This article was published in Journal of Clinical Nursing February 2018 by Timmins et al.
Background: While the provision of ICU care is vital, the nature and effect of the potential lack of privacy during death and dying in ICUs has not been extensively explored.
Aim: This paper aims to explore the issues surrounding privacy during death in ICU.
Design: A literature search using CINAHL and Pubmed revealed articles related to privacy, death and dying in ICU.
Method: Key words used in the search were ‘ICU’, ‘Privacy’, ‘Death’ and ‘Dying’. A combination of these terms using Boolean operators ‘or’ or ‘and’ revealed a total of 23 citations. Six papers were ultimately deemed suitable for inclusion in the review and were subjected to code analysis with Atlas.ti v8 QDA software.
Findings: The analysis of the studies revealed eight themes, and this paper presents the three key themes that were found to be recurring and strongly interconnected to the experience of privacy and death in ICU: ‘Privacy in ICU’, ‘ICU environment’ and ‘End-of-Life Care’.
Conclusions: Research has shown that patient and family privacy during the ICU hospitalisation and the provision of the circumstances that lead to an environment of privacy during and after death remains a significant challenge for ICU nurses. Family members have little or no privacy in shared room and cramped waiting rooms, while they wish to be better informed and involved in end-of-life decisions. Hence, death and dying for many patients takes place in open and/or shared spaces which is problematic in terms of both the level of privacy and respect that death ought to afford.
Relevance to clinical practice: It is best if end-of-life care in the ICU is planned and coordinated, where possible. Nurses need to become more self-reflective and aware in relation to end-of-life situations in ICU in order to develop privacy practices that are responsive to family and patient needs. This article is protected by copyright. All rights reserved.
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Critical-care nurses (CCNs) provide end-of-life (EOL) care on a daily basis as 1 in 5 patients dies while in intensive care units. Critical-care nurses overcome many obstacles to perform quality EOL care for dying patients | Dimensions of Critical Care Nursing
Objectives: The purposes of this study were to collect CCNs’ current suggestions for improving EOL care and determine if EOL care obstacles have changed by comparing results to data gathered in 1998.
Methods: A 72-item questionnaire regarding EOL care perceptions was mailed to a national, geographically dispersed, random sample of 2000 members of the American Association of Critical-Care Nurses. One of 3 qualitative questions asked CCNs for suggestions to improve EOL care. Comparative obstacle size (quantitative) data were previously published.
Results: Of the 509 returned questionnaires, 322 (63.3%) had 385 written suggestions for improving EOL care. Major themes identified were ensuring characteristics of a good death, improving physician communication with patients and families, adjusting nurse-to-patient ratios to 1:1, recognizing and avoiding futile care, increasing EOL education, physicians who are present and “on the same page,” not allowing families to override patients’ wishes, and the need for more support staff. When compared with data gathered 17 years previously, major themes remained the same but in a few cases changed in order and possible causation.
Conclusion: Critical-care nurses’ suggestions were similar to those recommendations from 17 years ago. Although the order of importance changed minimally, the number of similar themes indicated that obstacles to providing EOL care to dying intensive care unit patients continue to exist over time.
Full reference: Beckstrand, R.L. et al. (2017) Critical Care Nurses Suggestions to Improve End-of-Life Care Obstacles: Minimal Change Over 17 Years. Dimensions of Critical Care Nursing. 36(4) pp. 264–270
Coombs M.A. et al. (2017) BMJ Supportive & Palliative Care. 7:98-101
Objectives: Most people when asked, express a preference to die at home, but little is known about whether this is an option for critically ill patients. A retrospective cohort study was undertaken to describe the size and characteristics of the critical care population who could potentially be transferred home to die if they expressed such a wish.
Conclusions: A little over 20% of patients dying in critical care demonstrate potential to be transferred home to die. Staff should actively consider the practice of transferring home as an option for care at end of life for these patients.
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Beckstrand, R. et al. (2017) Dimensions of Critical Care Nursing. 36(2) pp. 94–105
Abstract: Background: Nurses working in intensive care units (ICUs) frequently care for patients and their families at the end of life (EOL). Providing high-quality EOL care is important for both patients and families, yet ICU nurses face many obstacles that hinder EOL care. Researchers have identified various ICU nurse-perceived obstacles, but no studies have been found addressing the progress that has been made for the last 17 years.
Conclusions: Obstacles in EOL care, as perceived by critical care nurses, still exist. Family-related obstacles have increased over time. Obstacles related to families may not be easily overcome as each family, dealing with a dying family member in an ICU, likely has not previously experienced a similar situation. On the basis of the current top 5 obstacles, recommendations for possible areas of focus include (1) improved health literacy assessment of families followed by earlier directed, appropriate, and specific EOL information; (2) improved physician/team communication; and (3) ensuring patients’ wishes are followed as written. In general, patient- and family-centered care using clear and open EOL communication regarding wishes and desires between patients and families, their physicians, and nurses will help decrease common obstacles, thus improving the quality of EOL care provided to dying patients and families.
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Families of people dying in intensive care need to receive personalised communication and ongoing support, and be involved in the dying process | NIHR
Researchers gathered evidence on how nurses care for patients and their families in intensive care when life-sustaining treatment is withdrawn. The included studies explored the care of the family before, during and after the process. Most of the studies in this small, mixed methods review were qualitative.
Reviewers identified three main ways, or themes, in which families are supported. First, information and good communication, such as the focus on careful use of language, was seen commonly. Second, by careful management of treatment withdrawal itself, for example by clarifying the gradual change expected when medically focussed life-sustaining treatments are withdrawn and family centred end-of-life care begins. Lastly they described a common focus on making the nursing contribution more visible, such as using techniques to build lasting memories for families.
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Alspach, J.G. (2016) Critical Care Nurse.36(6) pp. 10-11
Although no scientific conclusions can be legitimately drawn from a survey this small, knowing that even a few facilities have now launched meaningful efforts toward getting more critical care nurses to confront, consider, decide, and document their EOL preferences is encouraging.
When you next encounter a patient situation in which the lack of an advance directive creates confusion or stymies development of a clear plan of care, remember that patient could be you. If we don’t know what you want for care when the end of your life draws near, there is no way to ensure that your wishes are respected and followed. Let those who love you know where you want to be, what you want and do not want for care, and let all of your critical care colleagues know your wishes by preparing an advance directive and issuing a copy to whomever will be making decisions on your behalf.
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Mohamed, Z.M. et al. Indian Journal of Critical Care Medicine. 2016;20:459-64
Background and Aims: The practice of intensive care includes withholding and withdrawal of care, when appropriate, and the goals of care change around this time to comfort and palliation. We decided to survey the attitudes, training, and skills of intensive care residents in relation to end-of-life (EoL) care. All residents at our institute who has worked for at least a month in an adult Intensive Care Unit were invited to participate.
Materials and Methods: After Institutional Ethics Committee approval, a Likert-scale questionnaire, divided into five composite measures of EoL skills including training and attitude, was handed over to individual residents and completed data were anonymized. Frequency and descriptive analysis was performed for the demographic variables. Central tendency, variability, and reliability were examined for the five composite measures. Scale internal consistency was checked by Cronbach’s coefficient alpha. Multivariate forward conditional regression analysis was conducted to examine the association of demographic data or EoL experience to composite measures.
Results: Of the 170 eligible residents, we received 120 (70.5%) responses.
Conclusions:Internal medicine residents have more experience in caring for dying patients and conducting EoL discussions. Even though majority of participants reported that they are comfortable with the concept of EoL care, this does not always reflect the actual practice in the hospital. There is a need for further training in skills around EoL care. As this is a self-assessment survey, the specific measures of attitudes and skills in EoL are poorly reflected, indicating a need for further research.
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