Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016.

This article by Sprung and others was published in JAMA during October 2019
Importance:  End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.
Objective:  To determine the changes in end-of-life practices in European ICUs after 16 years.
Design, Setting, and Participants:  Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.
Exposures:  Comparison between the 1999-2000 cohort vs 2015-2016 cohort.
Main Outcomes and Measures:  End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.
Results:  Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001).
Conclusions and Relevance:  Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.

Meaningful experiences and end-of-life care in the intensive care unit: A qualitative study

This article by Stokes and colleagues was online during April 2019 in “Intensive and Critical Care Nursing”.
Objectives:  The purpose of this study was to provide a comprehensive exploration of nurses’ meaningful experiences of providing end-of-life care to patients and families in the intensive care unit (ICU). The objectives of this research were: (1) To explore what is meaningful practice for nurses regarding end-of-life care; (2) To describe how nurses create a good death in the intensive care unit and (3) To identify the challenges that nurses face that affect their meaningful experiences and ultimately the creation of a good death.
Research design:  This study utilised an interpretive phenomenological approach using Van Manen’s (1997) method.
Setting:  In-depth, face-to-face interviews were conducted with six intensive care nurses employed in a 32-bed medical/surgical intensive care unit of an academic tertiary care centre in Canada.
Findings:  The overarching theme from the analysis of this experience was “being able to make a difference” which was intricately woven around contributing to a good death. Three main themes were identified and included: creating a good death, navigating the challenges and making it work.
Conclusion:  The findings reveal how intensive care nurses provide good end-of-life care and create good deaths for patients and families.
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Privacy at end of life in ICU: a review of the literature

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 Suggestions to Improve End-of-Life Care Obstacles

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

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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

Transferring patients home to die: what is the potential population in UK critical care units?

Coombs M.A. et al. (2017) BMJ Supportive & Palliative Care. 7:98-101

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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.

Read the full article here

Critical Care Nurses’ Perceptions of End-of-Life Care Obstacles

Beckstrand, R. et al. (2017) Dimensions of Critical Care Nursing. 36(2) pp. 94–105

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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.

Read the full abstract here

How nurses support families of intensive care patients towards the end of life

Families of people dying in intensive care need to receive personalised communication and ongoing support, and be involved in the dying process | NIHR

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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.

 

Read the full overview here