan
| | - Yuma Ota
- Department of Nursing, Tokyo Healthcare University, Tokyo, Japan
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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2024; 39:715-732. [PMID: 37822226 DOI: 10.1177/08850666231204305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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Sykes M, Rosenberg-Yunger ZRS, Quigley M, Gupta L, Thomas O, Robinson L, Caulfield K, Ivers N, Alderson S. Exploring the content and delivery of feedback facilitation co-interventions: a systematic review. Implement Sci 2024; 19:37. [PMID: 38807219 PMCID: PMC11134935 DOI: 10.1186/s13012-024-01365-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 05/13/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Policymakers and researchers recommend supporting the capabilities of feedback recipients to increase the quality of care. There are different ways to support capabilities. We aimed to describe the content and delivery of feedback facilitation interventions delivered alongside audit and feedback within randomised controlled trials. METHODS We included papers describing feedback facilitation identified by the latest Cochrane review of audit and feedback. The piloted extraction proforma was based upon a framework to describe intervention content, with additional prompts relating to the identification of influences, selection of improvement actions and consideration of priorities and implications. We describe the content and delivery graphically, statistically and narratively. RESULTS We reviewed 146 papers describing 104 feedback facilitation interventions. Across included studies, feedback facilitation contained 26 different implementation strategies. There was a median of three implementation strategies per intervention and evidence that the number of strategies per intervention is increasing. Theory was used in 35 trials, although the precise role of theory was poorly described. Ten studies provided a logic model and six of these described their mechanisms of action. Both the exploration of influences and the selection of improvement actions were described in 46 of the feedback facilitation interventions; we describe who undertook this tailoring work. Exploring dose, there was large variation in duration (15-1800 min), frequency (1 to 42 times) and number of recipients per site (1 to 135). There were important gaps in reporting, but some evidence that reporting is improving over time. CONCLUSIONS Heterogeneity in the design of feedback facilitation needs to be considered when assessing the intervention's effectiveness. We describe explicit feedback facilitation choices for future intervention developers based upon choices made to date. We found the Expert Recommendations for Implementing Change to be valuable when describing intervention components, with the potential for some minor clarifications in terms and for greater specificity by intervention providers. Reporting demonstrated extensive gaps which hinder both replication and learning. Feedback facilitation providers are recommended to close reporting gaps that hinder replication. Future work should seek to address the 'opportunity' for improvement activity, defined as factors that lie outside the individual that make care or improvement behaviour possible. REVIEW REGISTRATION The study protocol was published at: https://www.protocols.io/private/4DA5DE33B68E11ED9EF70A58A9FEAC02 .
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Affiliation(s)
| | | | | | | | | | - Lisa Robinson
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Karen Caulfield
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
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Hirimuthugoda LK, De Silva P, Abeykoon P. Effects of health educational and participatory consumer group interventions in improving food handling practices in regional director of health services area Kalutara, Sri Lanka: non-randomized controlled community trial. BMC Public Health 2024; 24:972. [PMID: 38582854 PMCID: PMC10998395 DOI: 10.1186/s12889-024-18481-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/28/2024] [Indexed: 04/08/2024] Open
Abstract
INTRODUCTION Safe and nutritious food is the key to sustaining life and promoting good health. Unsafe food creates a vicious cycle of disease and malnutrition, particularly affecting infants, young children, the elderly, and the sick. METHODS The study consisted of two phases, a descriptive cross-sectional study, and an intervention study. Both studies were conducted in the Regional Director of Health Services area, Kalutara, Sri Lanka. The descriptive cross-sectional study [food handlers (n = 904), food establishments (n = 421)] was conducted with the objective of determining factors associated with food handling practices among food handlers and in food establishments. The interventional study was a three-arm non-randomized controlled community trial (n = 50 per arm) with interventions of a participatory consumer group, educational package group, and control group. RESULTS The food establishments assessment tool (FEAT) contained 11 domains including 75 items with more than a hundred assessment points with a guide to conduct an assessment of food handling. The descriptive cross-sectional study found that food handlers' knowledge of food handling practices of storing milk, fish, and meat and fast-food items containing fish and meat was very poor (96.6%). Visibility of the last place of processing inside the food establishments to consumers was inadequate (19.2%) and the absence of the above-mentioned factor was significantly associated with an unsatisfactory level of food handling score in food establishments (p = 0.03). The unsatisfactory level of food handling was significantly higher among food establishments with non-personal ownership (p = 0.005), a low number of notices issued by legal authorities (p = 0.02), dereliction of duty by owners/managers on supervising (p < 0.001) and lack of medical certification to food handlers (p < 0.0001). Participatory consumer group intervention and educational package interventions were effective in improving food handling practices in food establishments and among food handlers (p < 0.0001). Two independent sample analysis using the Mann-Whitney U test showed, the best improvement in food handling practices was by participatory consumer group intervention (p < 0.0001) and the second was educational package intervention (p < 0.0001). CONCLUSIONS Knowledge and practices of food handling among participants were poor. A participatory consumer group is more effective than an educational package on improving food handling practices both among food handlers and in food establishments.
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Affiliation(s)
| | - Padmal De Silva
- National Institute of Health Sciences, Ministry of Health, Colombo, Sri Lanka
| | - Palitha Abeykoon
- World Health Organization - Country Office, Colombo 05, Sri Lanka
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Naya K, Sakuramoto H, Aikawa G, Ouchi A, Yoshihara S, Ota Y, Okamoto S, Fukushima A, Hirashima H. Family Members' Feedback on the "Quality of Death" of Adult Patients Who Died in Intensive Care Units and the Factors Affecting the Death Quality: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e58344. [PMID: 38756296 PMCID: PMC11098527 DOI: 10.7759/cureus.58344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Intensive care units (ICUs) are designed for critically ill patients who often experience high mortality rates owing to the severity of their conditions. Although the primary goal is patient recovery, it is crucial to understand the quality of death in the ICU setting. Nevertheless, there is a notable lack of systematic reviews on measured death quality and its associated factors. This study aims to conduct a quantitative synthesis of evidence regarding the quality of death in the ICU and offers a comprehensive overview of the factors influencing this quality, including its relationship with the post-intensive care syndrome-family (PICS-F). A thorough search without any language restrictions across MEDLINE, CINAHL, PsycINFO, and Igaku Chuo Zasshi databases identified relevant studies published until September 2023. We aggregated the results regarding the quality of death care for patients who died in the ICU across each measurement tool and calculated the point estimates and 95% confidence intervals. The quantitative synthesis encompassed 19 studies, wherein the Quality of Dying and Death-single item (QODD-1) was reported in 13 instances (Point estimate: 7.0, 95% CI: 6.93-7.06). Patient demographic data, including age and gender, as well as the presence or absence of invasive procedures, such as life support devices and cardiopulmonary resuscitation, along with the management of pain and physical symptoms, were found to be associated with a high quality of death. Only one study reported an association between quality of death and PICS-F scores; however, no significant association was identified. The QODD-1 scale emerged as a frequently referenced and valuable metric for evaluating the quality of death in the ICU, and factors associated with the quality of ICU death were identified. However, research gaps persist, particularly regarding the variations in the quality of ICU deaths based on cultural backgrounds and healthcare systems. This review contributes to a better understanding of the quality of death in the ICU and emphasises the need for comprehensive research in this critical healthcare domain.
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Affiliation(s)
- Kazuaki Naya
- Department of Adult Nursing, Tokyo Healthcare University Wakayama Faculty of Nursing, Wakayama, JPN
| | - Hideaki Sakuramoto
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, JPN
| | - Gen Aikawa
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, Hitachi, JPN
| | - Akira Ouchi
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, Hitachi, JPN
| | - Shun Yoshihara
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, JPN
| | - Yuma Ota
- Department of Fundamental Nursing, Tokyo Healthcare University Faculty of Healthcare, Shinagawa, JPN
| | - Saiko Okamoto
- Department of Nursing, Hitachi General Hospital, Hitachi, JPN
| | - Ayako Fukushima
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, JPN
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Almalki N, Boyle B, O'Halloran P. What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries? A systematic review. BMC Palliat Care 2024; 23:87. [PMID: 38556888 PMCID: PMC10983740 DOI: 10.1186/s12904-024-01413-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/17/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND As many patients are spending their last days in critical care units, it is essential that they receive appropriate end-of -life care. However, cultural differences, ethical dilemmas and preference practices can arise in the intensive care settings during the end of life. Limiting therapy for dying patients in intensive care is a new concept with no legal definition and therefore there may be confusion in interpreting the terms 'no resuscitation' and 'comfort care' among physicians in Middle East. Therefore, the research question is 'What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries?' METHODS The authors conducted a comprehensive systematic literature review using five electronic databases. We identified primary studies from Medline, Embase, CINAHL, Psycinfo and Scopus. The team assessed the full-text papers included in the review for quality using the Joanna Briggs Institute checklist (JBI). We completed the literature search on the first of April 2022 and was not limited to a specific period. RESULTS We identified and included nine relevant studies in the review. We identified five main themes as end-of-life care challenges and/or facilitators: organisational structure and management, (mis)understanding of end-of-life care, spirituality and religious practices for the dying, communication about end-of-life care, and the impact of the ICU environment. CONCLUSIONS This review has reported challenges and facilitators to providing end-of-life care in ICU and made initial recommendations for improving practice. These are certainly not unique to the Middle East but can be found throughout the international literature. However, the cultural context of Middle East and North Africa countries gives these areas of practice special challenges and opportunities. Further observational research is recommended to confirm or modify the results of this review, and with a view to developing and evaluating comprehensive interventions to promote end-of-life care in ICUs in the Middle East.
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Affiliation(s)
- Nabat Almalki
- Prince Sultan Military College for Health Sciences, Dharan, Saudi Arabia.
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK.
| | - Breidge Boyle
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
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12
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Liu YX, Xu Y. Enhancing competency of clinical research nurses: A comprehensive training and evaluation framework. World J Clin Cases 2024; 12:1378-1381. [PMID: 38524510 PMCID: PMC10955526 DOI: 10.12998/wjcc.v12.i7.1378] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/19/2024] [Accepted: 02/04/2024] [Indexed: 02/29/2024] Open
Abstract
The Sun et al's training program for clinical research nurses (CRNs) in the World Journal of Clinical Cases is a comprehensive and scientific approach. It includes structured frameworks for CRN training, aiming to improve CRN competency. This program emphasizes practical abilities, updates training content, and improves evaluation methods. The cultivation of CRN talents focuses on enhancing the training system, establishing a multifaceted evaluation framework, and continuously refining the training programs. Regular feedback and evaluation are essential to improve CRNs' competency in practical settings.
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Affiliation(s)
- Yang-Xi Liu
- Tumor Interventional Department, Taizhou Municipal Hospital, Taizhou 318099, Zhejiang Province, China
| | - Yi Xu
- Tumor Interventional Department, Taizhou Municipal Hospital, Taizhou 318099, Zhejiang Province, China
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Takahashi Y, Utsumi S, Fujizuka K, Suzuki H, Nakamura M. Factors associated with healthcare providers' satisfaction with end-of-life care in the intensive care unit: A systematic review. Anaesth Crit Care Pain Med 2024; 43:101330. [PMID: 37984633 DOI: 10.1016/j.accpm.2023.101330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND We aimed to synthesize published data on and identify factors associated with healthcare providers' satisfaction with end-of-life care for critically ill adults. METHODS Electronic databases were searched from inception to January 23, 2023. We included trials involving adults admitted to intensive care units (ICUs) or high-dependency units to evaluate palliative care interventions. STUDY SELECTION The inclusion criteria were as follows: 1) Adult patients (age ≥18 years) or their family members admitted to the ICU or a high-dependency unit; 2) ICU palliative care interventions; 3) Randomized and non-randomized controlled trials; and 4) Full-text, peer-reviewed articles published in English. Two reviewers screened and extracted the data and assessed bias risk. The primary outcome was an improvement in the healthcare providers' satisfaction based on the validated scales. RESULTS Out of 12 studies, 9 investigated combined dimension intervention. Healthcare providers' satisfaction improved in 6/7 (85.7%) of the studies testing educational intervention, 5/7 (71.4%) studies testing the effectiveness of palliative care team involvement, 4/5 (80%) of studies testing communication interventions, while 0/2 (0%) study testing ethic consultations. CONCLUSIONS Most of the tested palliative care interventions were associated with improved healthcare provider satisfaction in intensive care units. The impacts of such intervention on mental health and burden remain to be investigated in this field.
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Affiliation(s)
- Yoshihiko Takahashi
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
| | - Shu Utsumi
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Kenji Fujizuka
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
| | - Hiroyuki Suzuki
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
| | - Mitsunobu Nakamura
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
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Shalman D. Clinical outcomes of a joint ICU and palliative care multidisciplinary rounding model: A retrospective cohort study. PLoS One 2024; 19:e0297288. [PMID: 38300936 PMCID: PMC10833514 DOI: 10.1371/journal.pone.0297288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/02/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES This retrospective cohort study assessed whether implementation of a joint inpatient palliative care (IPC) and ICU multidisciplinary rounding model affected clinical outcomes including ICU length of stay (LOS). METHODS Beginning in October of 2018, an IPC physician joined the pre-existing ICU multidisciplinary rounds. Data were collected for ICU patients admitted during a 6-month period before this intervention and a 6-month period after the intervention. Data were extracted from an integrated electronic medical records (EMR) data system and compared by Wilcoxon and chi-square test for continuous and categorical variables respectively. Negative binomial regression was used to analyze the primary outcome measure, ICU LOS. RESULTS Patients in the intervention group spent fewer days in the ICU (3.7 vs. 3.9 days, p = 0.05; RR 0.82, 95% CI 0.70-0.97, p = 0.02) and in the hospital (7.5 vs. 7.8 days, p<0.01) compared to the pre-intervention group. The rate of CPR was lower in the intervention group, but the difference was not statistically significant [13(3.1%) vs. 23(5.3%), p = 0.10]. The groups did not differ significantly in rate of hospital mortality, number of days connected to mechanical ventilation via endotracheal tube, or bounceback to the ED or hospital. Multivariable analysis of the primary outcome demonstrated that patients with prior palliative care involvement had longer ICU LOS (RR 1.46, 95% CI 1.04-2.06, p = 0.03) when controlling for other variables. CONCLUSION The presented joint IPC-ICU multidisciplinary rounding model was associated with a statistically significant reduction in ICU and hospital LOS, but the clinical significance of this reduction is unclear.
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Affiliation(s)
- Dov Shalman
- Department of Geriatric, Palliative, and Continuing Care, Kaiser Permanente Southern California, Los Angeles, California, United States of America
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15
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Kansal A, Latour JM, See KC, Rai S, Cecconi M, Britto C, Conway Morris A, Dominic Savio R, Nadkarni VM, Rao BK, Mishra R. Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study. Crit Care 2023; 27:487. [PMID: 38082302 PMCID: PMC10712165 DOI: 10.1186/s13054-023-04766-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources. METHODS A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice. RESULTS At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept. CONCLUSIONS This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.
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Affiliation(s)
- Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Jurong Health Campus, National University Health System, Singapore, Singapore.
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Canberra, Australia
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Carl Britto
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, USA
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics at the Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - B K Rao
- Department of Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
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Neville TH, Taich Z, Walling AM, Bear D, Cook DJ, Tseng CH, Wenger NS. The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End of Life. J Gen Intern Med 2023; 38:115-121. [PMID: 35581456 PMCID: PMC9113739 DOI: 10.1007/s11606-022-07638-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 04/22/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL. AIM To assess whether the 3WP is associated with improved ratings of EOL care. PROGRAM DESCRIPTION In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families. SETTING 2-hospital academic healthcare system. PARTICIPANTS Dying patients in the ICU and their families. PROGRAM EVALUATION A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care). RESULTS Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups. DISCUSSION The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.
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Affiliation(s)
- Thanh H Neville
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
| | - Zachary Taich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.,VA Greater Los Angeles Healthcare System, Veteran Affairs, Los Angeles, USA
| | - Danielle Bear
- UCLA Office of the Patient Experience, UCLA Health, Los Angeles, CA, USA
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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Integrating Narrative Goals of Care in the Medical Intensive Care Unit: Impact on Educational and Clinical Outcomes. ATS Sch 2022; 3:449-459. [PMID: 36312808 PMCID: PMC9585691 DOI: 10.34197/ats-scholar.2022-0003in] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background High-quality goals of care (GOC) communication is fundamental to providing excellent critical care. Objective Educate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation. Methods Guided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19). Results All PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% (P < 0.05); for patients age ⩾80 years, 3.54% versus 29.41% (P < 0.05); and for patients with MICU length of stay ⩾7 days, 2.78% versus 24.44% (P < 0.05). Conclusion Combining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.
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18
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Helgeson SA, Burnside RC, Robinson MT, Mack RC, Ball CT, Guru PK, Moss JE. Early Versus Usual Palliative Care Consultation in the Intensive Care Unit. Am J Hosp Palliat Care 2022; 40:544-551. [PMID: 35833450 DOI: 10.1177/10499091221115732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Palliative Medicine involvement in MICU patients have improved length of stay and mortality, but with varying effects on specific patient decision outcomes, such as, advance care planning. These studies have utilized Palliative Medicine later in the hospital or ICU course, with some evidence showing that earlier involvement resulted in better results. The purpose of this study was to evaluate the benefits of early (within 24 hours) palliative care consultation in medical ICU (MICU) patients to clinical and satisfaction outcomes. METHODS An unblinded randomized study performed in the MICU in one academic hospital in the USA. Ninety-one adult patients admitted to MICU received a Palliative care medicine consultation within 24 hours as the intervention. MEASUREMENTS AND RESULTS Ninety-one patients admitted to the MICU underwent randomization with 50 patients randomly assigned to receive Palliative Medicine consultation and 41 patients randomly assigned to receive standard-of-care based on predefined criteria. The median satisfaction score was 23 points higher for the patients in the intervention group (P < .001). The median length of MICU stay was 5 days shorter in the intervention group compared to the control group (95% CI; 1 day to 18 days, P = .018). Advance care planning was completed in the hospital for 34% of patients in the intervention arm and 12% of patients in the controls arm (absolute risk difference 22%, 95% CI 4% to 37%, P = .016). CONCLUSION Early Palliative Medicine consultation within 24 hours of MICU admission showed significant benefits to patients by improving satisfaction and decreasing length of stay. This study provides evidence that Palliative Medicine involvement earlier in the course of severe disease is important. Further studies in other types of intensive care units (neurological and Cardiovascular) are necessary to determine their impact.
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Affiliation(s)
- Scott A Helgeson
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Rebecca C Burnside
- Department of Critical Care Medicine, 8511Lexington Medical Center, West Columbia, SC, USA
| | - Maisha T Robinson
- Departments of Neurology and Palliative Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Rachel C Mack
- Department of Palliative Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Colleen T Ball
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - John E Moss
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
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Stapleton RD, Ford DW, Sterba KR, Nadig NR, Ades S, Back AL, Carson SS, Cheung KL, Ely J, Kross EK, Macauley RC, Maguire JM, Marcy TW, McEntee JJ, Menon PR, Overstreet A, Ritchie CS, Wendlandt B, Ardren SS, Balassone M, Burns S, Choudhury S, Diehl S, McCown E, Nielsen EL, Paul SR, Rice C, Taylor KK, Engelberg RA. Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients. J Pain Symptom Manage 2022; 63:e621-e632. [PMID: 35595375 PMCID: PMC9179950 DOI: 10.1016/j.jpainsymman.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 01/27/2023]
Abstract
CONTEXT Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree. OBJECTIVES Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families. METHODS This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness. RESULTS Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending. CONCLUSIONS IA is a feasible and reasonable approach to CPR discussions in selected patient populations.
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Affiliation(s)
- Renee D Stapleton
- Pulmonary and Critical Medicine, HSRF 222 (R.D.S), University of Vermont Larner College of Medicine, Burlington, Vermont, USA.
| | - Dee W Ford
- Division Director and Professor, Pulmonary, Critical Care, and Sleep Medicine, CSB 816, MSC 630 (D.W.F.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine R Sterba
- Public Health Sciences (K.R.S.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nandita R Nadig
- Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine (N.R.N.), Chicago, Illinois, USA
| | - Steven Ades
- Hematology and Oncology (S.A.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Anthony L Back
- Department of Medicine (A.L.B.), University of Washington, Seattle, Washington, USA
| | - Shannon S Carson
- Pulmonary and Critical Care Medicine (S.S.C.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katharine L Cheung
- Nephrology (K.L.C.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Janet Ely
- University of Vermont Cancer Center (J.E.), Burlington, Vermont, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care & Sleep Medicine, Co-Director of Cambia Palliative Care Center of Excellence at UW Medicine (E.K.K.), University of Washington, Seattle, Washington, USA
| | | | - Jennifer M Maguire
- Pulmonary and Critical Care Medicine (J.M.M.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Theodore W Marcy
- Pulmonary and Critical Care Medicine (T.W.M.), University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Jennifer J McEntee
- Internal Medicine and Pediatrics, Palliative Care and Hospice Medicine (J.J.M.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Prema R Menon
- Vertex Pharmaceuticals (P.R.M.), Boston, Massachusetts, USA
| | - Amanda Overstreet
- Geriatrics and Palliative Care (A.O.), Medical University of South Carolina, Charleston, SC
| | | | - Blair Wendlandt
- Pulmonary and Critical Care Medicine (B.W.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sara S Ardren
- University of Vermont Larner College of Medicine (S.S.A.), Burlington, Vermont, USA
| | - Michael Balassone
- Division of Pulmonary and Critical Care Medicine (M.B.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stephanie Burns
- University of Vermont Larner College of Medicine (S.B.), Burlington, Vermont, USA
| | - Summer Choudhury
- North Carolina Translational and Clinical Sciences Institute (S.C.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sandra Diehl
- University of Vermont Medical Center (S.D.), Burlington, Vermont, USA
| | - Ellen McCown
- Spiritual Care (E.M.), University of Washington Medical Center, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine (E.L.N), University of Washington, Seattle, Washington, USA
| | - Sudiptho R Paul
- Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Colleen Rice
- Pulmonary and Critical Care Medicine (S.R.P., C.R.), University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katherine K Taylor
- Pulmonary, Critical Care, and Sleep Medicine (K.K.T), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ruth A Engelberg
- Pulmonary, Critical Care & Sleep Medicine, Cambia Palliative Care Center of Excellence at UW Medicine (R.A.E.), University of Washington, Seattle, Seattle, Washington, USA
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Hua M, Wunsch H, Aslakson RA. Transformational Leaders Transcend Specialities. J Pain Symptom Manage 2022; 63:e647-e648. [PMID: 35595380 DOI: 10.1016/j.jpainsymman.2022.02.339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 11/25/2022]
Affiliation(s)
- May Hua
- Department of Anesthesiology (M.H., H.W.), Columbia University, New York, USA; Department of Epidemiology (M.H.), Mailman School of Public Health, Columbia University, New York, USA
| | - Hannah Wunsch
- Department of Anesthesiology (M.H., H.W.), Columbia University, New York, USA; Department of Critical Care Medicine (H.W.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine (H.W.), University of Toronto, Toronto, Ontario, Canada
| | - Rebecca A Aslakson
- Department of Anesthesiology, Perioperative & Pain Medicine (R.A.A.), Stanford University, Stanford, California, USA; Division of Primary Care and Population Health (R.A.A.), Department of Medicine, Palliative Care Section, Stanford University, Stanford, California, USA.
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21
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Bailey V, Beke DM, Snaman JM, Alizadeh F, Goldberg S, Smith-Parrish M, Gauvreau K, Blume ED, Moynihan KM. Assessment of an Instrument to Measure Interdisciplinary Staff Perceptions of Quality of Dying and Death in a Pediatric Cardiac Intensive Care Unit. JAMA Netw Open 2022; 5:e2210762. [PMID: 35522280 PMCID: PMC9077481 DOI: 10.1001/jamanetworkopen.2022.10762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/20/2022] [Indexed: 01/21/2023] Open
Abstract
Importance Lack of pediatric end-of-life care quality indicators and challenges ascertaining family perspectives make staff perceptions valuable. Cardiac intensive care unit (CICU) interdisciplinary staff play an integral role supporting children and families at end of life. Objectives To evaluate the Pediatric Intensive Care Unit Quality of Dying and Death (PICU-QODD) instrument and examine differences between disciplines and end-of-life circumstances. Design, Setting, and Participants This cross-sectional survey included staff at a single center involved in pediatric CICU deaths from July 1, 2019, to June 30, 2021. Exposures Staff demographic characteristics, intensity of end-of-life care (mechanical support, open chest, or cardiopulmonary resuscitation [CPR]), mode of death (discontinuation of life-sustaining therapy, treatment limitation, comfort care, CPR, and brain death), and palliative care involvement. Main Outcomes and Measures PICU-QODD instrument standardized score (maximum, 100, with higher scores indicating higher quality); global rating of quality of the moment of death and 7 days prior (Likert 11-point scale, with 0 indicating terrible and 10, ideal) and mode-of-death alignment with family wishes. Results Of 60 patient deaths (31 [52%] female; median [IQR] age, 4.9 months [10 days to 7.5 years]), 33 (55%) received intense care. Of 713 surveys (72% response rate), 246 (35%) were from nurses, 208 (29%) from medical practitioners, and 259 (36%) from allied health professionals. Clinical experience varied (298 [42%] ≤5 years). Median (IQR) PICU-QODD score was 93 (84-97); and quality of the moment of death and 7 days prior scores were 9 (7-10) and 5 (2-7), respectively. Cronbach α ranged from 0.87 (medical staff) to 0.92 (allied health), and PICU-QODD scores significantly correlated with global rating and alignment questions. Mean (SD) PICU-QODD scores were more than 3 points lower for nursing and allied health compared with medical practitioners (nursing staff: 88.3 [10.6]; allied health: 88.9 [9.6]; medical practitioner: 91.9 [7.8]; P < .001) and for less experienced staff (eg, <2 y: 87.7 [8.9]; >15 y: 91, P = .002). Mean PICU-QODD scores were lower for patients with comorbidities, surgical admissions, death following treatment limitation, or death misaligned with family wishes. No difference was observed with palliative care involvement. High-intensity care, compared with low-intensity care, was associated with lower median (IQR) rating of the quality of the 7 days prior to death (4 [2-6] vs 6 [4-8]; P = .001) and of the moment of death (8 [4-10] vs 9 [8-10]; P =.001). Conclusions and Relevance In this cross-sectional survey study of CICU staff, the PICU-QODD showed promise as a reliable and valid clinician measure of quality of dying and death in the CICU. Overall QODD was positively perceived, with lower rated quality of 7 days prior to death and variation by staff and patient characteristics. Our data could guide strategies to meaningfully improve CICU staff well-being and end-of-life experiences for patients and families.
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Affiliation(s)
- Valerie Bailey
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children’s Hospital, Boston, Massachusetts
| | - Dorothy M. Beke
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children’s Hospital, Boston, Massachusetts
| | - Jennifer M. Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Faraz Alizadeh
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah Goldberg
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth D. Blume
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Katie M. Moynihan
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Sydney Medical School, University of Sydney, Sydney, Australia
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22
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Stefanou MI, Sulyok M, Koehnlein M, Scheibe F, Fleischmann R, Hoffmann S, Hotter B, Ziemann U, Meisel A, Mengel AM. Withholding or withdrawing life support in long-term neurointensive care patients: a single-centre, prospective, observational pilot study. JOURNAL OF MEDICAL ETHICS 2022; 48:50-55. [PMID: 32371594 DOI: 10.1136/medethics-2019-106027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/24/2020] [Accepted: 03/03/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Scarce evidence exists regarding end-of-life decision (EOLD) in neurocritically ill patients. We investigated the factors associated with EOLD making, including the group and individual characteristics of involved healthcare professionals, in a multiprofessional neurointensive care unit (NICU) setting. MATERIALS AND METHODS A prospective, observational pilot study was conducted between 2013 and 2014 in a 10-bed NICU. Factors associated with EOLD in long-term neurocritically ill patients were evaluated using an anonymised survey based on a standardised questionnaire. RESULTS 8 (25%) physicians and 24 (75%) nurses participated in the study by providing their 'treatment decisions' for 14 patients at several time points. EOLD was 'made' 44 (31%) times, while maintenance of life support 98 (69%) times. EOLD patterns were not significantly different between professional groups. The individual characteristics of the professionals (age, gender, religion, personal experience with death of family member and NICU experience) had no significant impact on decisions to forgo or maintain life-sustaining therapy. EOLD was patient-specific (intraclass correlation coefficient: 0.861), with the presence of acute life-threatening disease (OR (95% CI): 18.199 (1.721 to 192.405), p=0.038) and low expected patient quality of life (OR (95% CI): 9.276 (1.131 to 76.099), p=0.016) being significant and independent determinants for withholding or withdrawing life-sustaining treatment. CONCLUSIONS Our findings suggest that EOLD in NICU relies mainly on patient prognosis and not on the characteristics of the healthcare professionals.
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Affiliation(s)
- Maria-Ioanna Stefanou
- Department of Neurology and Stroke and Hertie Institute of Clinical Brain Reseach, University Hospital Tübingen, Tübingen, Germany
| | - Mihaly Sulyok
- Department of Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Martin Koehnlein
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Franziska Scheibe
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Robert Fleischmann
- Department of Neurology, Universitätsklinik Greifswald, Greifswald, Germany
| | - Sarah Hoffmann
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke and Hertie Institute of Clinical Brain Reseach, University Hospital Tübingen, Tübingen, Germany
| | - Andreas Meisel
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Annerose Maria Mengel
- Department of Neurology and Stroke and Hertie Institute of Clinical Brain Reseach, University Hospital Tübingen, Tübingen, Germany
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Palliative care interventions in intensive care unit patients. Intensive Care Med 2021; 47:1415-1425. [PMID: 34652465 DOI: 10.1007/s00134-021-06544-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. METHODS We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. RESULTS Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. CONCLUSION Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
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Aslakson RA, Cox CE, Baggs JG, Curtis JR. Palliative and End-of-Life Care: Prioritizing Compassion Within the ICU and Beyond. Crit Care Med 2021; 49:1626-1637. [PMID: 34325446 DOI: 10.1097/ccm.0000000000005208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
- Division of Primary Care and Population Health, Department of Medicine, Palliative Care Section, Stanford University, Stanford, CA
| | - Christopher E Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Judith G Baggs
- School of Nursing, Oregon Health & Science University, Portland, OR
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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Khan S, Digby R, Giordano NA, Hade S, Bucknall TK. A 6-y retrospective cohort study of family satisfaction with critical care and decision-making in an Australian intensive care unit. Aust Crit Care 2021; 35:264-272. [PMID: 34384649 DOI: 10.1016/j.aucc.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 04/13/2021] [Accepted: 05/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Partnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically. OBJECTIVE The objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU). METHODS A retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from "poor" (0) to "excellent" (100). RESULTS In total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients' treatment in the ICU and appreciation for the care, skill, and professionalism of the staff. CONCLUSION Very high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards.
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Affiliation(s)
- Shahrukh Khan
- School of Nursing&Midwifery, Deakin University, Geelong, Australia
| | - Robin Digby
- School of Nursing&Midwifery, Deakin University, Geelong, Australia; Centre for Quality and Patient Safety Research-Alfred Health Partnership, Institute for Health Transformation, Deakin University, Australia; Nursing Services, Alfred Health, Melbourne, Australia
| | - Nicholas A Giordano
- School of Nursing&Midwifery, Deakin University, Geelong, Australia; Nursing Services, Alfred Health, Melbourne, Australia
| | - Sharon Hade
- Nursing Services, Alfred Health, Melbourne, Australia; Intensive Care Unit, Alfred Health, Australia
| | - Tracey K Bucknall
- School of Nursing&Midwifery, Deakin University, Geelong, Australia; Centre for Quality and Patient Safety Research-Alfred Health Partnership, Institute for Health Transformation, Deakin University, Australia; Nursing Services, Alfred Health, Melbourne, Australia.
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26
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Shepherd J, Waller A, Sanson-Fisher R, Clark K. Nurses' perceptions, experiences and involvement in the provision of end-of-life care in acute hospitals: A mapping review of research output, quality and effectiveness. Int J Nurs Stud 2021; 122:104007. [PMID: 34298319 DOI: 10.1016/j.ijnurstu.2021.104007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/10/2021] [Accepted: 06/17/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Safe and high-quality end of life care is not always achieved in acute care hospitals. Nurses represent a key source of information about current practice, and active participants in interventions to improve end of life care in these settings. Examining the volume, type and quality of publications in this field can help to determine whether research is following a natural scientific progression to inform best-practice end of life care. AIMS To systematically review: (i) whether the volume and type of publications (i.e. measurement, descriptive or interventions studies) examining nurses' perceptions of, and involvement in, end-of-life care delivered in acute hospitals changed over time (i.e. since 2000); (ii) the proportion of intervention studies involving nurses that meet Risk of Bias research design criteria; and (iii) the effectiveness of intervention studies that met minimum Risk of Bias criteria. METHODS MEDLINE, Embase, CINAHL, and PsychInfo were searched for data-based papers published in English between Jan 2000 and Dec 2020. Studies were included if they focused on nurses' perceptions of, or role in, the provision of end-of-life care in hospitals. Eligible papers were classified as descriptive, measurement or intervention studies. Intervention studies were assessed against the Risk of Bias methodological criteria for research design, and their effectiveness examined. RESULTS A total of 131 papers met eligibility criteria for inclusion in the review. The number increased by 31% in each time period (p < 0.0001). Most studies were descriptive (n = 70; 53%), 11 were measurement studies (8%), and the remainder were intervention studies (n = 50; 38%). Thirteen intervention studies (26%) met eligibility criteria. Methodological quality of the eligible intervention studies was variable. Randomisation and blinding of outcome assessors were the domains of greatest concern. Results were variable, with larger, system-wide interventions that incorporated the expertise of the multidisciplinary healthcare team showing the most promise. CONCLUSION There is an increasing number of studies examining nurses' perceptions of, and involvement in, end-of-life care delivered in acute hospitals. The difficulties of conducting intervention research in this field mean that many studies are descriptive in nature. Given the importance of intervention research in establishing causal relationships, larger-scale intervention studies are essential to improving the quality of end-of-life care provided to patients dying in hospital.
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Affiliation(s)
- Jan Shepherd
- University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
| | - Amy Waller
- University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Rob Sanson-Fisher
- University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; Hunter Medical Research Institute, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Katherine Clark
- Northern Sydney Local Health District, Royal North Shore Hospital Campus, Reserve Road, St Leonards, NSW 2065, Australia; Northern Clinical School, The University of Sydney, Royal North Shore Hospital Campus, Reserve Road, St Leonards, NSW 2065, Australia
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27
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Ramer SJ, Viola M, Maciejewski PK, Reid MC, Prigerson HG. Suffering and Symptoms At the End of Life in ICU Patients Undergoing Renal Replacement Therapy. Am J Hosp Palliat Care 2021; 38:1509-1515. [PMID: 33827273 DOI: 10.1177/10499091211005707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We know little about the end-of-life suffering and symptoms of intensive care unit (ICU) decedents in general and those who undergo renal replacement therapy (RRT) in particular. OBJECTIVES To examine differences in end-of-life suffering and various symptoms' contribution to suffering between ICU decedents who did not undergo RRT, those who underwent RRT for end-stage kidney disease (ESKD), and those who underwent RRT for acute kidney injury (AKI). METHODS This is a cross-sectional study conducted at a quaternary-level referral hospital September 2015-March 2017. Nurses completed interviews about ICU patients' suffering and symptoms in their final week. We dichotomized overall suffering into elevated and non-elevated and each symptom as contributing or not to a patient's suffering. RESULTS Sixty-four nurses completed interviews on 165 patients. Median patient age was 67 years (interquartile range 57, 78); 41% were female. In a multivariable model, undergoing RRT for AKI (odds ratio [OR] 2.95, 95% confidence interval [CI] 1.34-6.49) was significantly associated with elevated suffering compared to no RRT; undergoing RRT for ESKD was not. Adjusting for length of stay, AKI-RRT patients were more likely than non-RRT patients to have fecal incontinence (OR 2.21, 95% CI 1.00-4.93), painful broken skin (OR 2.41, 95% CI 1.14-5.12), and rashes (OR 3.61, 95% CI 1.35-9.67) contributing to their suffering. CONCLUSIONS Undergoing RRT for AKI was associated with elevated suffering in the last week of life in ICU decedents. Painful broken skin, rashes, and fecal incontinence were more likely to contribute to suffering in AKI-RRT patients than in non-RRT patients. How to reduce suffering associated with AKI-RRT in ICU patients merits further study.
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Affiliation(s)
- Sarah J Ramer
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA
| | - Martin Viola
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Center for Research on End-of-Life Care, Weill Cornell Medicine, NY, USA
| | - Paul K Maciejewski
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Center for Research on End-of-Life Care, Weill Cornell Medicine, NY, USA.,Department of Radiology, Weill Cornell Medicine, NY, USA
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Translational Research Institute on Pain in Later Life, Weill Cornell Medicine, NY, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Center for Research on End-of-Life Care, Weill Cornell Medicine, NY, USA
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28
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Cox CE, Riley IL, Ashana DC, Haines K, Olsen MK, Gu J, Pratt EH, Al-Hegelan M, Harrison RW, Naglee C, Frear A, Yang H, Johnson KS, Docherty SL. Improving racial disparities in unmet palliative care needs among intensive care unit family members with a needs-targeted app intervention: The ICUconnect randomized clinical trial. Contemp Clin Trials 2021; 103:106319. [PMID: 33592310 PMCID: PMC8330133 DOI: 10.1016/j.cct.2021.106319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The technologies used to treat the millions who receive care in intensive care unit (ICUs) each year have steadily advanced. However, the quality of ICU-based communication has remained suboptimal, particularly concerning for Black patients and their family members. Therefore we developed a mobile app intervention for ICU clinicians and family members called ICUconnect that assists with delivering need-based care. OBJECTIVE To describe the methods and early experiences of a clustered randomized clinical trial (RCT) being conducted to compare ICUconnect vs. usual care. METHODS AND ANALYSIS The goal of this two-arm, parallel group clustered RCT is to determine the clinical impact of the ICUconnect intervention in improving outcomes overall and for each racial subgroup on reducing racial disparities in core palliative care outcomes over a 3-month follow up period. ICU attending physicians are randomized to either ICUconnect or usual care, with outcomes obtained from family members of ICU patients. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 3 days post-randomization. Secondary outcomes include goal concordance of care and interpersonal processes of care at 3 days post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use hierarchical linear models to compare outcomes between the ICUconnect and usual care arms within all participants and assess for differential intervention effects in Blacks and Whites by adding a patient-race interaction term. We hypothesize that both compared to usual care as well as among Blacks compared to Whites, ICUconnect will reduce unmet palliative care needs, psychological distress and healthcare resource utilization while improving goal concordance and interpersonal processes of care. In this manuscript, we also describe steps taken to adapt the ICUconnect intervention to the COVID-19 pandemic healthcare setting. ENROLLMENT STATUS A total of 36 (90%) of 40 ICU physicians have been randomized and 83 (52%) of 160 patient-family dyads have been enrolled to date. Enrollment will continue until the end of 2021.
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Affiliation(s)
- Christopher E Cox
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Isaretta L Riley
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Deepshikha C Ashana
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Krista Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, North Carolina, United States of America.
| | - Maren K Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America.
| | - Jessie Gu
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Elias H Pratt
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Mashael Al-Hegelan
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Robert W Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, United States of America.
| | - Colleen Naglee
- Department of Anesthesia, Division of Neurology, Duke University, Durham, NC, United States of America.
| | - Allie Frear
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Hongqiu Yang
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America.
| | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics, Center for the Study of Aging and Human Development, Duke University, Durham, NC, United States of America; Durham Veterans Affairs Geriatrics Research Education and Clinical Center (GRECC), United States of America.
| | - Sharron L Docherty
- School of Nursing, Duke University, Durham, NC, United States of America.
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Quigley DD, McCleskey SG. Improving Care Experiences for Patients and Caregivers at End of Life: A Systematic Review. Am J Hosp Palliat Care 2021; 38:84-93. [PMID: 32551966 PMCID: PMC8526304 DOI: 10.1177/1049909120931468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND End-of-life care is increasing as the US population ages. Approaches to providing high-quality end-of-life care vary across setting, diseases, and populations. Several data collection tools measure patient and/or caregiver care experiences at end of life and can be used for quality improvement. Previous reviews examined palliative care improvements or available measures but none explicitly on improving care experiences. We reviewed literature on improving patient and/or caregiver end-of-life care experiences. DESIGN We searched U.S. English-language peer-reviewed and grey literature after 2000 on adult end-of-life care experiences. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for quantitative studies, Enhancing Transparency in Reporting the Synthesis of Qualitative Research approach for qualitative studies, and Assessment of Multiple Systematic Reviews tool for the literature reviews. SETTING Palliative and hospice care. POPULATION Full-text abstraction of 84 articles, identifying 16 articles. MEASURES Patient and/or caregiver end-of-life care experiences (captured through administrative data or direct report). RESULTS Articles examined palliative care experiences across settings; none studied hospice care experiences. Patients and/or caregivers assessed overall care experiences, clinician-staff interactions, provider communication, respect and trust, timeliness of care, spiritual support, caregiver knowledge of care plans, or bereavement support. Efforts aimed at improving end-of-life care experiences are limited and show mixed results. CONCLUSIONS Literature on improving patient and/or caregiver end-of-life care experiences is emerging and focused on palliative care experiences. Evidence on improving hospice care experiences is lacking. Research on strategies for improving end-of-life care experiences should go beyond overall care experiences to include specific aspects of palliative and hospice care experiences.
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Affiliation(s)
| | - Sara G McCleskey
- 8783UCLA Fielding School of Public Health, 650 Charles E. Young Dr. South, Los Angeles, CA, USA
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Forster GM, Bihari S, Tiruvoipati R, Bailey M, Pilcher D. The Association between Discharge Delay from Intensive Care and Patient Outcomes. Am J Respir Crit Care Med 2020; 202:1399-1406. [PMID: 32649212 DOI: 10.1164/rccm.201912-2418oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 07/10/2020] [Indexed: 02/05/2023] Open
Abstract
Rationale: ICU discharge delay occurs when a patient is considered ready to be discharged but remains in the ICU. The effect of discharge delay on patient outcomes is uncertain.Objectives: To investigate the association between discharge delay and patient outcomes including hospital mortality, readmission to ICU, and length of hospital stay after ICU discharge.Methods: Data were accessed from the Australian and New Zealand Intensive Care Society Adult Patient Database between 2011 and 2019. Descriptive analyses and hierarchical logistic and Cox proportional hazards regression were used to examine association between discharge delay and adjusted outcomes. Patients were stratified and analyzed by categories of mortality risk at ICU admission.Measurements and Main Results: The study included 1,014,540 patients from 190 ICUs: 756,131 (75%) were discharged within 6 hours of being deemed ready, with 137,042 (13%) discharged in the next 6 hours; 17,656 (2%) were delayed 48-72 hours; 31,389 (3.1%) died in hospital; and 45,899 (4.5%) patients were readmitted to ICU. Risk-adjusted mortality declined with increasing discharge delay and was lowest at 48-72 hours (adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.94). The effect was seen in patients with predicted risk of death on admission to ICU of greater than 5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.70-0.84). There was a progressive reduction in adjusted odds of readmission with increasing discharge delay.Conclusions: Increasing discharge delay in ICUs is associated with reduced likelihood of mortality and ICU readmission in high-risk patients. Consideration should be given to delay the discharge of patients with high risk of death on ICU admission.
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Affiliation(s)
- Gareth Mitchell Forster
- Department of Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Shailesh Bihari
- Department of Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences and
| | - Michael Bailey
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; and
| | - David Pilcher
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; and
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria, Australia
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Lee JD, Jennerich AL, Engelberg RA, Downey L, Curtis JR, Khandelwal N. Type of Intensive Care Unit Matters: Variations in Palliative Care for Critically Ill Patients with Chronic, Life-Limiting Illness. J Palliat Med 2020; 24:857-864. [PMID: 33156728 DOI: 10.1089/jpm.2020.0412] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: It is not clear whether use of specialty palliative care consults and "comfort measures only" (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p < 0.001) as well as presence of CMO order set at time of death (p < 0.001). Compared with medical ICUs, odds of palliative care consultation were highest in the cardiothoracic ICU and trauma ICU. Odds of CMO order set in place at time of death were highest in the neurology/neurosurgical ICU. Conclusion: Utilization of specialty palliative care consultations and CMO order sets varies across types of ICUs. Examining this variability within institutions may provide an opportunity to improve end-of-life care for patients with chronic, life-limiting illnesses who die in the ICU.
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Affiliation(s)
- Joshua D Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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Cox CE, Olsen MK, Casarett D, Haines K, Al-Hegelan M, Bartz RR, Katz JN, Naglee C, Ashana D, Gilstrap D, Gu J, Parish A, Frear A, Krishnamaneni D, Corcoran A, Docherty SL. Operationalizing needs-focused palliative care for older adults in intensive care units: Design of and rationale for the PCplanner randomized clinical trial. Contemp Clin Trials 2020; 98:106163. [PMID: 33007442 DOI: 10.1016/j.cct.2020.106163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The number of older adults who receive life support in an intensive care unit (ICU), now 2 million per year, is increasing while survival remains unchanged. Because the quality of ICU-based palliative care is highly variable, we developed a mobile app intervention that integrates into the electronic health records (EHR) system called PCplanner (Palliative Care planner) with the goal of improving collaborative primary and specialist palliative care delivery in ICU settings. OBJECTIVE To describe the methods of a randomized clinical trial (RCT) being conducted to compare PCplanner vs. usual care. METHODS AND ANALYSIS The goal of this two-arm, parallel group mixed methods RCT is to determine the clinical impact of the PCplanner intervention on outcomes of interest to patients, family members, clinicians, and policymakers over a 3-month follow up period. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 1 week post-randomization. Secondary outcomes include goal concordance of care, patient-centeredness of care, and quality of communication at 1 week post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use general linear models for repeated measures to compare outcomes across the main effects and interactions of the factors. We hypothesize that compared to usual care, PCplanner will have a greater impact on the quality of ICU-based palliative care delivery across domains of core palliative care needs, psychological distress, patient-centeredness, and healthcare resource utilization.
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Affiliation(s)
- Christopher E Cox
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Maren K Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America.
| | - David Casarett
- Department of Medicine, Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, United States of America.
| | - Krista Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, North, Carolina;, United States of America.
| | - Mashael Al-Hegelan
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Raquel R Bartz
- Department of Anesthesia, Division of Critical Care Medicine, Duke University, Durham, NC, United States of America.
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, United States of America.
| | - Colleen Naglee
- Department of Anesthesia, Division of Neurology, Duke University, Durham, NC, United States of America
| | - Deepshikha Ashana
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Daniel Gilstrap
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Jessie Gu
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America.
| | - Allie Frear
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Deepthi Krishnamaneni
- Duke Health Technology Solutions, Duke University, Durham, NC, United States of America.
| | - Andrew Corcoran
- Office of Academic Solutions and Information Systems, Duke University, Durham, NC, United States of America.
| | - Sharron L Docherty
- School of Nursing, Duke University, Durham, NC, United States of America.
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Boissier F, Seegers V, Seguin A, Legriel S, Cariou A, Jaber S, Lefrant JY, Rimmelé T, Renault A, Vinatier I, Mathonnet A, Reuter D, Guisset O, Cracco C, Durand-Gasselin J, Éon B, Thirion M, Rigaud JP, Philippon-Jouve B, Argaud L, Chouquer R, Papazian L, Dedrie C, Georges H, Lebas E, Rolin N, Bollaert PE, Lecuyer L, Viquesnel G, Leone M, Chalumeau-Lemoine L, Garrouste-Orgeas M, Azoulay E, Kentish-Barnes N. Assessing physicians' and nurses' experience of dying and death in the ICU: development of the CAESAR-P and the CAESAR-N instruments. Crit Care 2020; 24:521. [PMID: 32843097 PMCID: PMC7448438 DOI: 10.1186/s13054-020-03191-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/20/2020] [Indexed: 11/27/2022] Open
Abstract
Background As an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting. Most of these studies are centered on the patient’s and/or the relatives’ experience. Our study aimed to develop an instrument designed to assess the experience of physicians and nurses of patients who died in the ICU, using a mixed methodology and validated in a prospective multicenter study. Methods Physicians and nurses of patients who died in 41 ICUs completed the job strain and the CAESAR questionnaire within 24 h after the death. The psychometric validation was conducted using two datasets: a learning and a reliability cohort. Results Among the 475 patients included in the main cohort, 398 nurse and 417 physician scores were analyzed. The global score was high for both nurses [62/75 (59; 66)] and physicians [64/75 (61; 68)]. Factors associated with higher CAESAR-Nurse scores were absence of conflict with physicians, pain control handled with physicians, death disclosed to the family at the bedside, and invasive care not performed. As assessed by the job strain instrument, low decision control was associated with lower CAESAR score (61 (58; 65) versus 63 (60; 67), p = 0.002). Factors associated with higher CAESAR-Physician scores were room dedicated to family information, information delivered together by nurse and physician, families systematically informed of the EOL decision, involvement of the nurse during implementation of the EOL decision, and open visitation. They were also higher when a decision to withdraw or withhold treatment was made, no cardiopulmonary resuscitation was performed, and the death was disclosed to the family at the bedside. Conclusion We described and validated a new instrument for assessing the experience of physicians and nurses involved in EOL in the ICU. This study shows important areas for improving practices.
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Affiliation(s)
- Florence Boissier
- Medical Intensive Care, University Hospital of Poitiers, Poitiers, France.,INSERM CIC 1402 (ALIVE group), Poitiers University, Poitiers, France
| | - Valérie Seegers
- Data Management Research Department DRCI, Angers Hospital and SFR ICAT, University of Angers, Angers, France
| | - Amélie Seguin
- Medical Intensive Care, Caen University Hospital, Caen, France
| | | | - Alain Cariou
- Medical Intensive Care, Assistance Publique Hôpitaux de Paris, Cochin University Hospital, Paris, France.,Paris Descartes University, Paris, France
| | - Samir Jaber
- Saint Eloi Hospital, Centre Hospitalier Universitaire Montpellier, Anesthesia and Critical Care Department B, Montpellier, France.,PhyMedExp, University of Montpellier, Montpellier, France.,INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Jean-Yves Lefrant
- Anesthesia and Intensive Care, Carémeau University Hospital, Nîmes, France.,Nîmes University, Nîmes, France
| | - Thomas Rimmelé
- Anaesthesia and Intensive Care Medicine, Hospices Civils de Lyon, Edouard Herriot University Hospital, Lyon, France.,University Claude Bernard Lyon 1, Lyon, France
| | - Anne Renault
- Medical Intensive Care, Cavale Blanche University Hospital, Brest, France
| | - Isabelle Vinatier
- Medical Intensive Care, Les Oudairies Hospital, La Roche Sur Yon, France
| | | | - Danielle Reuter
- Medical Intensive Care, Assistance Publique Hôpitaux de Paris, Saint Louis University Hospital, Paris, France
| | - Olivier Guisset
- Medical Intensive Care, Saint André University Hospital, Bordeaux, France
| | | | | | - Béatrice Éon
- Anaesthesia and Intensive Care, La Timone University Hospital, Marseille, France
| | - Marina Thirion
- Medical Intensive Care, Victor Dupouy Hospital, Argenteuil, France
| | | | | | - Laurent Argaud
- Medical Intensive Care, Hospices Civils de Lyon, Edouard Herriot University Hospital, Lyon, France.,Lyon Est University, Lyon, France
| | | | - Laurent Papazian
- Medical Intensive Care, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France.,Aix-Marseille University, Marseille, France
| | | | | | - Eddy Lebas
- Intensive Care, Bretagne Atlantique Hospital, Vannes, France
| | - Nathalie Rolin
- Medical Intensive Care, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Pierre-Edouard Bollaert
- Medical Intensive Care, Nancy University Hospital, Nancy, France.,Lorraine University, Nancy, France
| | - Lucien Lecuyer
- Medical Intensive Care, Sud Francilien Hospital, Evry, France
| | | | - Marc Leone
- Aix-Marseille University, Marseille, France.,Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | | | - Elie Azoulay
- Medical Intensive Care, Assistance Publique Hôpitaux de Paris, Saint Louis University Hospital, Paris, France.,Biostatistics and Clinical Epidemiology Research Team, U1153, INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Nancy Kentish-Barnes
- Biostatistics and Clinical Epidemiology Research Team, U1153, INSERM, Paris Diderot Sorbonne University, Paris, France. .,Famiréa Research Group, Assistance Publique Hôpitaux de Paris, Saint Louis University Hospital, Paris, France. .,Medical ICU, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France.
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Laserna A, Durán-Crane A, López-Olivo MA, Cuenca JA, Fowler C, Díaz DP, Cardenas YR, Urso C, O'Connell K, Fowler C, Price KJ, Sprung CL, Nates JL. Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1671-1682. [PMID: 32833041 PMCID: PMC7444163 DOI: 10.1007/s00134-020-06139-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/26/2020] [Indexed: 01/08/2023]
Abstract
Purpose To review and summarize the most frequent medications and dosages used during withholding and withdrawal of life-prolonging measures in critically ill patients in the intensive care unit. Methods We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Virtual Health Library from inception through March 2019. We considered any study evaluating pharmaceutical interventions for pain management during the withholding or withdrawing of life support in adult critically ill patients at the end-of-life. Two independent investigators performed the screening and data extraction. We pooled data on utilization rate of analgesic and sedative drugs and summarized the dosing between the moment prior to withholding or withdrawal of life support and the moment before death. Results Thirteen studies met inclusion criteria. Studies were conducted in the United States (38%), Canada (31%), and the Netherlands (31%). Eleven studies were single-cohort and twelve had a Newcastle–Ottawa Scale score of less than 7. The mean age of the patients ranged from 59 to 71 years, 59–100% were mechanically ventilated, and 47–100% of the patients underwent life support withdrawal. The most commonly used opioid and sedative were morphine [utilization rate 60% (95% CI 48–71%)] and midazolam [utilization rate 28% (95% CI 23–32%)], respectively. Doses increased during the end-of-life process (pooled mean increase in the dose of morphine: 2.6 mg/h, 95% CI 1.2–4). Conclusions Pain control is centered on opioids and adjunctive benzodiazepines, with dosages exceeding those recommended by guidelines. Despite consistency among guidelines, there is significant heterogeneity among practices in end-of-life care. Electronic supplementary material The online version of this article (10.1007/s00134-020-06139-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andres Laserna
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | | | - María A López-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John A Cuenca
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cosmo Fowler
- Department of Medicine, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - Diana Paola Díaz
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Yenny R Cardenas
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Catherine Urso
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keara O'Connell
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clara Fowler
- Research Services and Assessment, Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristen J Price
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joseph L Nates
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Ke YX, Hu SH, Takemura N, Lin CC. Perceived quality of palliative care in intensive care units among doctors and nurses in Taiwan. Int J Qual Health Care 2019; 31:741-747. [PMID: 30855672 DOI: 10.1093/intqhc/mzz003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/21/2018] [Accepted: 01/28/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To compare perceptions of various aspects of palliative care for doctors and nurses; and examine factors contributing to perceived quality palliative care in intensive care units (ICUs). DESIGN A cross-sectional survey study conducted from November to December 2013. Questionnaires used were Knowledge, Attitudinal and Experiential Survey on Advance Directives (ADs), Clarke's Quality of Palliative Care and Nurses' Participation in the end-of-life (EOL) decision-making process. SETTING Seven adult medical and surgical ICUs at a medical center in Northern Taiwan. PARTICIPANTS In total, 172 doctors and nurses who worked in adult ICU for more than 3 months. MAIN OUTCOME MEASURES Nurses' and doctors' perception of quality palliative care. RESULTS Nurses provided better care than doctors in symptom management, comfort care and spiritual care; their participation in EOL decision-making was the sole modifiable contributor to perceived quality palliative care in ICUs (β = 0.24, P < 0.01). Both doctors and nurses had positive attitudes towards ADs (mean = 4.05/10; standard deviation [SD] = 1.38) while their knowledge of ADs was poor (mean = 29.72/40; SD = 3.00). More than half of nurses currently participated in EOL decision-making and over 80% of doctors and nurses agreed both parties should engage in EOL decision-making process. Majority of doctors (83.9%) reckoned nurses agreed with their EOL decisions while a significant percentage (40%) of nurses were uncertain about doctors' decisions (χ2 = 12.07, P < 0.01). CONCLUSIONS Nurses' participation in EOL decision-making and strengthening spiritual care are imperative to rendering quality palliative care in ICUs. Potential disagreements arose during EOL decision-making between doctors and nurses; and insufficient knowledge of ADs should be addressed.
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Affiliation(s)
- Ying-Xuan Ke
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.,Intensive Care Unit, Department of Nursing, Tri-Service General Hospital, Taipei, Taiwan
| | - Sophia H Hu
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Naomi Takemura
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Chia-Chin Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.,School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong.,Alice Ho Miu Ling Nethersole Charity Foundation Professor in Nursing, Hong Kong
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Reignier J, Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, Potel G, Dray S, Hugenschmitt D, Laurent A, Ricard-Hibon A, Vanderlinden T, Chouihed T. Withholding and withdrawing life-support in adults in emergency care: joint position paper from the French Intensive Care Society and French Society of Emergency Medicine. Ann Intensive Care 2019; 9:105. [PMID: 31549266 PMCID: PMC6757069 DOI: 10.1186/s13613-019-0579-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
For many patients, notably among elderly nursing home residents, no plans about end-of-life decisions and palliative care are made. Consequently, when these patients experience life-threatening events, decisions to withhold or withdraw life-support raise major challenges for emergency healthcare professionals. Emergency department premises are not designed for providing the psychological and technical components of end-of-life care. The continuous inflow of large numbers of patients leaves little time for detailed assessments, and emergency department staff often lack training in end-of-life issues. For prehospital medical teams (in France, the physician-staffed mobile emergency and intensive care units known as SMURs), implementing treatment withholding and withdrawal decisions that may have been made before the acute event is not the main focus. The challenge lies in circumventing the apparent contradiction between the need to make immediate decisions and the requirement to set up a complex treatment project that may lead to treatment withholding and/or withdrawal. Laws and recommendations are of little assistance for making treatment withholding and withdrawal decisions in the emergency setting. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and French Society of Emergency Medicine (Société Française de Médecine d'Urgence, SFMU) tasked a panel of emergency physicians and intensivists with developing a document to serve both as a position paper on life-support withholding and withdrawal in the emergency setting and as a guide for professionals providing emergency care. The task force based its work on the available legislation and recommendations and on a review of published studies.
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Affiliation(s)
- Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Hotel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France. .,Université de Nantes, Nantes, France.
| | - Anne-Laure Feral-Pierssens
- Assistance Publique Hôpitaux de Paris, Service des Urgences, Hôpital Européen Georges Pompidou Paris, Paris, France
| | - Thierry Boulain
- Service de Réanimation Médicale Polyvalente, Centre Hospitalier Régional Orléans, Orléans, France
| | - Françoise Carpentier
- Pôle Urgences Médecine Aigüe, Hôpital Universitaire des Alpes, Grenoble, France.,Université de Grenoble, Grenoble, France
| | - Pierrick Le Borgne
- Service d'Accueil des Urgences, Hôpital de Hautepierre, CHRU Strasbourg, Strasbourg, France
| | | | - Gilles Potel
- Université de Nantes, Nantes, France.,Service des Urgences, CHU de Nantes, Nantes, France
| | - Sandrine Dray
- Service de Réanimation Médicale, Hôpital Nord, CHU de Marseille, Marseille, France
| | | | - Alexandra Laurent
- Laboratoire Psy-DREPI, Université de Bourgogne Franche-Comté, EA7458, Dijon, France
| | - Agnès Ricard-Hibon
- SAMU-SMUR 95- Service des Urgences, Centre Hospitalier René Dubos, Pontoise, France
| | - Thierry Vanderlinden
- Service de Réanimation Polyvalente, Groupe Hospitalier Institut Catholique de Lille/Faculté Libre de Médecine/Université Lille Nord de France, Lille, France
| | - Tahar Chouihed
- SAMU-SMUR-Service d'Urgences, Hôpital Central, CHRU Nancy, Vandoeuvre les Nancy, France.,INSERM U1116, Université de Lorraine, Vandoeuvre les Nancy, France
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Kyeremanteng K, Beckerleg W, Wan C, Vanderspank-Wright B, D'Egidio G, Sutherland S, Hartwick M, Gratton V, Sarti AJ. Survey on Barriers to Critical Care and Palliative Care Integration. Am J Hosp Palliat Care 2019; 37:108-116. [PMID: 31416329 DOI: 10.1177/1049909119867658] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE It has been shown that integrating palliative care (PC) in intensive care unit (ICU) improves end-of-life care (EOLC), but very few Canadian hospitals have adopted this practice. Our study aims to evaluate the perceived quality of EOLC at participating institutions and explore barriers toward ICU-PC integration. MATERIALS AND METHODS A self-administered questionnaire was developed by a multidisciplinary team. Survey items were extracted from published quality indicators in EOLC and barriers to ICU-PC integration. The study took place at 2 academic institutions. Participants consisted of physicians and nurses, ICU administrators, and allied health workers. RESULTS An overall response of 45% was achieved. Of total, 85% of the respondents were ICU nurses. The following main themes were identified: (1) There is a poor presence of PC in the ICU and 78% of respondents felt that increasing ICU-PC integration will improve quality of EOLC; (2) the main barrier to integration was unrealistic patient and/or family expectations; and (3) criteria-triggered consultation to PC was the most feasible way to achieve integration. CONCLUSION Our findings indicate that the majority of respondents perceive that the presence of PC in ICU will improve EOLC. Future quality improvement initiatives can focus on developing a set of criteria for triggering PC consults.
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Affiliation(s)
- Kwadwo Kyeremanteng
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.,Institut du Savoir Montfort, Ottawa, Ontario, Canada.,The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada
| | | | - Cynthia Wan
- Faculty of Social Sciences, School of Psychology, University of Ottawa, Ontario, Canada
| | | | - Gianni D'Egidio
- The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada.,Division of Critical Care Medicine, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | | | | | - Aimee J Sarti
- The Ottawa Hospital-General Campus, Ottawa, Ontario, Canada
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Mah K, Powell RA, Malfitano C, Gikaara N, Chalklin L, Hales S, Rydall A, Zimmermann C, Mwangi-Powell FN, Rodin G. Evaluation of the Quality of Dying and Death Questionnaire in Kenya. J Glob Oncol 2019; 5:1-16. [PMID: 31162985 PMCID: PMC6613712 DOI: 10.1200/jgo.18.00257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 12/01/2022] Open
Abstract
PURPOSE A culturally appropriate, patient-centered measure of the quality of dying and death is needed to advance palliative care in Africa. We therefore evaluated the Quality of Dying and Death Questionnaire (QODD) in a Kenyan hospice sample and compared item ratings with those from a Canadian advanced-cancer sample. METHODS Caregivers of deceased patients from three Kenyan hospices completed the QODD. Their QODD item ratings were compared with those from 602 caregivers of deceased patients with advanced cancer in Ontario, Canada, and were correlated with overall quality of dying and death ratings. RESULTS Compared with the Ontario sample, outcomes in the Kenyan sample (N = 127; mean age, 48.21 years; standard deviation, 13.57 years) were worse on 14 QODD concerns and on overall quality of dying and death (P values ≤ .001) but better on five concerns, including interpersonal and religious/spiritual concerns (P values ≤ .005). Overall quality of dying was associated with better patient experiences with Symptoms and Personal Care, interpersonal, and religious/spiritual concerns (P values < .01). Preparation for Death, Treatment Preferences, and Moment of Death items showed the most omitted ratings. CONCLUSION The quality of dying and death in Kenya is worse than in a setting with greater PC access, except in interpersonal and religious/spiritual domains. Cultural differences in perceptions of a good death and the acceptability of death-related discussions may affect ratings on the QODD. This measure requires revision and validation for use in African settings, but evidence from such patient-centered assessment tools can advance palliative care in this region.
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Affiliation(s)
- Kenneth Mah
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Carmine Malfitano
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- University of Ferrara, Ferrara, Italy
| | | | - Lesley Chalklin
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care, Toronto, Ontario, Canada
| | - Sarah Hales
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Anne Rydall
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Gary Rodin
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review. J Crit Care 2019; 51:39-45. [DOI: 10.1016/j.jcrc.2019.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 11/22/2022]
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Mah K, Hales S, Weerakkody I, Liu L, Fernandes S, Rydall A, Vehling S, Zimmermann C, Rodin G. Measuring the quality of dying and death in advanced cancer: Item characteristics and factor structure of the Quality of Dying and Death Questionnaire. Palliat Med 2019; 33:369-380. [PMID: 30561236 DOI: 10.1177/0269216318819607] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Ensuring a good death in individuals with advanced disease is a fundamental goal of palliative care. However, the lack of a validated patient-centered measure of quality of dying and death in advanced cancer has limited quality assessments of palliative-care interventions and outcomes. Aim: To examine item characteristics and the factor structure of the Quality of Dying and Death Questionnaire in advanced cancer. Design: Cross-sectional study with pooled samples. Setting/participants: Caregivers of deceased advanced-cancer patients ( N = 602; mean ages = 56.39–62.23 years), pooled from three studies involving urban hospitals, a hospice, and a community care access center in Ontario, Canada, completed the Quality of Dying and Death Questionnaire 8–10 months after patient death. Results: Psychosocial and practical item ratings demonstrated negative skewness, suggesting positive perceptions; ratings of symptoms and function were poorer. Of four models evaluated using confirmatory factor analyses, a 20-item, four-factor model, derived through exploratory factor analysis and comprising Symptoms and Functioning, Preparation for Death, Spiritual Activities, and Acceptance of Dying, demonstrated good fit and internally consistent factors (Cronbach’s α = 0.70–0.83). Multiple regression analyses indicated that quality of dying was most strongly associated with Symptoms and Functioning and that quality of death was most strongly associated with Preparation for Death ( p < 0.001). Conclusion: A new four-factor model best characterized quality of dying and death in advanced cancer as measured by the Quality of Dying and Death Questionnaire. Future research should examine the value of adding a connectedness factor and evaluate the sensitivity of the scale to detect intervention effects across factors.
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Affiliation(s)
- Kenneth Mah
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sarah Hales
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Isuri Weerakkody
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Lucy Liu
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Samantha Fernandes
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Anne Rydall
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sigrun Vehling
- 3 Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,4 Palliative Care Unit, Department of Oncology, Hematology and Bone Marrow Transplantation with section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Camilla Zimmermann
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,5 Department of Medicine, University of Toronto, Toronto, ON, Canada.,6 Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,7 Global Institute of Psychosocial, Palliative and End-of-Life Care, University of Toronto and Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Gary Rodin
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,6 Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,7 Global Institute of Psychosocial, Palliative and End-of-Life Care, University of Toronto and Princess Margaret Cancer Centre, Toronto, ON, Canada
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Gutierrez C, Hsu W, Ouyang Q, Yao H, Pollack S, Pan CX. Palliative Care Intervention in the Intensive Care Unit: Comparing Outcomes among Seriously Ill Asian Patients and those of Other Ethnicities. J Palliat Care 2018. [DOI: 10.1177/082585971403000304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The literature describing the attitude of Asians toward palliative care in the intensive care unit (ICU) is scarce. Aim: The purpose of this study was to compare outcomes of Asians and people of other ethnicities after palliative care intervention in the ICU. Methods: A retrospective chart review was conducted of all ICU patients evaluated by palliative care; the outcomes measured were incidence of life-sustaining treatments, institution of advance care directives, and preferences for end-of-life care. Results: The palliative care team evaluated 119 patients (46.2 percent Caucasian, 27.2 percent Asian, and 26.1 percent other ethnicities). There were no differences in demographics or clinical variables. Thirty-six percent of the Asians, 49 percent of the Caucasians, and 28.6 percent of the patients of other ethnicities (p=0.19) had healthcare proxies. The palliative care team increased advance care directives by more than 40 percent in all groups (p<0.001). There were no differences in the use of life-sustaining treatments or preferences for comfort measures among ethnic groups. Conclusion: Asians are as likely as people of other ethnicities to decide on advance care directives, life-sustaining treatments, and comfort measures after palliative care evaluation in the ICU. Contexte: Il existe très peu de publications décrivant l'attitude des asiatiques envers l'intervention des spécialistes en soins palliatifs dans le service de soins intensifs. But: Cette étude avait pour but de comparer les résultats obtenus chez les asiatiques et d'autres groupes ethniques après l'intervention de ces spécialistes auprès des patients et de leur famille dans le service de soins intensifs. Méthode: On a fait l'analyse rétrospective des dossiers de tous les patients ayant été rencontrés par l'équipe de soins palliatifs; les résultats de l'analyse portaient sur la fréquence des traitements de prolongation de vie, les directives de fin de vie, et les préférences des patients en ce qui avait trait aux soins de fin de vie. Résultats: L'équipe de soins palliatifs a évalué les dossiers de 119 patients (46,2 pourcent d'origine caucasienne, 27,2 pourcent d'origine asiatique, et 26,1 pourcent de diverses origines). Trente-six pourcent des asiatiques, 49 pourcent des caucasiens, et 28,6 pourcent des autres ethniques (p=19) avaient déjà choisi leur mandataire légal. L'équipe de soins palliatifs a augmenté le recours aux directives de fin de vie par plus de 40 pourcent dans tous les groupes (p=<0,001). Il n'y avait aucune différence entre ces groupes quant au recours aux traitements de fin de vie et aux mesures de confort du patient. Conclusion: Suite à une rencontre avec l'équipe de soins palliatifs, les asiatiques, tout comme les autres groupes ethniques, sont tout autant susceptibles de décider de leurs traitements de fin de vie et de recourir aux mesures de confort et aux directives préalables.
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Affiliation(s)
- Cristina Gutierrez
- Critical Care Medicine Service, Department of Medicine, New York Hospital Queens, 56–45 Main Street, Room WA-100, Flushing, New York 11355, USA
| | - William Hsu
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Qin Ouyang
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Haijun Yao
- Department of Pathology and Laboratory, Lutheran Medical Center, Brooklyn, New York, USA
| | - Simcha Pollack
- Computer Information Systems and Decision Sciences, Tobin College of Business, St. John's University, Jamaica, New York, USA
| | - Cynthia X. Pan
- Geriatrics and Palliative Care Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
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Lesieur O, Herbland A, Cabasson S, Hoppe MA, Guillaume F, Leloup M. Changes in limitations of life-sustaining treatments over time in a French intensive care unit: A prospective observational study. J Crit Care 2018; 47:21-29. [DOI: 10.1016/j.jcrc.2018.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 01/31/2023]
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Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, Potel G, Dray S, Hugenschmitt D, Laurent A, Ricard-Hibon A, Vanderlinden T, Chouihed T, Reignier J. Limitations et arrêts des traitements de suppléance vitale chez l’adulte dans le contexte de l’urgence. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, Potel G, Dray S, Hugenschmitt D, Laurent A, Ricard-Hibon A, Vanderlinden T, Chouihed T, Reignier J. Limitations et arrêts des traitements de suppléance vitale chez l’adulte dans le contexte de l’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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46
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Le François L, Tapp D. Improving end-of-life care in an intensive care unit: a collaborative quality improvement project. Int J Palliat Nurs 2018; 24:378-386. [PMID: 30141710 DOI: 10.12968/ijpn.2018.24.8.378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The shift from curative to palliative care is one of the most challenging situations in intensive care units. AIMS The purpose of this collaborative project was to develop and implement a pilot intervention aimed at improving end-of-life care for patients in an open intensive care unit in Quebec City, Canada. METHODS Individual and group interviews were first conducted to identify strengths and needs for improvement in care. After the main needs for improvement were determined, interventions were implemented in a concerted manner. These included training in end-of-life care as well as the adaptation of tools to promote communication with the patient and his or her family, or to facilitate interdisciplinary work. RESULTS Preliminary results obtained through individual interviews indicate participant satisfaction with the project, but additional data need to be gathered to evaluate improvements in practice. CONCLUSIONS Other collaborative quality improvement projects need to be implemented to improve end-of-life practices in intensive care units.
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Affiliation(s)
- Lisa Le François
- Masters Student Faculty of Nursing, Laval University, Quebec City, Quebec, Canada
| | - Diane Tapp
- Researcher, Quebec Heart and Lung Institute Research Center; Associate Professor, Faculty of Nursing, Laval University, Quebec City, Quebec, Canada
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Long AC, Kross EK, Curtis JR. Family-centered outcomes during and after critical illness: current outcomes and opportunities for future investigation. Curr Opin Crit Care 2018; 22:613-620. [PMID: 27685849 DOI: 10.1097/mcc.0000000000000360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Family-centered outcomes during and after critical illness assess issues that are most important to family members. An understanding of family-centered outcomes is necessary to support the provision of family-centered care and to foster development of interventions to improve care and communication in the ICU. RECENT FINDINGS Current family-centered outcomes in critical care include satisfaction with care, including end-of-life care, symptoms of psychological distress, and health-related quality of life. Novel measures include assessments of decisional conflict, decision regret, therapeutic alliance, and caregiver burden, as well as positive adaptations and resilience. SUMMARY Critical illness places a significant burden on family members. A wide variety of family-centered outcomes are available to guide improvements in care and communication. Future research should focus on developing sensitive and responsive measures that capture key elements of the family member experience during and after critical illness.
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Affiliation(s)
- Ann C Long
- aDivision of Pulmonary and Critical Care Medicine, Harborview Medical Center bCambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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48
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Gutiérrez Sánchez D, Pérez Cruzado D, Cuesta-Vargas AI. The quality of dying and death measurement instruments: A systematic psychometric review. J Adv Nurs 2018; 74:1803-1818. [PMID: 29672911 DOI: 10.1111/jan.13687] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 11/29/2022]
Abstract
AIMS To identify instruments that could assess the quality of dying and death and their psychometric properties. To assess the methodological quality of studies on measurement properties. BACKGROUND A high quality of death is regarded as a goal at the end of life and, therefore, an assessment of the end of life experience is essential. Many instruments have been developed to evaluate the quality of dying and death. The selection of the most appropriate measure to be used in clinical and research settings is crucial. DESIGN Psychometric systematic review. DATA SOURCES We systematically searched ProQuest Medline, SciELO and ProQuest PsycINFO from 1970 - May 2016. REVIEW METHODS Identification and evaluation of instruments that assessed quality of dying and death. Papers were evaluated by two independent reviewers according to the COSMIN checklist with a 4-point scale. RESULTS A total of 19 studies were included in this review. Seven instruments were found that were specifically designed for assessing quality of dying and death. A retrospective carer proxy report to evaluate this construct was used in most of the papers. The methodological quality of the studies was fair for most of the psychometric characteristics analyzed. CONCLUSION Many instruments have been developed to assess the quality of dying and death. The Quality of Dying and Death Questionnaire is the best available measure of the quality of dying and death. It is the only questionnaire identified in this review where all psychometric properties according to the COSMIN checklist have been evaluated.
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Affiliation(s)
- Daniel Gutiérrez Sánchez
- Fundación Cudeca. Av. del Cosmos, s/n, 29631 Arroyo de la Miel, Málaga, Spain
- Departamento de Fisioterapia, Instituto de Investigación Biomédico de Málaga (IBIMA), Universidad de Málaga, C/ Arquitecto Francisco Peñalosa, Ampliación Campus Teatinos, 29071 Malaga, Spain
| | - David Pérez Cruzado
- Departamento de Fisioterapia, Instituto de Investigación Biomédico de Málaga (IBIMA), Universidad de Málaga, C/ Arquitecto Francisco Peñalosa, Ampliación Campus Teatinos, 29071 Malaga, Spain
| | - Antonio I Cuesta-Vargas
- Departamento de Fisioterapia, Instituto de Investigación Biomédico de Málaga (IBIMA), Universidad de Málaga, C/ Arquitecto Francisco Peñalosa, Ampliación Campus Teatinos, 29071 Malaga, Spain
- School of Clinical Sciences, Faculty of Health at the Queensland University of Technology, Queensland, Australia
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Aslakson RA, Reinke LF, Cox C, Kross EK, Benzo RP, Curtis JR. Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes. J Palliat Med 2018; 20:329-343. [PMID: 28379812 DOI: 10.1089/jpm.2016.0567] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members. OBJECTIVE The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps. METHODS We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future. RESULTS We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions. CONCLUSIONS The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.
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Affiliation(s)
- Rebecca A Aslakson
- 1 Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine , Baltimore, Maryland.,2 Department of Oncology and Palliative Care Program in the Kimmel Comprehensive Cancer Center at Johns Hopkins , Baltimore, Maryland.,3 Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Lynn F Reinke
- 4 Department of Veterans Affairs, Puget Sound Healthcare System , Seattle, Washington.,5 Department of Biobehavioral Nursing and Health Systems, University of Washington , Seattle, Washington
| | - Christopher Cox
- 6 Department of Medicine, Duke University , Durham, North Carolina
| | - Erin K Kross
- 7 Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington.,8 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Roberto P Benzo
- 9 Mindful Breathing Laboratory, Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota
| | - J Randall Curtis
- 7 Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington.,8 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
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Ang K, Hepgul N, Gao W, Higginson IJ. Strategies used in improving and assessing the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions: A systematic review. Palliat Med 2018; 32:500-516. [PMID: 28691583 DOI: 10.1177/0269216317717369] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Implementation fidelity is critical in evaluating effectiveness of interventions. AIM Identifying and summarising strategies to improve and assess the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions. DESIGN Systematic review. DATA SOURCES Published and completed randomised controlled trials from 2000 to current evaluating effectiveness of specialised palliative care services on patient-centred outcomes in adult patients were examined. MEDLINE was searched from 2008 to 29 September 2015 and supplemented by randomised controlled trials identified in a 2008 systematic review. RESULTS Altogether, 20 randomised controlled trials involving 8426 patients were reviewed using 40 subcomponents of five elements of implementation fidelity (resulting in 20 × 40 = 800 items). Over 88 strategies were identified, classified under the following elements: 'treatment design', 'training providers', 'delivery of treatment', 'receipt of treatment' and 'enactment of treatment skills'. No single overarching strategy was discovered. Strategies under 'treatment design' aimed to ensure equivalent treatment dose between and within intervention and control groups, and delivery of necessary ingredients. Ongoing 'training (of) providers' included supervision and ensuring skill acquisition. Use of treatment manuals and implementation checklists aimed to aid 'delivery of treatment'. Research teams aimed to improve 'receipt of treatment' by transmitting clear information and verifying understanding, while improving 'enactment of treatment skills' by reviewing and reinforcing prior content. Only 26% of the items received sufficient reporting; 34% were either not used or reported on. CONCLUSION Implementation fidelity in palliative care is under-recognised. A table to collate these strategies to improve implementation fidelity in palliative care research and clinical practice is proposed.
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Affiliation(s)
- Kexin Ang
- 1 Department of Neurology, National Neuroscience Institute, Singapore.,2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nilay Hepgul
- 2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Wei Gao
- 2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Irene J Higginson
- 2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
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