End of Life Decisions
Recently in our ICU we have had an increase in the number of patient deaths. Many of these patients had multiple co-morbidities and quickly succumbed despite efforts to revive them. We have all types of gadgets to keep people alive that require extensive training but less attention is given to dealing with the difficult ethical questions of allowing natural death (Sviri & Heerden, 2014). Barriers to these important discussions are due to lack of advanced directives, insufficient training, lack of time, and lack of palliative care services (Sviri & Heerde, 2014). This results in patients dying in the ICU when they could have had options presented such as dying at home on hospice. As and ICU nurse, I have coded patients only to find out later from family members that advanced measures was not what they wanted. Addressing the end-of-life issues should occur prior to an untoward event occurring. Communicating with patient and family is key in successful transition to end-of-life care. They need to be provided the risks and long-term outcomes of a catastrophic event prior to an event occurring. These conversations are difficult but will provide address their needs long before the event occurs. Please share any tips that you have come across in dealing with end-of-life issues.
Sviri, S. & van Heerden, P. (2014) Discussing End-of-Life Decisions in the ICU-Are We
Doing Our Best. Critical Care Medicine. 42(6), pp. 1560-1561. doi:
10.1097/CCM.0000000000000284
Suzanne,
ReplyDeleteI enjoyed reading your blog site. I have included a link to an article that I had published last November for end of life issues. I absolutely agree with you that education regarding end of life should be provided in the critical care area's. In our facility, we require some type of annual end of life care course for all nurses. The Hospice and Palliative care concept has been slowly trending for several decades now, but until recently has it been in the spotlight. Patients and families should have the knowledge of these services that are offered, and be able to choose for themselves. All to frequently, our hospice and palliative care unit will receive a direct admission from the ICU, only to have the patient die upon arrival or within minutes. Rewind several months, had the doctors asked themselves the question "do I think this patient will make it another 6 months"?, the outcome could have been more pleasant for all involved. Tremendous job!
http://nursing.advanceweb.com/Features/Articles/No-Patient-Should-Die-Alone.aspx.
Kristen,
DeleteI have recently been on the family end of this and just lost my grandfather a little after midnight. They presented this information to my mother in the ICU but she was not ready to let go. I have a lot of respect for the hospice nurses. As soon as he was transferred out of critical care to that unit he was comfortable and the nurses were very helpful and compassionate.
Kristen,
DeleteWe too require an End of Life Course annually for all of our nurses. I think it is hugely important. It is also a Joint Commission requirement that we cover this in orientation and ongoing as needed. We had one particular surveyor that believe that ongoing as needed was the equivalent to annually. Definitely an appropriate subject in today's health care.
Dawn
Hi Dawn,
DeleteYes, we additionally require annual training for all nursing staff hospital wide, also social worker, and chaplains. Also, we cover this training in orientation too. If you have a chance check out my article with the link I provided above titled: No patient should die alone..A holistic approach to end of life care.
Sarah,
I am sorry to hear of the loss of your grandfather, and the hard decisions your mother had to make. Being a difficult time in people's lives, nurses have to display the compassion, and comfort that families need. My deepest condolences to you and your family. ~Kristen
Suzanne,
ReplyDeleteLee (2013) stated that there are six components to consider when creating a blog: context, audience, purpose, channel, noise, and feedback. Intended messages that participants send to each other should be clear. These messages could be distorted due to participants’ beliefs, feeling, and attitudes. According to Lee (2013), “Evidence-based writing calls for a clear and credible presentation of the writer’s claims and evidence to the target audience” (p. 246). I think your presentation was both clear and credible. I think it will reach your target audience and beyond.
Gunelius (n. d.) stated that the use of white is typically considered to be a symbol of purity and cleanliness. The use of purple has been known to evoke a sense of spirituality and creativity. Do you think these are the emotions/feelings you are trying to convey?
Culbertson (2011) stated that an effective blog has content that is compelling and causes the reader to take action in some way. Will your readers be able to relate to the content? What action has your blog caused the readers to take?
This subject has brought up strong emotions for me. I just lost my grandfather a little after midnight in the hospice unit. His struggle was long and tumultuous. My mother was afraid to let go. He was unable to speak or swallow and three days ago he was able to write a note to my mom and it said, “I am ready to go. I am. Goodbye.” It was with those words that my mom was able to ask for hospice care. He went peacefully once they started their interventions, but not a minute before. Thank you for your post.
References
Culbertson, M. (2011). Five ways to critique your blog. Retrieved from http://www.bloggingbasics101.com/five-ways-to-critique-your-blog/
Gunelius, S. (n. d.). The meanings of colors matter in web design. Retrieved from weblogs.about.com/od/blogdesign/tp/How-Color-Psychology-Affects-Blog-Design.htm
Lee, C. (2013). Teaching evidence-based writing using corporate blogs. IEEE Transactions on Professional Communication, 56(3), 242-254. doi:10.1109/TPC.2013.2273117
Suzanne,
ReplyDeleteI was involved with a lot of end of life issues when I worked on a progressive care unit. It is very tough. When it seemed that every intervention had been done for a patient but the patient was still unable to get better, we would put in a consult to the palliative care team. The team was wonderful! They would discuss alternative options with the patient and family; and report back to the physician to come to a consensus towards a plan of care that the patient was comfortable with. I noticed families who had the palliative care team involved experienced a better outcome due to being knowledgeable and apart of the decision making process versus when the team was not involved.
Leticia
Suzanne,
ReplyDeleteI agree this is a topic that should be addressed among nurses. I encourage our preceptors to address the subject of dying with the new nurses they are training to give them an open forum to discuss their thoughts. I know this is a jumping off place for your blog and I am sure there will be many more thought provoking discussions forthcoming.
Dawn
Death is a subject that is uncomfortable for many healthcare workers to talk about with families and even each other. Especially when you work in a department that doesn't deal with death directly. A blog is a good place to start the conversation.
DeleteLinda I completely agree that a blog is great venue to start this hard conversation. Death is very uncomfortable for so many people and being able to start a conversation is the first step.
DeleteSuzanne,
ReplyDeleteAt our facility the physicians would discuss this subject with family members only to leave them very confused. The nurse's would re-educate the family members on what hospice or palliative care is and what their service provides. If the family needs additional information or is agreeable to speak with the hospice nurse, we have 2 on staff.
It's unfortunate that the physicians often leave the family members feeling confused after reviewing such an important and stressful topic. I'm glad that your facility has two hospice nurses on staff. I do not believe my facility has that, although we do have resources for families going through this. Thanks for your informative post.
DeleteJulie
Suzanne,
ReplyDeleteI think this is a topic that really needs to be reinforced in the outpatient setting as well. With patients living longer, having multiple comorbidities, and the increase in hospital readmissions, discussion about quality of life should be the focus instead of being subjected to procedures that may not improve quality of living. More education is definitely needed for medical personnel, patients and families.
Gayla, I agree. I hadn't thought about it in the outpatient setting. But that may be the best time to approach the topic; when things are calm and emotions are not running as high.
DeleteAn important topic that sometimes people are afraid to talk about. Educating others may help to alleviate that fear somewhat. Having experience in dealing with death is the right person to hear this knowledge from even though we are all afraid of death on some level.
ReplyDeleteSuzanne,
ReplyDeleteI think this is a great blog. Even though this one is focused on CVICU I feel that I can relate in the sense of dealing with death and dying frequently. I work in pediatric oncology and never thought that I would see death on such a frequent basis as I do. This blog encourages me to find one that could possibly focus on my field of nursing as I see this as very beneficial. Thank you!
Sarah, I agree with you about the blog. I cannot imagine dealing with death in peds. I work med-surg and it is difficult to deal with death, especially when it is unexpected. This topic does cross specialty areas and barriers. It is so important to find out family cooperation with patient desires prior to them having to deal with it on the spot.
DeleteSuzanne, your topic is VERY important. People's wishes concerning end of life care should be known PRIOR to their hospitalization, but most people don't like to think about such things, and don't plan accordingly. Or they don't make their wishes known because they don't want to upset their family. Working in the NICU has given me a different perspective. We knew the parent's wishes right away. We may not have agreed with them but at least we could act accordingly. End of life care and decisions are tough for everyone involved and need to be discussed openly.
ReplyDeleteYou're right when you say that some people don't like to think about such things. My elderly mother will not discuss advance directive wishes saying she would just rather leave those decisions up to me. She thinks that because I'm a nurse, I am able to be objective. I think objectivity flies out of the window where family is concerned.
DeleteSuzanne,
ReplyDeleteI really enjoyed both of your topics on this blog. I have done the discussion with my own family on End of Life Decisions, in 2010 because my mother was put on a ventilator against her wishes, and my father did not know how to end it. When we as nurses can give a family member some guidence in End of Life decisions than we are giving them a way out. I have also helped people in the emergency room with information that they need to hear, but were afraid to ask the doctor. We are nurses, but we also are advocates for our patients.
I'm so sorry for your loss. What a tough and heartbreaking decision your father had to make. I know nurses can be empathetic and supportive, but you experiencing this discussion yourself enables you to understand what families are really going through.
DeleteI agree that as nurses, we must address advance directives early on in patient care. You never know when a patient is going to take a turn for the worse, and not be able to tell you their wishes. Thanks for discussing this very important issue.
ReplyDeleteSuzanne, as difficult as an advanced directive is to address, it is so important. I worked in In-Patient Surgery (IPS) prior to being on our combined Med-Surg unit. Pre-operatively, it is imperative to find out if an advanced directive is available. On Med-Surg, it is equally important because one never knows patient outcome, and when the necessity to know what the patient would want, will arise. Communication is key to every aspect of patient care. You have chosen a rather touchy subject if tact is not well-displayed by the caregiver. While pain may still be present when a family member is facing end-of-life issues, the healing process can begin so much sooner if everyone is in agreement and well-informed of patient wishes.
ReplyDeleteThis is a very interesting blog. In the ER we often don't find out about advance directives until after we have worked a code. Other times, the patient's advance directives are known but members of the family disagree with their decision so we are forced to work the code beyond what the patient would have wanted. It is not uncommon for family members to disagree, leaving us to perform interventions the patient most likely would have wanted. Communication is very important, but even communication sometimes does not serve the patient well until all members of the family agree on a course of action.
ReplyDeleteAs a former ICU nurse, I took care of many patients that did not want heroic measures. I also had many patients that the families did not want to let go, so the patient suffered against their wishes. This is such a delicate subject, but so necessary. I think that everyone should have their "end of life desires" discussion with their families to avoid unnecessary grief.
ReplyDeleteAs a former ICU nurse, I took care of many patients that did not want heroic measures. I also had many patients that the families did not want to let go, so the patient suffered against their wishes. This is such a delicate subject, but so necessary. I think that everyone should have their "end of life desires" discussion with their families to avoid unnecessary grief.
ReplyDeleteI like the blog and like how you already have posts in relation to the topic. This particular topic of "end of life" is a great one, it's so hard for patients families to know what they wanted if they've never told them and then they hold on to them infinitely. Everyone should express to their loved ones what they want before the time comes, so the family isn't trying to argue over what should be done.
ReplyDelete