For the open-ended question about additional obstacles, participants identified several concerns regarding the provision of aggressive care. One nurse commented about having to continue aggressive care while waiting for out-of-town family members to arrive. Another nurse described having to provide aggressive care when a patient's prognosis is poor. Other nurses identified a lack of education for patients and families about prognosis and the need for EOL care. Also, a nurse said family members had expressed that not providing aggressive care was related to prejudice. Other comments about obstacles included having no care plan for comfort care, having to respond to very emotional family members, encountering language barriers, perceiving that the ethics committee had no power, and the inability to silence alarms.
Supports for Providing EOL Care in Critical Care Settings
Twenty-three of the 24 support questions were perceived as very helpful to the nurses (mean >3) (Table 3). The top supportive behavior was "having one family member be the designated contact person…" (item 1). The 4.57 helpfulness mean for this question was the highest intensity mean and corresponded to the highest perceived obstacle, which was about family and friends calling the nurse frequently. Support items perceived as very supportive (mean >4) that were done frequently (mean >3), which resulted in a high PSBS (15.51-13.30), were providing a peaceful and dignified bedside scene after death, having MDs agree about the direction care should go, allowing family members time to be alone with patient after death, and teaching family members how to act around dying patient (items 3, 4, 5, 9). Other support items perceived as very supportive (intensity >4) but occurring infrequently (frequency <2) were having support staff compile paperwork after a death, having the unit designed for patients to grieve in private, and having the MD meet with the family after death (items 6, 7, 10).
When support items were perceived as very helpful (mean >3) and did not occur frequently (mean <2), the PSBS was lower. For example, the support (item 18) about an ethics committee member routinely attending unit rounds had a helpfulness mean of 3.64 (very helpful), but the frequency mean was 0.64 (almost never occurs). The resulting PSBS was 2.33, which ranked 24 of 24 items. Because looking at the PSBS alone does not indicate an accurate picture of how helpful the nurse perceived a support to be, the support data in this study are organized by the descending intensity of helpfulness means (Table 3) rather than by the PSBS.
In the open-ended questions about supportive behaviors, nurses added the importance of support for families and the nurse. Support for families included nursing representation at family care conferences, providing a lounge for family respite, and a space for families to spend time with a patient's body following death. Other helpful supports identified by the participants were more MD involvement in supporting and educating family about the transition from aggressive to comfort care, help in preparing the body after death, emotional support for the nurse, and the charge nurse making the call regarding organ donation. In addition, the EOL questionnaire asked respondents to identify one thing they would change to improve EOL care. Participants' comments focused on developing consensus and coordination, providing a peaceful environment, and having palliative care guidance from MDs.
Knowledge Survey Findings
Nurses ranked cultural aspects, ethical issues, and communication concerns in EOL care as the top knowledge needs (Table 1). Nurses added comments about difficult communication with MDs. A nurse wrote, "MDs and nurses should be on the same page [so the] family is not given widely different information about prognosis and plan of care." Another nurse explained, "MDs should not 'sugar-coat' things." Additional concerns addressed the need to respect the patient's wishes in family decision making and prevent unnecessary pain and suffering.
The greatest concerns for the nurses in this study, as in the Beckstrand and Kirchhoff study,20 were about family issues. Obstacles to providing effective EOL care included families not understanding or accepting the patient's prognosis, what aggressive lifesaving measures mean, overriding patient wishes, and nurses having to deal with angry and conflicted family members. Critical care nurses have a fast-paced work environment in which their understanding, knowledge, and decision making may be several steps ahead of family members' ability to grasp the EOL situation. Communication with family members experiencing a crisis in EOL situations is challenging, and they may find it difficult to understand and absorb information.18 Nurses' responses to the survey indicate that they would like a family member to be the designated contact person.
The hospital could develop a guideline to have a designated family member be the representative for other family members in both providing and requesting information. Although this approach may be less effective for families who have conflicts, having an expectation for the channel of communication will facilitate a clearer communication process for many families and reduce the stress of many requests for information to the nurse who is providing care.
Nurses indicated that family members do not understand how lifesaving measures may mean additional pain and suffering for the patient. The nurses would like to see more education for families about prognosis and potential consequences of lifesaving measures such as an explanation of what is involved in a full code procedure. Nurses also perceived that providers in some situations have difficulty recognizing the dying trajectory of patients and the futility of lifesaving measures. In these situations, there is tension between the medical model that emphasizes cure and the nursing model that emphasizes care and comfort. A philosophy that values cure above comfort contributes to perceived obstacles such as (1) the nurse not having enough time for EOL care because of being consumed with carrying out lifesaving measures, (2) not allowing a natural death, (3) inaccurate optimism about survival, and (4) the perception that MDs do not value the nurses' opinions. Nurses were also concerned about providing a peaceful environment for EOL care; they indicated that poor unit design did not allow for privacy. In the time since the study was conducted, the adult ICUs at this institution have been remodeled to feature individual rooms that better accommodate families in all situations.
Many of the obstacles that had a high PIS could potentially be reduced through having a completed advanced directive (AD) that specifies the patient's preference for EOL treatment. Ideally, an AD is completed with the individual, a qualified professional, and the patient's family and/or desired kinship networks prior to a hospital admission. However, the reality is that in the crisis of life-threatening illness, it can be difficult to determine the patient's preference. Also, family members who have not previously become familiar with the patient's preferences may have difficulty deciding on the appropriate goal of care for their family member.
Items that nurses perceived as very important (intensity >4) but occurred infrequently (frequency <2) need to be addressed because there is a discrepancy between what nurses believe to be helpful and what actually happens. Nurses would like support staff to compile paperwork after a death so that they can focus on meeting the needs of the grieving family. Nursing administration may be unaware of how nurses perceive completing the paperwork surrounding a death as an obstacle to quality EOL care. Although it is not reasonable to expect to staff for such occurrences, particularly in these trying economic times, supervisors could solicit nurses and clerks from other units to come and assist for a short time. Another support that nurses identified in the study as important but occurring infrequently was a place for the family to grieve in private, which has been accomplished with the remodeling of the unit. Also, nurses would like MDs to talk with the family after a death. Although this is a standard of care, the nurses in the study perceived that MDs rarely spoke to family members following a patient's death (frequency = 1.84). Interdisciplinary communication between leadership in nursing and medicine is needed to ensure that this standard is being met.
In regard to knowledge needed for providing effective EOL care, nurses identified cultural issues as the most important knowledge need. The patient population at this institution is highly uninsured, primarily low-income, and diverse in racial, ethnic, and/or religious backgrounds. The nursing staff is primarily of European descent. The nuances of the complicated health care environment, particularly in critical care settings, along with the difficulty of decisions surrounding EOL contribute to challenging communication. The lack of adequate knowledge about culture, race, ethnicity, and/or religion becomes an obstacle to effective EOL care. Providing nurses with the education, skills, and knowledge to build relationships across these cultural differences could increase nurses' skills for supporting ethnically diverse families when their loved one is having an EOL experience.
Participants identified ethical concerns as their second most important knowledge need. Education and discussion of ethical issues in EOL care can potentially increase both the recognition of difficult ethical challenges and help share the burden of ethical conflict. When nurses learn how to apply ethical principles to resolve ethical problems encountered in EOL care, they can move toward a clearer picture of "the right thing to do" and "who decides." In addition, the ability to analyze ethical problems (1) provides rationale for supporting care recommendations to other health care team members, (2) leads to advocacy for what is best for the patient and family,18 and (3) reduces moral distress of nurses.21
Implications for Practice, Education, and Research
Study findings support the need to integrate palliative care approaches into critical care settings, consistent with the initiatives of IPACC and ELNEC. Critical care nurses need more knowledge, skill, and a sense of cultural competency in communicating with patients and families about prognoses, limits of aggressive treatment, and lifesaving measures. They also need institutional support for their role as advocates for the patients and their families at the EOL. Families and patients need clear, direct, and consistent information to make EOL decisions. The nurse has an important role to play in fostering communication, which will contribute to a more humane environment for the patient receiving EOL care in critical care units. (See Table 4 for suggested strategies for improving the delivery of EOL care in critical care settings.)
Nursing leadership has a responsibility to create a supportive environment for evaluating the quality of EOL care. One recommendation is to establish an interdisciplinary, collaborative work group to develop hospitalwide EOL care plans that integrate palliative care. This includes adopting an EOL care philosophy into the critical care setting. Nurses should also use evidence-based literature, institute policy, and apply professional standards for initiating quality approaches to EOL care. All health care professionals need to promote discussion of ADs with patients who have decision-making capacity, their families, and kinship networks. However, it is also important to initiate outreach to people in community settings to help them to consider their preferences before a health care crisis occurs.
Study findings indicate the need for strengthening educational strategies to prepare nurses for the challenges of providing EOL nursing care. In response to nurses' perceptions about barriers to and supports for EOL care and their identified knowledge needs, the researchers made recommendations for strategies to improve EOL care in critical care settings. First, the researchers presented findings to the EBNP Committee in the hospital, followed by presentations and dialogue with other leadership groups. In addition to providing information, educational initiatives need to include a reflective component to be more effective. A newly formed workgroup including representatives from the EBNP Committee developed a pilot project in one of the critical care units to increase the knowledge and skills for nurses. Nurses and staff from other disciplines will be invited to complete selected online ELNEC modules from the areas that were identified as the most important knowledge needs in the survey. After each module, a dialogue session will be led by a nurse to discuss new learning, questions, and challenges identified by participating nurses and interdisciplinary staff. The planned dialogues will provide an opportunity to reflect on the meaning of the new knowledge and its relevance to practice.
Future research initiatives should explore effective strategies for responding to cultural barriers or obstacles, given the context of a multicultural community with diverse languages, religions, and socioeconomic backgrounds. Intervention studies that evaluate communication strategies in working with families who have a relative having an EOL experience are also needed. Another area for research is the evaluation of patient and family outcomes and nurse satisfaction following the implementation of EOL care plans.
Nurses must strengthen their role as liaisons between the patient and other health professionals to promote quality EOL care. They need to advocate for the integration of a palliative care approach, such as the IPACC model into critical care settings. This model emphasizes comfort and decreasing suffering while improving the overall quality of life for the patient. Integrating Palliative and Critical Care requires education and a new way of thinking for all involved. Physicians, nurses, and organizational leaders need to collaborate with patients and families to improve EOL care. Nurses should lead the paradigm shift that supports IPACC.
The authors thank Michelle Noltimier, nurse manager, the nurses who participated in the survey, the EBNP Committee, and the graduate nursing students from Bethel University for reviewing the literature. They also thank the Minnesota Nurses Association Foundation, which provided funds for the study, and the authors' institution for their contribution of professional time and administrative support to complete the study.
1. Cole RJ. End-of-life
care in the ICUs. Nurs Spectr
2. National Institute of Nursing Research. Improving palliative care and communication in the ICU. Am Nurse Today
3. Asch D, Shea J, Jedrziewski K, Bosk C. The limits of suffering: critical care
nurses' view of hospital care at the end of life. Soc Sci Med
4. Jezuit D. Advanced practice: suffering of critical care
nurses with end-of-life
decisions. Medsurg Nurs
5. Badger J. A descriptive study of coping strategies used by medical intensive care unit nurses during transitions from cure- to comfort-oriented care. Heart Lung
6. Badger J. Factors that enable or complicate end-of-life
transitions in critical care
. Am J Crit Care
7. Kirchhoff KT, Spuhler V, Walker L, Hutton A, Cole BV, Clemmer T. Intensive care nurses' experiences with end-of-life
care. Am J Crit Care
8. Puntillo K. The role of critical care
nurses in providing and managing end-of-life
care. In: Curtis J, Rubenfeld G, eds. Managing Death in the Intensive Care Unit
: The Transition From Cure to Comfort
. New York: Oxford University Press; 2001:149-164.
9. Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntrye LM, Tulsky JA. In search of a good death: observations of patients, families and providers. Ann Intern Med
10. Hodd NM, Engelberg RA, Treece PD, Steinberg KP, Curtis JR. Factors associated with nurse assessment of the quality of dying and death in the intensive care unit. Crit Care Med
11. Levy CR, Ely EW, Payne K, Engelber RA, Patrick DL, Curtis JR. Quality of dying and death in two medical ICUs: perceptions of family and clinicians. Chest
12. Mularski RA, Heine CE, Osborne ML, Ganzini L, Curtis JR. Quality of dying in the ICU: ratings by family members. Chest
13. Beckstrand R, Callister L, Kirchhoff K. Providing a "good death": critical care
nurses' suggestions for improving end-of-life
care. Am J Crit Care
14. Curtis JR, Patrick DL, Shannon SE, Treece PD, Engelberg RA, Rubenfeld GD. The family conference as a focus to improve communication about end-of-life
care in the intensive care unit: opportunities for improvement. Crit Care Med
15. Lentz J. Hospice and palliative care: closing the knowledge gap. Am Nurse Today
16. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, Second Edition
. http:// www.nationalconsensusproject.org
. Accessed May 20, 2009.
17. Rushton C, Williams MA, Sabatier KH. The integration of palliative care and critical care
: one vision, one voice. Crit Care Nurs Clin North Am
18. Schaffer M, Norlander L. Being Present
: A Nurse's Resource for End-of-Life Communication
. Indianapolis, IN: Sigma Theta Tau International; 2009.
20. Beckstrand R, Kirchhoff K. Providing end-of-life
care to patients: critical care
nurses' perceived obstacles and supportive behaviors. Am J Crit Care
21. Zuzelo PR. Exploring the moral distress of registered nurses. Nurs Ethics
Keywords:© 2010 Lippincott Williams & Wilkins, Inc.
Critical care; End-of-life; End-of-life care knowledge needs; Obstacles and supports for end-of-life care