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The intensive care nurse's role in withdrawing and withholding treatment
d
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AUSTRALIAN CRITICAL C A W
other physiological variables?' and, 'Does family stimulation differ from that of the nurse in its effect on ICP and other physiological variables!' It was hypothesised that ICP would decrease with family as opposed to nurse stimulation, where no decrease was expected. The sample for this study included 18 subjects, 12 males and six females, with varying pathologies who had an intraventricular ICP-measuring device in sinc. After a 30-minute rest period, data was collected at 1-minute intervals for 15 minutes prior to stimulation. The period of stimulation by either family or nurse was contained to 20 minutes, with data being collected every minute. This was followed by another 15-minute period of post-stimulation data collection, with data also being collected at 1-minute intervals. Inferential statistical analysis demonstrated a decrease in ICP during family stimulation, with little effect demonstrated by nurse stimulation. The implications for nursing practice include the establishment of flexible visiting policies, given that family stimulation exhibited no significant increase in ICP during the current study.
wcv rawing an with
University of Sydney, Sydney, New South Wales Progress in medical technology has created new possibilities for the maintenance and support of patients with multi-system organ failure. In such a context, it is not surprising that the issue of withdrawing and withholding treatment has taken on new meanings and a new relevance. Changing community expectations, legislation, medicolegal issues and ethical considerations must be balanced when considering the use of this technology. The role of the nurse in the process of withdrawing and withholding treatment in the intensive care setting is unclear. This paper presents the results of a qualitative research study which explored the perceived roles experienced intensive care nurses undertake during the process of withdrawing and withholding treatment. Semi-structured interviews were audiotaped and transcribed, which allowed the various perceived roles to be explored. The data was analysed using the constant comparative method of grounded theory. The identified roles include those of carer/supporter, advocate, team member and educator. The project also identified difficulties that intensive care nurses experience in the process. These involve conflict, role perceptions and dealing with specific patient or family circumstances. The identification of the various roles undertaken by these nurses, and the difficulties encountered, has implications for education, management and practice.
Objectives: to identify the mode of death in ICU, quantify the frequency that therapy is withdrawn or withheld and optimise the management of dying patients. Method: a retrospective review of the case notes of patients who died in the period from March 1, 1994 to February 28, 1995 provided information on patient demographics, reason for admission, admission APACHE II/III scores, interventions provided, time on maximal therapy and events leading to the patient's death ie whether treatment was withdrawn or withheld. Results: 1214 patients were admitted to the ICU over the study period. Of these, 120 died. The age of the patients who died ranged from 5 to 88 years. The predominant reasons for admission were cardiac (n = 22), sepsis (n = 20) and trauma (n = 15). The mean APACHE 111111 scores on admission were 28.61 and 108.82 respectively. Of the patients reviewed, 54 died on maximal therapy, nine were diagnosed as brain dead and the remainder had therapy withdrawn or withheld. Of the last group, 30 had all therapies withdrawn, while 21 remained ventilated with no increase in therapy. Sedation was provided to most patients. Family conferences were conducted in all cases. The results reinforce the success of the policy in affording dying patients in ICU a dignified and comfortable death.
Intensive Care Unit, Monash Medical Centre, Clayton, Victoria Introduction: instruments to predict the development of pressure sores (PS) are generally of limited value in critical care settings because (1) the predictive measures are often subjective and categorical, (2) they are generally performed on admission to a unit and do not take into account rapid changes in patient conditions and therapeutic interventions, which includes the routine practice of PS prevention carried out in ICU, and (3) they are not validated in ICU settings. Objective: to design an instrument which measures potential risk factors for the development of PSs in ICU patients. Method: a literature review was conducted and six risk categories for PS development were identified. These factors included circulation/hydration, oxygen delivery, nutrition, sepsis, biochemical factors and nursing management factors. The predication of pressure sore (POPS) scale operationally defined these six categories, using physiological and clinical measures routinely monitored during patient management. Results: the POPS scale measured objective, interval-level data and clinical rating scales. It could be administered every 24 hours and was therefore sensitive to changes in patient condition and management. Also, it had a high degree of acceptability among intensive care nurses as it incorporated parameters that were measured routinely in ICU.
A policy for 'Active Management of the Dying Patient' was implemented in the Liverpool Hospital Intensive Care Unit (ICU) in 1989. The policy aims for a consistent approach to managing dying patients.
Conclusion: the POPS scale is a suitable instrument for evaluating the potential risk factor categories identified in the development of PSs in critically ill patients in ICU settings.
VOLUME 9 NUMBER 1 MARCH 1996
-M*
AUSTRALIAN CRITICAL C A W
other physiological variables?' and, 'Does family stimulation differ from that of the nurse in its effect on ICP and other physiological variables!' It was hypothesised that ICP would decrease with family as opposed to nurse stimulation, where no decrease was expected. The sample for this study included 18 subjects, 12 males and six females, with varying pathologies who had an intraventricular ICP-measuring device in sinc. After a 30-minute rest period, data was collected at 1-minute intervals for 15 minutes prior to stimulation. The period of stimulation by either family or nurse was contained to 20 minutes, with data being collected every minute. This was followed by another 15-minute period of post-stimulation data collection, with data also being collected at 1-minute intervals. Inferential statistical analysis demonstrated a decrease in ICP during family stimulation, with little effect demonstrated by nurse stimulation. The implications for nursing practice include the establishment of flexible visiting policies, given that family stimulation exhibited no significant increase in ICP during the current study.
wcv rawing an with
University of Sydney, Sydney, New South Wales Progress in medical technology has created new possibilities for the maintenance and support of patients with multi-system organ failure. In such a context, it is not surprising that the issue of withdrawing and withholding treatment has taken on new meanings and a new relevance. Changing community expectations, legislation, medicolegal issues and ethical considerations must be balanced when considering the use of this technology. The role of the nurse in the process of withdrawing and withholding treatment in the intensive care setting is unclear. This paper presents the results of a qualitative research study which explored the perceived roles experienced intensive care nurses undertake during the process of withdrawing and withholding treatment. Semi-structured interviews were audiotaped and transcribed, which allowed the various perceived roles to be explored. The data was analysed using the constant comparative method of grounded theory. The identified roles include those of carer/supporter, advocate, team member and educator. The project also identified difficulties that intensive care nurses experience in the process. These involve conflict, role perceptions and dealing with specific patient or family circumstances. The identification of the various roles undertaken by these nurses, and the difficulties encountered, has implications for education, management and practice.
Objectives: to identify the mode of death in ICU, quantify the frequency that therapy is withdrawn or withheld and optimise the management of dying patients. Method: a retrospective review of the case notes of patients who died in the period from March 1, 1994 to February 28, 1995 provided information on patient demographics, reason for admission, admission APACHE II/III scores, interventions provided, time on maximal therapy and events leading to the patient's death ie whether treatment was withdrawn or withheld. Results: 1214 patients were admitted to the ICU over the study period. Of these, 120 died. The age of the patients who died ranged from 5 to 88 years. The predominant reasons for admission were cardiac (n = 22), sepsis (n = 20) and trauma (n = 15). The mean APACHE 111111 scores on admission were 28.61 and 108.82 respectively. Of the patients reviewed, 54 died on maximal therapy, nine were diagnosed as brain dead and the remainder had therapy withdrawn or withheld. Of the last group, 30 had all therapies withdrawn, while 21 remained ventilated with no increase in therapy. Sedation was provided to most patients. Family conferences were conducted in all cases. The results reinforce the success of the policy in affording dying patients in ICU a dignified and comfortable death.
Intensive Care Unit, Monash Medical Centre, Clayton, Victoria Introduction: instruments to predict the development of pressure sores (PS) are generally of limited value in critical care settings because (1) the predictive measures are often subjective and categorical, (2) they are generally performed on admission to a unit and do not take into account rapid changes in patient conditions and therapeutic interventions, which includes the routine practice of PS prevention carried out in ICU, and (3) they are not validated in ICU settings. Objective: to design an instrument which measures potential risk factors for the development of PSs in ICU patients. Method: a literature review was conducted and six risk categories for PS development were identified. These factors included circulation/hydration, oxygen delivery, nutrition, sepsis, biochemical factors and nursing management factors. The predication of pressure sore (POPS) scale operationally defined these six categories, using physiological and clinical measures routinely monitored during patient management. Results: the POPS scale measured objective, interval-level data and clinical rating scales. It could be administered every 24 hours and was therefore sensitive to changes in patient condition and management. Also, it had a high degree of acceptability among intensive care nurses as it incorporated parameters that were measured routinely in ICU.
A policy for 'Active Management of the Dying Patient' was implemented in the Liverpool Hospital Intensive Care Unit (ICU) in 1989. The policy aims for a consistent approach to managing dying patients.
Conclusion: the POPS scale is a suitable instrument for evaluating the potential risk factor categories identified in the development of PSs in critically ill patients in ICU settings.
VOLUME 9 NUMBER 1 MARCH 1996