Transcending the silos: toward an interdisciplinary approach to end-of-life care in the ICU.
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Decision Making↗
Biomedical subjects
Sarah E Shannon
Publications and source records attributed to Sarah E Shannon.
Missed opportunities during family conferences about end-of-life care in the intensive care unit.
BACKGROUND: Improved communication with family members of critically ill patients can decrease the prolongation of dying in the intensive care unit (ICU), but few data exist to guide the conduct of this communication. OBJECTIVE: Our objective was to identify missed opportunities for physicians to provide support for or information to family during family conferences. METHODS: We identified ICU family conferences in four hospitals that included discussions about withdrawing life support or delivery of bad news. Fifty-one conferences were audiotaped, including 214 family members. Thirty-six physicians led the conferences and some physicians led more than one. We used qualitative methods to identify and categorize missed opportunities, defined as an occurrence when the physician had an opportunity to provide support or information to the family and did not. MAIN RESULTS: Fifteen family conferences (29%) had missed opportunities identified. These fell into three categories: opportunities to listen and respond to family; opportunities to acknowledge and address emotions; and opportunities to pursue key principles of medical ethics and palliative care, including exploration of patient preferences, explanation of surrogate decision making, and affirmation of nonabandonment. The most commonly missed opportunities were those to listen and respond, but examples from other categories suggest value in being aware of these opportunities. CONCLUSIONS: Identification of missed opportunities during ICU family conferences provides suggestions for improving communication during these conferences. Future studies are needed to demonstrate whether addressing these opportunities will improve quality of care.
Adult↗
Three approaches to qualitative content analysis.
Content analysis is a widely used qualitative research technique. Rather than being a single method, current applications of content analysis show three distinct approaches: conventional, directed, or summative. All three approaches are used to interpret meaning from the content of text data and, hence, adhere to the naturalistic paradigm. The major differences among the approaches are coding schemes, origins of codes, and threats to trustworthiness. In conventional content analysis, coding categories are derived directly from the text data. With a directed approach, analysis starts with a theory or relevant research findings as guidance for initial codes. A summative content analysis involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context. The authors delineate analytic procedures specific to each approach and techniques addressing trustworthiness with hypothetical examples drawn from the area of end-of-life care.
Humans↗
Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction.
OBJECTIVE: Family members of critically ill patients report dissatisfaction with family-clinician communication about withdrawing life support, yet limited data exist to guide clinicians in this communication. The hypothesis of this analysis was that increased proportion of family speech during ICU family conferences would be associated with increased family satisfaction. DESIGN: Cross-sectional study. SETTING: We identified family conferences in intensive care units of four Seattle hospitals during which discussions about withdrawing life support were likely to occur. PARTICIPANTS: Participants were 214 family members from 51 different families. There were 36 different physicians leading the conferences, as some physicians led more than one conference. INTERVENTIONS: Fifty-one conferences were audiotaped. MEASUREMENTS: We measured the duration of time that families and clinicians spoke during the conference. All participants were given a survey assessing satisfaction with communication. RESULTS: The mean conference time was 32.0 mins with an sd of 14.8 mins and a range from 7 to 74 mins. On average, family members spoke 29% and clinicians spoke 71% of the time. Increased proportion of family speech was significantly associated with increased family satisfaction with physician communication. Increased proportion of family speech was also associated with decreased family ratings of conflict with the physician. There was no association between the duration of the conference and family satisfaction. CONCLUSIONS: This study suggests that allowing family members more opportunity to speak during conferences may improve family satisfaction. Future studies should assess the effect of interventions to increase listening by critical care clinicians on the quality of communication and the family experience.
Communication↗
Physicians' interactions with health care teams and systems in the care of dying patients: perspectives of dying patients, family members, and health care professionals.
This study investigated the specific physician skills required to interact with health care systems in order to provide high quality care at the end of life. We used focus groups of patients with terminal diseases, family members, nurses and social workers from hospice or acute care settings, and physicians. We performed content analysis based on grounded theory. Groups were interviewed. Two domains were found related to physician interactions with health care systems: 1) access and continuity, and 2) team communication and coordination. Components of these domains most frequently mentioned included taking as much time as needed with the patient, accessibility, and respect shown in working with health team members. This study highlights the need for both physicians and health care systems to improve accessibility for patients and families and increase coordination of efforts between health care team members when working with dying patients and their families.
Delivery of Health Care↗
Dying patients' need for emotional support and personalized care from physicians: perspectives of patients with terminal illness, families, and health care providers.
This study addressed the emotional and personal needs of dying patients and the ways physicians help or hinder these needs. Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care workers, and physicians. Content analyses were performed based on grounded theory. Emotional support and personalization were 2 of the 12 domains identified as important in end-of-life care. Components of emotional support were compassion, responsiveness to emotional needs, maintaining hope and a positive attitude, and providing comfort through touch. Components of personalization were treating the whole person and not just the disease, making the patient feel unique and special, and considering the patient's social situation. Although the levels of emotional support and personalization varied, there was a minimal level, defined by compassion and treating the whole person and not just the disease, that physicians should strive to meet in caring for all dying patients. Participants also identified intermediate and advanced levels of physician behavior that provide emotional and personal support.
Adult↗
Studying communication about end-of-life care during the ICU family conference: development of a framework.
PURPOSE: Family-clinician communication in the intensive care unit (ICU) about withholding and withdrawing life support occurs frequently, yet few data exist to guide clinicians in its conduct. The purpose of this study was to develop an understanding of the way this communication is currently conducted. METHODS: We identified family conferences in the ICUs of 4 Seattle-area hospitals. Conferences were eligible if the physician leading the conference believed that discussion about withholding or withdrawing life support or the delivery of bad news was likely to occur and if all conference participants consented to participate. Fifty conferences were audiotaped, transcribed, and analyzed by using the principles of grounded theory. RESULTS: We developed 2 frameworks for describing and understanding this communication. The first framework describes communication content, including introductions, information exchange, discussions of the future, and closings. The second framework describes communication styles and support provided to families and other clinicians and includes a variety of techniques such as active listening, acknowledging informational complexity and emotional difficulty of the situation, and supporting family decision making. These frameworks identify what physicians discuss, how they present and respond to issues, and how they support families during these conferences. CONCLUSIONS: This article describes a qualitative methodology to understand clinician-family communication during the ICU family conference concerning end-of-life care and provides a frame of reference that may help guide clinicians who conduct these conferences. We also identify strategies clinicians use to improve communication and enhance the support provided. Further analyses and studies are needed to identify whether this framework or these strategies can improve family understanding or satisfaction or improve the quality care in the ICU.
Adolescent↗
Technology available in nursing programs: implications for developing virtual end-of-life educational tools.
BACKGROUND: To overcome insufficient attention to end-of-life (EOL) care in nursing education, the authors are developing the "Toolkit for Nursing Excellence at End-of-Life Transition" (TNEEL). METHOD: An evidence-based design process was used to create a computerized (CD-ROM) multimedia toolkit of instructional aides. An online survey of all U.S. undergraduate nursing programs was conducted to identify their current technologic infrastructures available for innovative teaching aides. Expert review process guided pedagogic decisions. RESULTS: Survey findings enabled TNEEL development to be responsive to nurse educators' needs and preferences. CONCLUSION: Educators can use TNEEL to actively engage students in meaningful learning about EOL care.
Clinical Competence↗
Patients, nurses, and physicians have differing views of quality of critical care.
PURPOSE: To compare patient, nurse, and physician assessments of quality of care and patient satisfaction in selected critical care units. DESIGN: As part of a study of patient outcomes from critical care, data were collected between December 1991 and March 1993 from 489 patients, 518 nurses, and 515 physicians in 25 critical care units located in 14 hospitals in the U.S. Pacific Northwest. METHODS: Views of patient satisfaction and quality of care were measured using standardized instruments. All data were aggregated to the unit level (N = 25) and were normalized to a common scale for analysis. FINDINGS: Physicians rated quality of care higher than did either patients or nurses within the same critical care unit, and nurses had the lowest perceptions of quality. Nurses and patients had similar views of patient satisfaction, but physicians tended to overestimate patients' satisfaction. However, physicians', nurses', and patients' scores varied considerably within and between units. Physicians' and nurses' views of quality and patient satisfaction were strongly related to processes such as MD-RN collaboration and outcomes such as nurses' job satisfaction. CONCLUSIONS: Patients, nurses, and physicians viewed quality of care and patient satisfaction differently. Nurses' and physicians' perspectives were more related to their views of the work environment than to organizational factors, patient characteristics, or commonly used outcome measures.
Attitude↗
Patients' perspectives on physician skill in end-of-life care: differences between patients with COPD, cancer, and AIDS.
OBJECTIVES: Patients' views of physician skill in providing end-of-life care may vary across different diseases, and understanding these differences will help physicians improve the quality of care they provide for patients at the end of life. The objective of this study was to examine the perspectives of patients with COPD, cancer, or AIDS regarding important aspects of physician skill in providing end-of-life care. DESIGN: Qualitative study using focus groups and content analysis based on grounded theory. SETTING: Outpatients from multiple medical settings in Seattle, WA. PATIENTS: Eleven focus groups of 79 patients with three diseases: COPD (n = 24), AIDS (n = 36), or cancer (n = 19). RESULTS: We identified, from the perspectives of patients, the important physician skills for high-quality end-of-life care. Remarkable similarities were found in the perspectives of patients with COPD, AIDS, and cancer, including the importance of emotional support, communication, and accessibility and continuity. However, each disease group identified a unique theme that was qualitatively more important to that group. For patients with COPD, the domain concerning physicians' ability to provide patient education stood out as qualitatively and quantitatively more important. Patients with COPD desired patient education in five content areas: diagnosis and disease process, treatment, prognosis, what dying might be like, and advance care planning. For patients with AIDS, the unique theme was pain control; for patients with cancer, the unique theme was maintaining hope despite a terminal diagnosis. CONCLUSIONS: Patients with COPD, AIDS, and cancer demonstrated many similarities in their perspectives on important areas of physician skill in providing end-of-life care, but patients with each disease identified a specific area of end-of-life care that was uniquely important to them. Physicians and educators should target patients with COPD for efforts to improve patient education about their disease and about end-of-life care, especially in the areas defined above. Physicians caring for patients with advanced AIDS should discuss pain control at the end of life, and physicians caring for patients with cancer should be aware of many patients' desires to maintain hope. Physician understanding of these differences will provide insights that allow improvement in the quality of care.
Acquired Immunodeficiency Syndrome↗
Damage compounded or damage lessened? Disparate impact or the compromises of multiculturalism?
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Black or African American↗
Technology survey of nursing programs: implications for electronic end-of-life teaching tool development.
From an online survey of current technological capabilities of US undergraduate nursing programs, we found almost universal use of Microsoft Windows-based computers and Microsoft Office Suite software. Netscape and Microsoft Internet Explorer were the most popular browsers for Internet access. The survey also assessed faculty preferences for end-of-life care teaching materials and found that nurse educators preferred simple easy-to-use tools provided on CD-ROM or the Internet, with instructions provided via CD-ROM, the Internet, and demonstration workshops. Our findings have numerous implications for the development of electronic teaching materials for nursing.
Computer-Assisted Instruction↗
TNEEL workshop. Interactive methods for teaching end-of-life care.
Nurse educators have identified lack of end-of-life content as a serious deficit in undergraduate nursing education. TNEEL, a new software program with tools for teaching end-of-life topics, was created to help educators overcome this problem. The authors implemented an experiential workshop to help educators learn how to use TNEEL's wide variety of educational tools. Trainers provided information about TNEEL and coached participants (N = 94) as they practiced using laptop computers to increase their familiarity and comfort in using the toolkit. Workshop participants completed pre- and posttest evaluations addressing their opinions and beliefs about using this computer tool. Findings support the workshop as an effective way to facilitate adoption of this innovative educational resource and support the development of a nation-wide training plan for TNEEL with experiential workshops.
CD-ROM↗