The 'dis-ease' of dying: challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study

BACKGROUND: Changes in health care and an ageing population have meant that more people are dying in the acute hospital setting. While palliative care principles have resulted in quality care for the dying, many patients die in an acute care, still receiving aggressive/resuscitative care. AIMS: The aims were to explore nurses' 'recognition of' and 'responsiveness to' dying patients and to understand the nurses' influence on end-of-life care. DESIGN: A qualitative approach was taken utilising non-participant observation to elicit rich data, followed by focus groups and individual semi-structured interviews for clarification. SETTING/PARTICIPANTS: This study was conducted in two acute medical wards in one health service, identified as having the highest rates of death, once palliative care and critical care areas were excluded. Twenty-five nurses consented to participate, and 20 episodes of observation were conducted. RESULTS: Nurses took a passive role in recognising dying, providing active care until a medical officer's declaration of dying. Ward design, nurse allocation and nurses' attitude to death impacts patient care. End-of-life care in a single room can have negative consequences for the dying. Nurses demonstrated varying degrees of discomfort, indicating that they were underprepared for this role. CONCLUSION: When patients are terminally ill, acknowledgement of dying is essential in providing appropriate care. It should not be assumed that all nurses are adequately prepared to provide dying care. Further work is necessary to investigate how the attitudes of nurses towards caring for dying patients in the acute hospital setting may impact care of the dying patient.

Ensuring cultural sensitivity for Muslim patients in the Australian ICU: considerations for care

Australia is a diverse and multicultural nation, made up of a population with a predominant Christian faith. Islam, the second largest religion in the world, has demonstrated significant growth in Australia in the last decade. Coming from various countries of origin and cultural backgrounds, Muslim beliefs can range from what is considered ‘traditional’ to very ‘liberal’.

It is neither possible nor practical for every intensive care clinician to have an intimate understanding of Islam and Muslim practices, and cultural variations amongst Muslims will mean that not all beliefs/practices will be applicable to all Muslims. However, being open and flexible in the way that care is provided and respectful of the needs of Muslim patients and their families is essential to providing culturally sensitive care.

This discussion paper aims to describe the Islamic faith in terms of Islamic teachings, beliefs and common practices, considering how this impacts upon the perception of illness, the family unit and how it functions, decision-making and care preferences, particularly at the end of life in the intensive care unit.

Considering Aboriginal palliative care models: the challenges for mainstream services

This review discusses palliative care and end-of-life models of care for Aboriginal people in the Australian state New South Wales, and considers Aboriginal palliative care needs by reflecting on recent literature and lessons derived from Aboriginal consultation. Aboriginal people in Australia account for a very small proportion of the population, have poorer health outcomes and their culture demonstrates a clear resistance to accessing mainstream health services which are viewed as powerful, isolating and not relevant to their culture, way of life, family and belief systems. Aboriginal people regard their land as spiritual and their culture dictates that an Aboriginal person needs to know their origins, emphasising the value placed on kin and also demonstrating a strong desire to remain within their own country. Currently Aboriginal people tend to not access palliative care services in mainstream facilities; and there is very little data on Aboriginal admissions to palliative care centres. Over the last two decades only two models of palliative care focusing on and developed in Aboriginal communities have been implemented. The seminal contribution to Aboriginal Palliative Care was in the form of a resource kit developed to support palliative care providers to examine their practice for cultural appropriateness for Aboriginal and Torres Strait Islanders. The "living model" coming from this project is adaptive and flexible, enabling implementation in different Aboriginal country as a participative process with community input. The Australian government"s National Indigenous Palliative Care Needs Study similarly indicated that Australian empirical research on Aboriginal palliative care service provision is in its infancy, and comprehensive data on the rates of Aboriginal access to palliative care services did not exist. What literature does exist is drawn together in an argument for the development and need for culturally specific Aboriginal palliative care models, which are culturally appropriate, locally accessible and delivered in collaboration and partnership with Aboriginal controlled health services. This is essential because Aboriginal people are a minority cultural group who are disconnected from mainstream health service delivery, and have a sense of cultural isolation when accessing mainstream services. It is preferable that palliative care is delivered in a collaboration between Aboriginal Controlled Health Service and mainstream palliative care services to ensure a dignified end of life for the Aboriginal person. These collaborations and partnerships are fundamental to ensure that a critical mass of Aboriginal clinicians are trained and experienced in end of life care and palliation. Developing palliative care programs within Aboriginal communities and training Aboriginal Health Workers, promoted and developed in partnership with the Aboriginal community, are important strategies to enhance palliative care service provision. Further partnerships should be championed in this collaborative process, acknowledging a need for palliative care models that fit with Aboriginal peoples" community values, beliefs, cultural/ spiritual rituals, heritage and place.

Recognising dying in acute care

The article reports on terminal care services which are offered to patients in Australia and discusses a terminal care program called the Liverpool Care Pathway which was implemented in Great Britain and is being tested in Australia. In the article the author offers her opinions on terminal care in Australia, on the Liverpool Care Pathway and on the education that Australian nurses receive the dying phase of the human life cycle.

Providing end-of-life care in the intensive care unit : issues that impact on nurse professionalism

With death a frequent event in intensive care units how, people die and the impact on family and staffs is becoming increasingly recognised as an issue requiring significant attention. Caring for a dying patient in these environments challenges the dominant ethos of seeking to cure critically ill patients. Family members require particular care as they keep vigil with their loved one and this forms a major area of work and concern for nurses. Mortality rates are higher in intensive care units than in most other settings and this impacts on staff. This paper builds on a qualitative exploratory study utilising focus groups that was undertaken to describe how nurses support family members during and after a death in the intensive care unit. This study identified issues that challenged the nurses' ability to maintain professionalism and the ways in which nurses ensured self-care. They highlighted organisational constraints, support for families and for their nursing colleagues as important issues for discussion.

Family needs of critically ill patients in the emergency department

INTRODUCTION: Family members' experience a range of physiological, psychological and emotional impacts when accompanying a critically ill relative in the emergency department. Family needs are influenced by their culture and the context of care, and accurate clinician understanding of these needs is essential for patient- and family-centered care delivery. The aim of this study was to describe the needs of Taiwanese family members accompanying critically ill patients in the emergency department while waiting for an inpatient bed and compare these to the perceptions of emergency nurses. METHODS: A prospective cross-sectional survey was conducted in a large medical center in Taiwan. Data were collected from 150 family members and 150 emergency nurses who completed a Chinese version of the Critical Care Family Needs Inventory. RESULTS: Family members ranked needs related to 'communication with family members,' as most important, followed by 'family member participation in emergency department care', 'family member support' and 'organizational comfort'; rankings were similar to those of emergency nurses. Compared to nurses, family members reported higher scores for the importance of needs related to 'communication with family members' and 'family members' participation in emergency department care'. CONCLUSIONS: Family members place greater importance than emergency nurses on the need for effective communication.

Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to emergency departments

BACKGROUND: The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear.

METHODS: Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010.

RESULTS: Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%).

CONCLUSIONS: Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.

Lateral positioning for critically ill adult patients

BACKGROUND: Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes. OBJECTIVES: To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals. SELECTION CRITERIA: We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects. DATA COLLECTION AND ANALYSIS: We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias. MAIN RESULTS: We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review. AUTHORS' CONCLUSIONS: Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.

Intensive care unit discharge policies prior to treatment completion

In this study we explore a model to optimize the Intensive Care Unit (ICU) discharging decisions prior to service completion as a result of capacity-constrained situation under uncertainty. Discharging prior to service completion, which is called demand-driven discharge or premature discharging, increases the chance that a patient to be readmitted to the ICU in the near future. Since readmission imposes an additional load on ICUs, the cost of demand-driven discharge is pertained to the surge of readmission chance and the length of stay (LOS) in the ICU after readmission. Hence, the problem is how to select a current patient in the ICU for demand-driven discharge to accommodate a new critically ill patient. In essence, the problem is formulated as a stochastic dynamic programming model. However, even in the deterministic form i.e. knowing the arrival and treatment times in advance, solving the dynamic programming model is almost unaffordable for a sizable problem. This is illustrated by formulating the problem by an integer programming model. The uncertainties and difficulties in the problem are convincing reasons to use the optimization-simulation approach. Thus, using simulations, we evaluate various scenarios by considering Weibull distribution for the LOS. While it is known that selecting a patient with the lowest readmission risk is optimum under certain conditions and supposing a memory-less distribution for LOS; we remark that when LOS is non-memory-less, considering readmission risk and remaining LOS rather than just readmission risk leads to better results.

Trauma in critically ill children : transfusion and osmotherapy practices

Les accidents sont la cause la plus fréquente de décès chez l’enfant, la plupart du temps à cause d’un traumatisme cranio-cérébrale (TCC) sévère ou d’un choc hémorragique. Malgré cela, la prise en charge de ces patients est souvent basée sur la littérature adulte. Le mannitol et le salin hypertonique (3%) sont des traitements standards dans la gestion de l’hypertension intracrânienne, mais il existe très peu d’évidence sur leur utilité en pédiatrie. Nous avons entrepris une revue rétrospective des traumatismes crâniens sévères admis dans les sept dernières années, pour décrire l’utilisation de ces agents hyperosmolaires et leurs effets sur la pression intracrânienne. Nous avons établi que le salin hypertonique est plus fréquemment utilisé que le mannitol, qu’il ne semble pas y avoir de facteurs associés à l’utilisation de l’un ou l’autre, et que l’effet sur la pression intracrânienne est difficile à évaluer en raison de multiples co-interventions. Il faudra mettre en place un protocole de gestion du patient avec TCC sévère avant d’entreprendre des études prospectives. La transfusion sanguine est employée de façon courante dans la prise en charge du patient traumatisé. De nombreuses études soulignent les effets néfastes des transfusions sanguines suggérant des seuils transfusionnels plus restrictifs. Malgré cela, il n’y a pas de données sur les transfusions chez l’enfant atteint de traumatismes graves. Nous avons donc entrepris une analyse post-hoc d’une grosse étude prospective multicentrique sur les pratiques transfusionnelles des enfants traumatisés. Nous avons conclu que les enfants traumatisés sont transfusés de manière importante avant et après l’admission aux soins intensifs. Un jeune âge, un PELOD élevé et le recours à la ventilation mécanique sont des facteurs associés à recevoir une transfusion sanguine aux soins intensifs. Le facteur le plus prédicteur, demeure le fait de recevoir une transfusion avant l’admission aux soins, élément qui suggère probablement un saignement continu. Il demeure qu’une étude prospective spécifique des patients traumatisés doit être effectuée pour évaluer si une prise en charge basée sur un seuil transfusionnel restrictif serait sécuritaire dans cette population.

Functional outcomes in the Cleft Care UK study - Part 3:oral health and audiology

OBJECTIVES: To compare oral health and hearing outcomes from the Clinical Standards Advisory Group (CSAG, 1998) and the Cleft Care UK (CCUK, 2013) studies. SETTING AND SAMPLE POPULATION: Two UK-based cross-sectional studies of 5-year-olds born with non-syndromic unilateral cleft lip and palate undertaken 15 years apart. CSAG children were treated in a dispersed model of care with low-volume operators. CCUK children were treated in a centralized, high volume operator system. MATERIALS AND METHODS: Oral health data were collected using a standardized proforma. Hearing was assessed using pure tone audiometry and middle ear status by otoscopy and tympanometry. ENT and hearing history were collected from medical notes and parental report. RESULTS: Oral health was assessed in 264 of 268 children (98.5%). The mean dmft was 2.3, 48% were caries free, and 44.7% had untreated caries. There was no evidence this had changed since the CSAG survey. Oral hygiene was generally good, 96% were enrolled with a dentist. Audiology was assessed in 227 of 268 children (84.7%). Forty-three per cent of children received at least one set of grommets--a 17.6% reduction compared to CSAG. Abnormal middle ear status was apparent in 50.7% of children. There was no change in hearing levels, but more children with hearing loss were managed with hearing aids. CONCLUSIONS: Outcomes for dental caries and hearing were no better in CCUK than in CSAG, although there was reduced use of grommets and increased use of hearing aids. The service specifications and recommendations should be scrutinized and implemented.

Trauma in critically ill children : transfusion and osmotherapy practices

Les accidents sont la cause la plus fréquente de décès chez l’enfant, la plupart du temps à cause d’un traumatisme cranio-cérébrale (TCC) sévère ou d’un choc hémorragique. Malgré cela, la prise en charge de ces patients est souvent basée sur la littérature adulte. Le mannitol et le salin hypertonique (3%) sont des traitements standards dans la gestion de l’hypertension intracrânienne, mais il existe très peu d’évidence sur leur utilité en pédiatrie. Nous avons entrepris une revue rétrospective des traumatismes crâniens sévères admis dans les sept dernières années, pour décrire l’utilisation de ces agents hyperosmolaires et leurs effets sur la pression intracrânienne. Nous avons établi que le salin hypertonique est plus fréquemment utilisé que le mannitol, qu’il ne semble pas y avoir de facteurs associés à l’utilisation de l’un ou l’autre, et que l’effet sur la pression intracrânienne est difficile à évaluer en raison de multiples co-interventions. Il faudra mettre en place un protocole de gestion du patient avec TCC sévère avant d’entreprendre des études prospectives. La transfusion sanguine est employée de façon courante dans la prise en charge du patient traumatisé. De nombreuses études soulignent les effets néfastes des transfusions sanguines suggérant des seuils transfusionnels plus restrictifs. Malgré cela, il n’y a pas de données sur les transfusions chez l’enfant atteint de traumatismes graves. Nous avons donc entrepris une analyse post-hoc d’une grosse étude prospective multicentrique sur les pratiques transfusionnelles des enfants traumatisés. Nous avons conclu que les enfants traumatisés sont transfusés de manière importante avant et après l’admission aux soins intensifs. Un jeune âge, un PELOD élevé et le recours à la ventilation mécanique sont des facteurs associés à recevoir une transfusion sanguine aux soins intensifs. Le facteur le plus prédicteur, demeure le fait de recevoir une transfusion avant l’admission aux soins, élément qui suggère probablement un saignement continu. Il demeure qu’une étude prospective spécifique des patients traumatisés doit être effectuée pour évaluer si une prise en charge basée sur un seuil transfusionnel restrictif serait sécuritaire dans cette population.

Nutritional requirements of the critically ill patient

Objective: Given the inaccessibility of indirect calorimetry, intensive care units generally use predictive equations or recommendations that are established by international societies to determine energy expenditure. The aim of the present study was to compare the energy expenditure of critically ill patients, as determined using indirect calorimetry, to the values obtained using the Harris-Benedict equation. Methods: A retrospective observational study was conducted at the Intensive Care Unit 1 of the Centro Hospitalar do Porto. The energy requirements of hospitalized critically ill patients as determined using indirect calorimetry were assessed between January 2003 and April 2012. The accuracy (± 10% difference between the measured and estimated values), the mean differences and the limits of agreement were determined for the studied equations. Results: Eighty-five patients were assessed using 288 indirect calorimetry measurements. The following energy requirement values were obtained for the different methods: 1,753.98±391.13 kcal/ day (24.48 ± 5.95 kcal/kg/day) for indirect calorimetry and 1,504.11 ± 266.99 kcal/day (20.72±2.43 kcal/kg/day) for the HarrisBenedict equation. The equation had a precision of 31.76% with a mean difference of -259.86 kcal/day and limits of agreement between -858.84 and 339.12 kcal/day. Sex (p=0.023), temperature (p=0.009) and body mass index (p< 0.001) were found to significantly affect energy expenditure Conclusion: The Harris-Benedict equation is inaccurate and tends to underestimate energy expenditure. In addition, the Harris-Benedict equation is associated with significant differences between the predicted and true energy expenditure at an individual level

Update in the management of critically ill burned patients

The management of critically ill burn patients is challenging. These patients have to be managed in specialized centers, where the expertise of physicians and nursing personnel guarantees the best treatment. Mortality of burn patients has improved over the past decades due to a better understanding of burn shock pathophysiology, optimal surgical management, infection control and nutritional support. Indeed, a more aggressive resuscitation, early excision and grafting, the judicious use of topical antibiotics, and the provision of an adequate calorie and protein intake are key to attain best survival results. General advances in critical care have also to be implemented, including protective ventilation, glycemic control, selective decontamination of the digestive tract, and implementation of sedation protocols.

Iowa's Barriers to Prenatal Care Project: 2-14 Data Summary, July 2015

The findings in this summary are based on the Iowa Barriers to Prenatal Care project. Ongoing since 1991, the purpose of this project is to obtain brief, accurate information about women delivering babies in Iowa hospitals. Specifically, the project seeks to learn about women’s experiences getting prenatal or delivery care during their current pregnancy. Other information is included which may be pertinent to health planners or those concerned with the systematic development of health care services. This project is a cooperative venture of all of Iowa’s maternity hospitals, the University of Northern Iowa Center for Social and Behavioral Research, and the Iowa Department of Public Health. The Robert Wood Johnson Foundation funded the first three years of this project. The current funding is provided by the Iowa Department of Public Health. The Director is Dr. Mary Losch, University of Northern Iowa Center for Social and Behavioral Research. The Coordinator for the project is Rodney Muilenburg. The questionnaire is distributed to nearly ninety maternity hospitals across the state of Iowa. Nursing staff or those responsible for obtaining birth certificate information in the obstetrics unit are responsible for approaching all birth mothers prior to dismissal and requesting their participation in the study. The questionnaire takes approximately ten minutes to complete. Completed questionnaires are returned to the University of Northern Iowa Center for Social and Behavioral Research for data entry and analysis. Returns are made monthly, weekly, or biweekly depending on the number of births per week in a given hospital. Except in the case of a mother who is too ill to complete the questionnaire, all mothers are eligible to be recruited for participation. The present yearly report includes an analysis of large Iowa cities, African American mothers, and a trend analysis of the last ten years. Also presented in this report is a frequency analysis of all variables included in the 2012 questionnaire. Unless otherwise noted, all entries reflect percentages. Please note that because percentages were rounded, total values may not equal 100%. Data presented are based upon 2012 questionnaires received to date (n = 23,674). All analyses reflect unweighted percentages of those responding.