Strategies to Improve End-of-Life Care in the Intensive Care Unit

Strategies to Improve End-of-Life Care in the Intensive Care Unit
as Perceived by Nurses
Céline Gélinas1,2,3, N, PhD • Lise Fillion3,5,6, N, PhD • Marie-Anik Robitaille4,5, M.Sc. • Manon Truchon7,8, PhD
1. School of Nursing, McGill University, Montréal, QC, Canada
2. Centre for Nursing Research and Lady Davis Institute, Jewish General
Hospital, Montréal, QC, Canada
3. Groupe de recherche interuniversitaire en interventions en sciences
infirmières du Québec (GRIISIQ), Montréal, QC, Canada
4. Centre de recherche du Centre hospitalier universitaire de Québec,
Québec, QC, Canada
5. Équipe de recherche de la Maison Michel Sarrazin, Québec, QC, Canada
6. Faculté des sciences infirmières, Université Laval, Québec, QC, Canada
7. Département des relations industrielles, Université Laval, Québec,
QC, Canada
8. Centre interdisciplinaire de recherche en réadaptation et en réintégration
sociale, Québec, QC, Canada
Results: Identified Strategies to improve EoL care in ICU
Nurses are facing organizational, professional and personal sources of stress when
providing end-of-life (EoL) care 1 in the Intensive Care Unit (ICU) 3,6. One of their
major challenges is to shift from curative care to EoL care in a short period of time 3,6.
While sources of stress are well described 2,4,5, less is known about nursing strategies
to improve EoL care in this critical environment. This study aimed to describe
strategies to improve EoL care in the ICU from the perspective of nurses.
Methods
A total of 42 nurses working on different shifts (days, evening, and night) in ICUs of
five clinical settings from three regions of the province of Quebec participated in
this descriptive qualitative study. Ten focus groups with a duration of 40 to
60 minutes were completed using a semi-structured interview guide. The content
was audiotaped, transcribed, double coded, and analyzed using InVivo software.
Themes were identified and classified according to strategies related to 3 categories
of sources of stress: organizational, professional and personal.
“The first time I had to provide
palliative care in the ICU […] "This is
your patient, we expect him to live
for another couple of hours" […] the
person who presented me was next
to me and I was like "[…] I never had
to really deal with death before […]
how do I react? […] how often do I
give the morphine? […] How do I
know, what signs am I looking for?
And she really helped me. It was on
the job with someone who had their
own patient so it would be good if I
did have a day where you're paired
with someone so they don't have to
take their time away from their
patient at the same time”.
“Because we get stuck if stuff
happens in the evening, stuff
happens at night, you have to deal
with it by yourself. They have an
emergency social worker. But then
everything stops at four o'clock […]
from Monday to Friday. On the
week-end you’re totally without
support, you have nobody”.
ORGANIZATIONAL
(About Human Resources)
• Develop an organizational culture
of EoL in the ICU
• Specific Human and Material
Resources Strategies
Background
Human Resources Strategies
• Nurses available to support families
• Access to specialized palliative care
nurses in the ICU
• Access to other palliative care
specialists/ethics consultants
“Having a special unit for them.
Private space just for them because
the noise... sometimes pretty
elevated in the unit […] quiet space
that the patient and the family can
be together […] more rooms,
more space”.
(About Material Resources)
Material Resources Strategies
• Private conference room for family meetings
• Private room for the patient and the family,
promoting intimacy and confidentiality
• Better access to medication for symptom
management and comfort care
• An ICU that is adapted for EoL care
(ex.: quiet environment, more space for
human interaction, and a space where
technology is less apparent at the bedside)
PERSONAL
Discussion and Conclusions
Table 1: Sample characteristics
Sites
N
µ Years of
experience
µ Age
A
7
10.7
37.3
B
6
14.1
43
C
9
10.6
36.2
D
12
14.0
45.1
E
8
6.6
35
TOTAL
42
11.3
39.1
Acknowledgement of Funding:
• Canadian Institutes of Health Research (CIHR)
• Canadian Health Services Research Foundation (CHSRF)
• Ministère de la Santé et des Services Sociaux (MSSS)
• Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST)
Providing EoL care is stressful for ICU nurses. When interviewed, nurses
proposed relevant strategies to help reduce organizational, professional
and personal sources of stress that could contribute to improve their
well-being and satisfaction at work. These suggestions are consistent with
clinical recommendations made by the American College of Critical Care
Medicine to improve end-of-life care in the ICU 7 which includes the
development of ICU clinicians' competencies in providing this type of care,
improved communication with family, and the development of
bereavement programs. Research is needed to further adapt, implement
and evaluate programs to better support ICU nurses in EoL care. The
impact of such programs on retention of nurses, on nurses’ well-being and
job satisfaction as well as organizational and patients’ clinical outcomes,
needs to be documented.
“My wish is to have to be able to give
all the care I want to give to that
person, not just, you know, to the
person but the family supportively.
As long as I can have the time to do
everything I want to do with
thatperson that includes pain meds,
that includes everything, but I want to
be able to do it- have the time”.
PROFESSIONAL
Professional Strategies
• Educational training of the ICU team and
other professionals; providing care and
services to the ICU team re: Ethics counsel
for EoL issues
• Interprofessional communication
• Gaining knowledge and competence in
symptom management and comfort
in EoL care
• Improved communication between
members of the ICU team and the family.
• Specific care protocol and directives
• Coaching with experienced nurses
• Follow-up and supervision after the training
• Improving standards of decision making
• Recognition of ICU nurses’ work
• Evidence-based interventions
• Clinical supervision (e.g., mindful reflexive practice following training)
• Provide good EoL care and derive meaning from providing good EoL care
References
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