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Factors influencing the provision of end-of-life care in critical care settings
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PAPERS AND POSTER ABSTRACTS / Australian Critical Care 26 (2013) 81–98
Conclusions: This finding has implications for consent and nonconsent decisions in both organ and tissue donation circumstances. http://dx.doi.org/10.1016/j.aucc.2013.02.004 Factors influencing the provision of end-of-life care in critical care settings K. Ranse 1,∗ , P. Yates 2 , F. Coyer 2 1
Queensland University of Technology/University of Canberra, Australia 2 Queensland University of Technology, Australia Introduction: Critical care units are designed and resourced to save lives, yet end-of-life care (EOLC) comprises a significant component of work. Research to identify factors influencing the provision of EOLC is needed to inform the development of strategies to support nurses and improve practice. Methods: An online survey, containing items measured on a 5-point scale (1 = strongly disagree – 5 = strongly agree), was distributed to a convenience sample of ACCCN members. Responses from 392 critical care nurses (response rate 25%) were analysed using descriptive statistics and exploratory factor analysis. Results: Eight factors influencing the provision of EOLC were identified: palliative values, patient and family preferences, knowledge, preparedness, organisational culture, resources, care planning and emotional support. Strong agreement was noted with items reflecting the importance of EOLC (M = 4.5, SD = 0.7) and inclusion of families in decisions (M = 4.2, SD = 0.7). Variation was noted in agreement for items regarding EOLC content in in-service (M = 2.7, SD = 1.2) and postgraduate education (M = 3.1, SD = 1.2), yet most respondents agreed that they felt adequately prepared (M = 4.0, SD = 0.9). Generally, participants agreed that counselling is available (M = 3.6, SD = 1.0) and that their colleagues will ask them if they are OK (M = 3.9, SD = 0.8). Conclusion(s): Critical care nurses’ responses reflected values consistent with a palliative approach and a strong commitment to the inclusion of families in EOLC. Critical care nurses autonomously engage in the provision of EOLC, within the constraints of an environment designed for curative care. Generally, nurses felt adequately prepared to provide EOLC despite limited educational opportunities. The findings raise implications for the education and emotional support of critical care nurses. http://dx.doi.org/10.1016/j.aucc.2013.02.005 The lived experience of critically ill patients in intensive care—A phenomenological inquiry A. Tembo 1,∗ , V. Parker 2 , I. Higgins 1 1 2
University of Newcastle, Australia University of New England, Australia
Introduction: This paper disseminates the findings of a study about the experiences of critically ill patients in intensive care (ICU). The aim was to describe and understand the experience of critical illness in ICU and bring about practice with thoughtfulness and deeper understanding in the ICU professionals. Changing demographics and the Cartesian approach have led to increased admissions of critically ill patients to ICU. Technological advances and evidence based practice have resulted in better physical health care outcomes for the critically ill patients. However, patients’ perspectives on their quality of life after their critical illness experience in ICU have not been explored extensively. Methods and materials: Twelve participants from 18 years of age who fulfilled the enrolment criteria were enrolled into the
study. The participants were asked to describe their experience of ICU in In-depth face-to-face interviews at two weeks after discharge and repeated at six months. The participants were recruited from a 20 bed ICU at a tertiary referral hospital in regional Australia. Results: One overarching theme of Being in Limbo with three major themes emerged. These were Being disrupted, Being Imprisoned and Being trapped. Being disrupted refers to how most of the participants likened their sedation time of their ICU stay as the profound absence from the world and the inability to sense the world and the unresponsiveness that went with it. Being Imprisoned elucidates the participants, bound and restricted experience of critical illness in ICU. Being trapped describes the participants’ changed bodies and their struggle to reclaim their old self. Conclusion: Although technology and evidenced practice have resulted in improved physical health care outcomes for critically ill people in ICU, survival of critical illness may not be the only important thing for them. Without consideration of the critically ill patients, medicalisation of the experience is likely to overwhelm them. More qualitative research is needed to improve the experiences of elderly people in ICU. http://dx.doi.org/10.1016/j.aucc.2013.02.006 Concurrent rapid lactate clearance and autonomous nursing resuscitation practice predicts mortality in severe sepsis patients: A mixed methods study D. Chamberlain Flinders University South Australia, Australia Introduction: Severe sepsis (SS) remains the most common cause of death in intensive care units, and has a mortality of 30–50%. Australian literature reports lower mortality rates to the rest of the world with the hypothesis that autonomous nursing resuscitation practice contributes to this phenomenon. Objectives: To investigate what unique elements of the resuscitation 6 h processes of care were associated with improved survival in Australian SS patients? Methods: A 1 year prospective observational mixed methods cohort study was conducted over 5 sites to determine clinical epidemiological and ethnography data of resuscitation processes of care in SS patients. Results: A total of 1022 patients (347 shock) met the criteria of SS on ICU admission. In a stepwise multivariate logistic regression mortality model, rapid blood lactate clearance > 50% (RBL > 50%) in the first 6 h was the strongest predictor of survival (Adjusted OR 0.379, 95% CI 0.265–0.543, p < 0.000). RBL > 50% was associated with initial fluid bolus > 20 ml/kg (2 349.586, Cramer V = 0.5146, p < 0.000), the use of vasopressors within the first hour (2 433.415, Cramer V = 0.5728, p < 0.000) and a MAP target of ≥75 mmHg (2 282.340, Cramer V = 0.462, p < 0.000) but not a MAP target of ≥65 mmHg (2 54.038, Cramer V = −0.2023, p < 0.000)). Concurrent ethnography confirmed senior experienced nurses as active participants in the resuscitation processes often predicting, guiding and commencing prescribed resuscitation therapy. Conclusion(s): Lactate clearance > 50% in the first 6 h driven by autonomous nursing resuscitation processes is a unique significant predictor of survival in Australian sepsis patients. http://dx.doi.org/10.1016/j.aucc.2013.02.007
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 26 (2013) 81–98
Conclusions: This finding has implications for consent and nonconsent decisions in both organ and tissue donation circumstances. http://dx.doi.org/10.1016/j.aucc.2013.02.004 Factors influencing the provision of end-of-life care in critical care settings K. Ranse 1,∗ , P. Yates 2 , F. Coyer 2 1
Queensland University of Technology/University of Canberra, Australia 2 Queensland University of Technology, Australia Introduction: Critical care units are designed and resourced to save lives, yet end-of-life care (EOLC) comprises a significant component of work. Research to identify factors influencing the provision of EOLC is needed to inform the development of strategies to support nurses and improve practice. Methods: An online survey, containing items measured on a 5-point scale (1 = strongly disagree – 5 = strongly agree), was distributed to a convenience sample of ACCCN members. Responses from 392 critical care nurses (response rate 25%) were analysed using descriptive statistics and exploratory factor analysis. Results: Eight factors influencing the provision of EOLC were identified: palliative values, patient and family preferences, knowledge, preparedness, organisational culture, resources, care planning and emotional support. Strong agreement was noted with items reflecting the importance of EOLC (M = 4.5, SD = 0.7) and inclusion of families in decisions (M = 4.2, SD = 0.7). Variation was noted in agreement for items regarding EOLC content in in-service (M = 2.7, SD = 1.2) and postgraduate education (M = 3.1, SD = 1.2), yet most respondents agreed that they felt adequately prepared (M = 4.0, SD = 0.9). Generally, participants agreed that counselling is available (M = 3.6, SD = 1.0) and that their colleagues will ask them if they are OK (M = 3.9, SD = 0.8). Conclusion(s): Critical care nurses’ responses reflected values consistent with a palliative approach and a strong commitment to the inclusion of families in EOLC. Critical care nurses autonomously engage in the provision of EOLC, within the constraints of an environment designed for curative care. Generally, nurses felt adequately prepared to provide EOLC despite limited educational opportunities. The findings raise implications for the education and emotional support of critical care nurses. http://dx.doi.org/10.1016/j.aucc.2013.02.005 The lived experience of critically ill patients in intensive care—A phenomenological inquiry A. Tembo 1,∗ , V. Parker 2 , I. Higgins 1 1 2
University of Newcastle, Australia University of New England, Australia
Introduction: This paper disseminates the findings of a study about the experiences of critically ill patients in intensive care (ICU). The aim was to describe and understand the experience of critical illness in ICU and bring about practice with thoughtfulness and deeper understanding in the ICU professionals. Changing demographics and the Cartesian approach have led to increased admissions of critically ill patients to ICU. Technological advances and evidence based practice have resulted in better physical health care outcomes for the critically ill patients. However, patients’ perspectives on their quality of life after their critical illness experience in ICU have not been explored extensively. Methods and materials: Twelve participants from 18 years of age who fulfilled the enrolment criteria were enrolled into the
study. The participants were asked to describe their experience of ICU in In-depth face-to-face interviews at two weeks after discharge and repeated at six months. The participants were recruited from a 20 bed ICU at a tertiary referral hospital in regional Australia. Results: One overarching theme of Being in Limbo with three major themes emerged. These were Being disrupted, Being Imprisoned and Being trapped. Being disrupted refers to how most of the participants likened their sedation time of their ICU stay as the profound absence from the world and the inability to sense the world and the unresponsiveness that went with it. Being Imprisoned elucidates the participants, bound and restricted experience of critical illness in ICU. Being trapped describes the participants’ changed bodies and their struggle to reclaim their old self. Conclusion: Although technology and evidenced practice have resulted in improved physical health care outcomes for critically ill people in ICU, survival of critical illness may not be the only important thing for them. Without consideration of the critically ill patients, medicalisation of the experience is likely to overwhelm them. More qualitative research is needed to improve the experiences of elderly people in ICU. http://dx.doi.org/10.1016/j.aucc.2013.02.006 Concurrent rapid lactate clearance and autonomous nursing resuscitation practice predicts mortality in severe sepsis patients: A mixed methods study D. Chamberlain Flinders University South Australia, Australia Introduction: Severe sepsis (SS) remains the most common cause of death in intensive care units, and has a mortality of 30–50%. Australian literature reports lower mortality rates to the rest of the world with the hypothesis that autonomous nursing resuscitation practice contributes to this phenomenon. Objectives: To investigate what unique elements of the resuscitation 6 h processes of care were associated with improved survival in Australian SS patients? Methods: A 1 year prospective observational mixed methods cohort study was conducted over 5 sites to determine clinical epidemiological and ethnography data of resuscitation processes of care in SS patients. Results: A total of 1022 patients (347 shock) met the criteria of SS on ICU admission. In a stepwise multivariate logistic regression mortality model, rapid blood lactate clearance > 50% (RBL > 50%) in the first 6 h was the strongest predictor of survival (Adjusted OR 0.379, 95% CI 0.265–0.543, p < 0.000). RBL > 50% was associated with initial fluid bolus > 20 ml/kg (2 349.586, Cramer V = 0.5146, p < 0.000), the use of vasopressors within the first hour (2 433.415, Cramer V = 0.5728, p < 0.000) and a MAP target of ≥75 mmHg (2 282.340, Cramer V = 0.462, p < 0.000) but not a MAP target of ≥65 mmHg (2 54.038, Cramer V = −0.2023, p < 0.000)). Concurrent ethnography confirmed senior experienced nurses as active participants in the resuscitation processes often predicting, guiding and commencing prescribed resuscitation therapy. Conclusion(s): Lactate clearance > 50% in the first 6 h driven by autonomous nursing resuscitation processes is a unique significant predictor of survival in Australian sepsis patients. http://dx.doi.org/10.1016/j.aucc.2013.02.007