Critical Care Nurses Suggestions to Improve End-of-Life Care Obstacles

Critical-care nurses (CCNs) provide end-of-life (EOL) care on a daily basis as 1 in 5 patients dies while in intensive care units. Critical-care nurses overcome many obstacles to perform quality EOL care for dying patients | Dimensions of Critical Care Nursing

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Objectives: The purposes of this study were to collect CCNs’ current suggestions for improving EOL care and determine if EOL care obstacles have changed by comparing results to data gathered in 1998.

Methods: A 72-item questionnaire regarding EOL care perceptions was mailed to a national, geographically dispersed, random sample of 2000 members of the American Association of Critical-Care Nurses. One of 3 qualitative questions asked CCNs for suggestions to improve EOL care. Comparative obstacle size (quantitative) data were previously published.

Results: Of the 509 returned questionnaires, 322 (63.3%) had 385 written suggestions for improving EOL care. Major themes identified were ensuring characteristics of a good death, improving physician communication with patients and families, adjusting nurse-to-patient ratios to 1:1, recognizing and avoiding futile care, increasing EOL education, physicians who are present and “on the same page,” not allowing families to override patients’ wishes, and the need for more support staff. When compared with data gathered 17 years previously, major themes remained the same but in a few cases changed in order and possible causation.

Conclusion: Critical-care nurses’ suggestions were similar to those recommendations from 17 years ago. Although the order of importance changed minimally, the number of similar themes indicated that obstacles to providing EOL care to dying intensive care unit patients continue to exist over time.

Full reference: Beckstrand, R.L. et al. (2017) Critical Care Nurses Suggestions to Improve End-of-Life Care Obstacles: Minimal Change Over 17 Years. Dimensions of Critical Care Nursing. 36(4) pp. 264–270

End of life care in a care home

About a fifth of all people who die in any one year in England die in a care home. This means that training for all staff in end of life care planning, and for some in palliative care is a priority.

Most care home residents are over 85 years old, with an average life expectancy of less than two and a half years. This means that caring for people approaching the end of their lives must be a large part of what care homes, with or without specialist nursing care, must provide.

The Social Care Institute for Excellence has produced, End of life care in a care home which includes a Checklist for owners and managers.

In addition, My Home Life has developed a step-by-step guide to good practice in end-of-life-care

Passed away, kicked the bucket, pushing up daisies – the many ways we don’t talk about death

Adjusting to bodily decline at the end-of-life

The purpose of this study was to better understand the lived experience of functional decline for people with advanced cancer living at home | BMJ Supportive & Palliative Care

Context: People with advanced cancer experience bodily change resulting in debilitating functional decline. Although inability to participate in everyday activities (occupation) contributes to profound suffering, limited research has examined the relationship between altered bodily experience (embodiment) and functional ability.

Conclusions: This study highlights the role active participation in everyday activities plays in mediating adjustment to functional decline. These findings challenge us to look beyond palliation of physical symptoms and psychospiritual care as ends in themselves. Symptom control and palliation should be viewed as mechanisms to optimise active participation in essential and valued activities.

Full reference: Morgan, D.D., et al. (2017) Living actively in the face of impending death: constantly adjusting to bodily decline at the end-of-life

Nurses’ experiences of pain management for people with advanced dementia approaching the end of life

De Witt Jansen, B. et al. (2017) Journal of Clinical Nursing. 26(9-10) pp. 1234–1244

Aims and objectives: To explore hospice, acute care and nursing home nurses’ experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

Background: Pain management in end-stage dementia is a fundamental aspect of end-of-life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

Conclusions: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

Relevance to clinical practice: Nurses considered pain management fundamental to end-of-life care provision; however, nurses working in acute care and nursing home settings may be undersupported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology.

Read the abstract here

Organization-level principles and practices to support spiritual care at the end of life

Holyoke, P. & Stephenson, B. BMC Palliative Care | Published online: 11 April 2017

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Background: Though most models of palliative care specifically include spiritual care as an essential element, secular health care organizations struggle with supporting spiritual care for people who are dying and their families. Organizations often leave responsibility for such care with individual care providers, some of whom are comfortable with this role and well supported, others who are not. This study looked to hospice programs founded and operated on specific spiritual foundations to identify, if possible, organizational-level practices that support high-quality spiritual care that then might be applied in secular healthcare organizations.

Conclusions: These Principles, and the practices underlying them, could increase the quality of spiritual care offered by secular health care organizations at the end of life.

Read the article here

Care of dying adults in the last days of life

This quality standard covers the clinical care of adults (aged 18 and over) who are dying, during the last 2 to 3 days of life. It describes high-quality care in priority areas for improvement.

Care of dying adults in the last days of life |Quality standard [QS144]  | Published date: March 2017

See also NICE interactive flowchart – End of life care for people with life-limiting conditions