Hanne Irene Jensen

Withholding or withdrawing therapy in intensive care units: an analysis of collaboration among healthcare professionals

PurposeThe purpose of the study was to determine the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the intensive care unit (ICU).MethodsA questionnaire survey was conducted in seven hospitals in the Region of Southern Denmark, including six regional and four university ICUs. Four hundred ninety-five nurses, 135 intensivists, and 146 primary physicians participated in the study. The primary physicians came from two regional hospitals.ResultsThe unified response rate was 84%. “Futile therapy” and “Patient’s wish” were for all participants the main reasons for considering withholding or withdrawing therapy. Of primary physicians 63% found their general experience of collaboration very or extremely satisfactory compared to 36% of intensivists and 27% of nurses. Forty-three percent of nurses, 29% of intensivists, and 2% of primary physicians found that decisions regarding withdrawal of therapy were often, very often, or always unnecessarily postponed. Intensivists with ICU as their main workplace were more satisfied with the collaboration and more rarely found that end-of-life decisions were changed or postponed compared to intensivists who did not have ICU as their main workplace.ConclusionNurses, intensivists and primary physicians differ in their perception of collaboration and other aspects of withholding and withdrawing therapy practises at the ICU. Multi-disciplinary patient conferences, nurse involvement in the decision-making process, and guidelines for withholding and withdrawing therapy are recommended.

User satisfaction is influenced by the interval between a health care service and the assessment of the service

In order to improve the quality of patient care, questionnaires are often used to identify users experiences and evaluations, but only a few studies have examined whether measuring user satisfaction at different time points influences the assessment of health care. Several studies have shown equivalency between paper and electronic patient reported outcomes; however, none of these studies have considered the fact that electronic questionnaires are usually completed at the hospital, while paper questionnaires are typically completed at home weeks after the visit. In order to ensure that the comparison of results collected by the two different methods are not biased, the aim of this study was to determine if the interval between an outpatient visit and the assessment of the quality of care influences user satisfaction and to compare response rates between questionnaires completed at different times. In a follow-up study, parents from a paediatric outpatient clinic in Denmark were quasi-randomised to 1 of 3 groups: group 1 completed an electronic questionnaire on a touch screen computer in the outpatient clinic and a paper questionnaire 3-6 weeks after the visit; group 2 completed a paper questionnaire in the outpatient clinic and a paper questionnaire 3-6 weeks after the visit; and group 3 completed a paper questionnaire 3-6 weeks after the visit. A total of 1148 parents completed at least 1 questionnaire. User satisfaction was significantly lower when the assessment was made after a visit to the outpatient clinic compared to an assessment made at the clinic. The response rates of questionnaires completed at the clinic were significantly higher than the response rates of questionnaires completed after the visit. Both the timing of surveys and response rates need to be taken into consideration when planning user surveys. Outcomes from surveys conducted at different times are not readily comparable.

Withholding or withdrawing therapy in Danish regional ICUs: frequency, patient characteristics and decision process.

Background: New options for intensive therapy have increased the necessity of considering withholding or withdrawing therapy at intensive care units (ICUs), but the practice varies according to regional and cultural differences. The aim of this study was to investigate the frequency of withholding or withdrawing therapy in two secondary Danish ICUs, to describe the characteristics of patients in whom such decisions were made and to examine the existing documentation of the decision process.

Challenges in End-of-Life Decisions in the Intensive Care Unit: An Ethical Perspective

When making end-of-life decisions in intensive care units (ICUs), different staff groups have different roles in the decision-making process and may not always assess the situation in the same way. The aim of this study was to examine the challenges Danish nurses, intensivists, and primary physicians experience with end-of-life decisions in ICUs and how these challenges affect the decision-making process. Interviews with nurses, intensivists, and primary physicians were conducted, and data is discussed from an ethical perspective. All three groups found that the main challenges were associated with interdisciplinary collaboration and future perspectives for the patient. Most of these challenges were connected with ethical issues. The challenges included different assessments of treatment potential, changes and postponements of withholding and withdrawing therapy orders, how and when to identify patients’ wishes, and suffering caused by the treatment. To improve end-of-life decision-making in the ICU, these challenges need to be addressed by interdisciplinary teams.

Assessment of health care by children and adolescents depends on when they respond to the questionnaire

OBJECTIVE The aim of this study was to examine the assessments and priorities by children and adolescents of health care in a paediatric outpatient clinic, to examine the influence of the time factor on the assessments and priorities by children and adolescents of health care, and to determine their preferred method of evaluation. DESIGN A quasi-randomized follow-up study in which children and adolescents either completed a questionnaire at an outpatient clinic and again 3-6 weeks after the visit, or only 3-6 weeks after the visit. SETTING A Danish paediatric outpatient clinic. PARTICIPANTS Children and adolescents from the outpatient clinic. MAIN OUTCOME MEASURES Comparison between assessments given at the clinic and assessments given 3-6 weeks after the visit. RESULTS Three hundred forty-six children and adolescents completed at least one questionnaire. Children and adolescents were generally satisfied with the consultation at the paediatric outpatient clinic, but the visit was assessed less positive 3-6 weeks post-visit compared with assessments given immediately after the visit. Assessments and priorities of more general matters were not influenced by the time factor. Electronic surveys via touch screen computers were preferred to paper questionnaires by children and adolescents. CONCLUSIONS When comparing user satisfaction from different studies and when planning a survey of user satisfaction, the interval between the rendering of the health-care service and the assessment should be taken into consideration.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool

Background Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). Objectives To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. Methods Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. Results Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. Conclusions The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians’ behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

End-of-life practices in Danish ICUs: development and validation of a questionnaire

BackgroundPractices for withholding or withdrawing therapy vary according to professional, cultural and religious differences. No Danish-validated questionnaire examining withholding and withdrawing practices exists, thus the aim of this study was to develop and validate a questionnaire for surveying the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the ICU.MethodsA questionnaire was developed on the basis of literature, focus group interviews with intensive care nurses and intensivists, and individual interviews with primary physicians. The questionnaire was validated in the following 3 phases: a qualitative test with 17 participants; a quantitative pilot test with 60 participants; and a survey with 776 participants. The validation process included tests for face and content validity (by interviewing participants in the qualitative part of the pilot study), reliability (by assessing the distribution of responses within the individual response categories), agreement (by conducting a test-retest, evaluated by paired analyses), known groups’ validity (as a surrogate test for responsiveness, by comparing two ICUs with a known difference in end-of-life practices), floor and ceiling effect, and missing data.ResultsFace and content validity were assessed as good by the participants in the qualitative pilot test; all considered the questions relevant and none of the participants found areas lacking. Almost all response categories were used by the participants, thus demonstrating the questionnaires ability to distinguish between different respondents, agreement was fair (the average test-retest agreement for the Likert scale responses was 0.54 (weighted kappa; range, 0.25-0.73), and known groups’ validity was proved by finding significant differences in level of satisfaction with interdisciplinary collaboration and in experiences of withdrawal decisions being unnecessarily postponed. Floor and ceiling effect was in accordance with other questionnaires, and missing data was limited to a range of 0-7% for all questions.ConclusionsThe validation showed good and fair areas of validity of the questionnaire. The questionnaire is considered a useful tool to assess the perceptions of collaboration and other aspects of withholding and withdrawing therapy practices in Danish ICUs amongst nurses, intensivists, and primary physicians.

Associations between demographics and health-related quality of life for chronic non-malignant pain patients treated at a multidisciplinary pain centre: a cohort study

OBJECTIVE To describe the associations between demographics and health-related quality of life for chronic non-malignant pain patients. DESIGN A cohort study. SETTING A multidisciplinary Danish pain centre. STUDY PARTICIPANTS All patients treated at the centre between 2007 and 2013. MAIN OUTCOME MEASURES Levels of pain, anxiety and depression, and physical and mental status. The Hospital Anxiety and Depression Scale and the Medical Outcomes Study Short-Form Health Survey (SF-36) were used. RESULTS A total of 1176 patients were included. The majority were women (64%), the mean age was 46.7 ± 14.4 (range 18-89), and 21% were able to work full or part time. On a Numeric Rating Scale from 0 to 10, median pain-intensity was 8 (interquartile range 7-8) and pain-discomfort 8 (interquartile range 7-9) at time of referral. More than half of the patients had symptoms of anxiety and depression. Most of the individual SF-36 domains had median scores between 0 and 40 (Scale from 0 to 100). Patients younger than 50 years of age as well as patients on sick leave/disability pension had significantly lower SF-36 scores. Level of pain, anxiety and depression decreased and SF-36-scores increased significantly after a course of treatment which in most cases consisted of both medical, physiotherapeutic and psychological treatment as well as health-oriented education. The chi-square test, Mann-Whitney U-test, the Kruskal-Wallis and Wilcoxon Signed-rank test were used for analyses. CONCLUSIONS In order to improve treatment at a multidisciplinary pain centre, it may be of value to target treatments to different patient subgroups based on, amongst other things, age and employment status.

Smoking history, nicotine dependence and opioid use in patients with chronic non-malignant pain.

Previous studies have demonstrated a positive association between smoking and addiction to opioids in patients with chronic non‐malignant pain. This could be explained by a susceptibility in some patients to develop addiction. Another explanation could be that nicotine influences both pain and the opioid system. The objective of the study was to investigate whether smoking, former smoking ± nicotine use and nicotine dependence in patients with chronic non‐malignant pain were associated with opioid use and addiction to opioids.

Comparing Quality of Dying and Death Perceived by Family Members and Nurses for Patients Dying in US and Dutch ICUs

Background: The Quality of Dying and Death (QODD) questionnaire is used as a self‐reported measure to allow families and clinicians to assess patients’ quality of dying and death. We evaluated end‐of‐life (EOL) experiences as measured by the QODD completed by families and nurses in the United States and the Netherlands to explore similarities and differences in these experiences and identify opportunities for improving EOL care. Methods: Questionnaire data were gathered from family members of patients dying in the ICU and nurses caring for these patients. In The Netherlands, data were gathered in three teaching hospitals, and data was gathered from 12 sites participating in a randomized trial in the United States. The QODD consists of 25 items and has been validated in the United States. Results: Data from 446 patients were analyzed (346 in the United States and 100 in the Netherlands). Dutch patients were older than those in the United States (72 + 10.2 years vs 65 + 16.0 years; P < .0025). The family‐assessed overall QODD score was the same in both countries: the Netherlands = median, 9; interquartile range (IQR), 8–10 and the United States = median, 8; IQR, 5–10. US family members rated the quality of two items higher than did the Netherlands families: “time spent with loved ones” and “time spent alone.” Nurse‐assessed QODD ratings varied: the single‐item QODD summary score was significantly higher in the Netherlands (the Netherlands: median, 9; IQR, 8–10 vs the United States: median, 7; IQR, 5–8; P < .0025), whereas the QODD total score was higher in the United States (the Netherlands: median, 6.9; IQR, 5.5–7.6 vs the United States: median, 7.1; IQR, 5.8–8.4; P = .014), although it did not meet our criteria for statistical significance. Of the 22 nurse‐assessed items, 10 were significantly different between the Netherlands and the United States, with eight having higher scores in the United States and 2 having higher scores in the Netherlands. Conclusions: The QODD was rated similarly by family members in the United States and the Netherlands but varied when assessed by nurses. These differences may be due to organizational or cultural differences between the two countries or to expectations of respondents.