Certainty and uncertainty about end of life care nursing practices in New Zealand Intensive Care Units: A mixed methods study

Abstract

Keywords:56 57Death and dying, end of life care, intensive care, intensive care nurse, treatment withdrawal, been undertaken to explore EOL care in the context of New Zealand (NZ) intensive care nursing. 10 11Objective: To investigate NZ intensive care nurses' experiences of, and attitudes towards EOL 12 13 care. 15 16Design: Sequential mixed methods study using cross sectional survey with follow-on focus groups. 18 19Methods: NZ intensive care nurses (N=465) across four large tertiary intensive care units (ICUs) 20 21 were contacted to complete a 43-item web-based survey. A follow-on focus group was conducted 22 23 24 in each of the sites to explore specific aspects of the survey findings. 26 27Results: 203 fully completed surveys were returned (response rate 44%) from the four ICUs. Over was ethically more acceptable than withdrawing it. Whilst nurses generally supported reducing 35 36 inspired oxygen to air for ventilated patients at EOL (71%, n=139) this was also an area that 37 38 demonstrated one of the highest levels of uncertainty (21%, n=41 piloted on 14 ICU nurses from a non-tertiary ICU in NZ to determine cultural relevance to NZ. 21Minor amendments were made to clarify clinical phrases commonly used. In preparation for data collection, the study was presented to staff in each of the four study sites Results from Phase I were reviewed by MC and PF and areas of similarity and difference in 1 2 experiences and attitudes towards EOL between European and NZ ICU nurses were identified. 4Based on this, a focus group guide was developed and used in Phase 2.In Phase Two, follow-on focus groups were undertaken using a developed focus group guide to 11 12 13 explore: EOL in ICU, use of fluids, nutritional support and passive limb exercises during EOL care. 15Participants were drawn from participants in Phase One. Consent was gained prior to focus group were considered to be much less important (63%, n = 128 and 44%, n = 90; respectively). 32Most respondents indicated that the patient's (68%, n = 138) and family's (55%, n = 111) the religious views of medical or nursing staff to be as important (see Table 2.) Most 37 38important was considered to be the medical and nursing teams' assessment that the The majority of nurses who had been directly involved in EOL care of a patient had also actively 4 5 participated in decision-making about withholding or withdrawing treatment (70%, n = 137). 7Furthermore, there was a significant association between active involvement in EOL-decision- EOL decision-making process. Focus group participants held varying views on the use of intravenous fluids and nutrition at EOL. 50Some identified that there was confusion around their purpose and that 'dehydration was a Although results of this study cannot be generalised, the survey response rate suggests that Phase 22One results can reasonably be assumed to broadly represent the views of tertiary New Zealand specific aspects of nursing care at EOL is required.

An integrative review of how families are prepared for, and supported during withdrawal of life‐sustaining treatment in intensive care

“…The use of passive limb exercises, while not usually recognized as a treatment, was also debated by nurses in one study where the decision to withdraw this was informed by whether seeing this take place gave families comfort or distress (Coombs et al . )…”

“…), concern, rapport (Coombs et al . ), relieving burdens (Epstein ), comfort (Heland ) and expressing emotions (Pattison et al . ).…”

Limitation of therapeutic effort experienced by intensive care nurses

“…For the nurses, LTE can involve important ethical conflicts related to the role of carer. 11 , 12 , 36 , 37 These ethical conflicts consisted in the fact that the order of withdrawing life support, on occasions, entails the non-application of care measures that could have been maintaining the patients comfort, such as analgesia, postural mobilizations, and nutrition. 11 , 37 In a study by Coombs et al, 12 over half of the nurses surveyed (55%, n = 111) disagreed that withholding and withdrawing life support treatment were ethically the same thing and 78% (n = 159) of nurses felt that withholding treatment was ethically more acceptable than withdrawing the same.…”

“…hygiene measures) which guarantee a degree of comfort and are supportive of ensuring a ''good death'' for patients. 2,10,11 However, despite representing a regular component of ICU work, Coombs et al 12 reported that ICU nurses in New Zealand experienced difficulties and were uncertain about the use of continued nutritional support, continued passive limb exercises, the use of deep sedation and the reduction of inspired oxygen for ventilated patients during final stages of life.…”

Effect of the Integrated Prospective Payment Program on Family Members' Knowledge and Acceptance of Hospice Care of Patients on Prolonged Mechanical Ventilation

“…For example, this type of decision is well accepted by Western physicians, [22][23][24][25][26][27] but Asian physicians tend to be more accepting of withholding such treatment and less accepting of withdrawing treatment that is already in place. 28 Nurses in Europe 29 and Australia 30 tend to be more accepting of withholding or withdrawing life-sustaining treatment, whereas Turkish 31 and Iranian 32 nurses' attitudes range from negative to neutral regarding the use of life-sustaining treatments.…”