Melissa Bloomer

End of life management of adult patients in an Australian metropolitan intensive care unit: A retrospective observational study.

BACKGROUND Death in the intensive care unit is often predictable. End of life management is often discussed and initiated when futility of care appears evident. Respect for patients wishes, dignity in death, and family involvement in the decision-making process is optimal. This goal may often be elusive. PURPOSE Our purpose was to review the end of life processes and family involvement within our Unit. METHODS We conducted a chart audit of all deaths in our 10 bed Unit over a 12-month period, reviewing patient demographics, diagnosis on admission, patient acuity, expectation of death and not-for-resuscitation status. Discussions with the family, treatments withheld and withdrawn and extubation practices were documented. The presence of family or next-of-kin at the time of death, the time to death after withdrawal of therapy and family concerns were recorded. RESULTS There were 70 patients with a mean age of 69 years. Death was expected in 60 patients (86%) and not-for-resuscitation was documented in 58 cases (85%). Family discussions were held in 63 cases (90%) and treatment was withdrawn in 34 deaths (49%). After withdrawal of therapies, 31 patients (44%) died within 6h. Ventilatory support was withdrawn in 24 cases (36%). Family members were present at the time of death in 46 cases (66%). Family concerns were documented about the end of life care in only 1 case (1.4%). CONCLUSION Our data suggests that death in our Unit was often predictable and that end of life management was a consultative process.

The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study

Background: Changes in health care and an ageing population have meant that more people are dying in the acute hospital setting. While palliative care principles have resulted in quality care for the dying, many patients die in an acute care, still receiving aggressive/resuscitative care. Aims: The aims were to explore nurses’ ‘recognition of’ and ‘responsiveness to’ dying patients and to understand the nurses’ influence on end-of-life care. Design: A qualitative approach was taken utilising non-participant observation to elicit rich data, followed by focus groups and individual semi-structured interviews for clarification. Setting/participants: This study was conducted in two acute medical wards in one health service, identified as having the highest rates of death, once palliative care and critical care areas were excluded. Twenty-five nurses consented to participate, and 20 episodes of observation were conducted. Results: Nurses took a passive role in recognising dying, providing active care until a medical officer’s declaration of dying. Ward design, nurse allocation and nurses’ attitude to death impacts patient care. End-of-life care in a single room can have negative consequences for the dying. Nurses demonstrated varying degrees of discomfort, indicating that they were underprepared for this role. Conclusion: When patients are terminally ill, acknowledgement of dying is essential in providing appropriate care. It should not be assumed that all nurses are adequately prepared to provide dying care. Further work is necessary to investigate how the attitudes of nurses towards caring for dying patients in the acute hospital setting may impact care of the dying patient.

People with dementia and the hospital environment: the view of patients and family carers

BACKGROUND A metropolitan geriatric evaluation and management (GEM) facility in Australia was undergoing expansion, and consideration for the needs of individuals with dementia and their family carers was identified as important in planning the new facility. Existing literature revealed that people in hospital value privacy, minimal noise, family amenities and homeliness, but these findings did not consider the perspectives of the person with dementia specifically. AIM The aim was to elicit the perspectives of current inpatients with dementia, and their family carers, about the environment/design features that they believe are necessary for people with dementia, and their family carers. METHOD AND DESIGN This qualitative study utilised in-depth semi-structured interviews to obtain information from current inpatients with dementia and their family carers. RESULTS Participants described how the care received was more important than the physical environment; however, participants also valued homeliness, privacy for the patient and for conversations, a shared space without a television and a connection to the outside. Participants described how accommodating carers, providing quiet spaces and appropriate amenities were also important. CONCLUSIONS While participants valued care over the physical surroundings, they also offered valuable information about their experience in the ward environment. Despite cognitive difficulties, people with dementia were able to provide useful information about the environment within which they were being cared. IMPLICATIONS FOR PRACTICE Consumer opinions about hospital design/environment should be considered as an important source of data. Privacy and personal space for people with dementia and their family carers, a connection with the outside environment , and the needs of carers and visitors are all important considerations when designing healthcare environments.

End‐of‐life care in acute hospitals: an integrative literature review

bloomer mj, moss c & cross wm (2011)Journal of Nursing and Healthcare of Chronic Illness 3, 165–173 End-of-life care in acute hospitals: an integrative literature review Aim.  To explore and define the current status of published literature related to end-of-life care in the acute hospital setting. Background.  Chronic illness is now the leading cause of death in developed countries because the population is and the advances in health care delivery. In Australia, two-third of people with chronic illness who die is inpatient in an acute hospital. Whilst most of the attention regarding end-of-life care and dying has focused on palliative care settings, there is a need to consider those dying outside of specialist palliative care settings. Design.  Integrative literature review. Methods.  Using an integrative approach, electronic searches of selected databases were undertaken, using comprehensive search terms. Secondary sources were also identified through the reference lists of retrieved literature. Results.  The literature review identified a lack of high-quality scientific evidence to direct end-of-life care as delivered in the acute (non-palliative care) sector. From the literature available, five core themes/issues were generated to reflect the literature. Conclusions.  There is a need for research to investigate end-of-life care in the acute hospital setting. Care pathways are in use to varying degrees without validation, but implementation alone does not ensure quality end-of-life care. Cultural factors can impede/impact practice and the ability of clinicians to recognise ‘active dying’ has been shown to be problematic, delaying the transition to end-of-life care. Relevance to clinical practice.  Given that the majority of deaths in Australia occur in acute hospital settings, clinicians should be delivering expert life-sustaining acute care and also quality end-of-life care.

Factors affecting peritoneal dialysis selection in Taiwanese patients with chronic kidney disease

BACKGROUND Taiwan has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world with 55,499 ESRD patients on long-term dialysis. Nevertheless, 90.96% of these patients are managed on maintenance haemodialysis (HD), with only 9.03% enrolled in a peritoneal dialysis (PD) programme. AIM The study aim was to identify the factors affecting Taiwanese patients selection of PD in preference to HD for chronic kidney disease. METHODS A cross-sectional research design was utilized with 130 chronic renal failure (CRF) patients purposively selected from outpatient nephrology clinics at four separate Taiwan hospitals. Logistic regression was used to identify the main factors affecting the patients choice of dialysis type. RESULTS Single-factor logistic regression found significant differences in opinion related to age, education level, occupation type, disease characteristics, lifestyle modifications, self-care ability, know-how of dialysis modality, security considerations and findings related to the decisions made by medical personnel (P < 0.05). Moreover, multinomial logistic regression after adjustment for interfering variables found that self-care ability and dialysis modality know-how were the two main factors affecting the persons selection of dialysis type. CONCLUSIONS Self-care ability and the persons knowledge of the different types of dialysis modality and how they function were the major determinants for selection of dialysis type in Taiwan based on the results from this study. The results indicate that the education of CRF patients about the types of dialysis available is essential to enable them to understand the benefits or limitations of both types of dialysis.

The environment of inpatient healthcare delivery and its influence on the outcome of care

Aim: This paper addresses issues arising in the literature regarding the environmental design of inpatient healthcare settings and their impact on care. Background: Environmental design in healthcare settings is an important feature of the holistic delivery of healthcare. The environmental influence of the delivery of care is manifested by such things as lighting, proximity to bedside, technology, family involvement, and space. The need to respond rapidly in places such as emergency and intensive care can override space needs for family support. In some settings with aging buildings, the available space is no longer appropriate to the needs—for example, the need for privacy in emergency departments. Many aspects of care have changed over the last three decades and the environment of care appears not to have been adapted to contemporary healthcare requirements nor involved consumers in ascertaining environmental requirements. The issues found in the literature are addressed under five themes: the design of physical space, family needs, privacy considerations, the impact of technology, and patient safety. Conclusion: There is a need for greater input into the design of healthcare spaces from those who use them, to incorporate dignified and expedient care delivery in the care of the person and to meet the needs of family.

Australians living with and managing hepatitis C

This paper discusses the psychosocial impact of being diagnosed with hepatitis C virus (HCV). The paper clarifies some of the key misconceptions about the virus, especially the impact HCV has on people who have been recently diagnosed. An individuals reaction to the HCV diagnosis and the subsequent lifestyle challenges to maintain health, well-being, family, and social networks are discussed, particularly the issues surrounding mental health in respect to a recent chronic illness diagnosis and how to manage the trajectory of the illness in the community and individually. HCV disclosure and its effect on intimacy are also detailed. For people living with both a diagnosed mental illness and HCV, managing the illness can be complicated. Not only are these individuals concerned about their mental illness, its treatment, and the social stigma and discrimination associated with it, they also may be alarmed over their future physical health. The paper is preliminary to research using the psychotherapeutic approach of Cognitive Behavioural Therapy (CBT) in groups of persons with a dual diagnosis of mental illness and HCV.

Loss and grief in the workplace: What can we learn from the literature?

Purpose – The purpose of this paper is to determine how Australian workplaces, their managers and employees respond to those who are grieving at work, as a result of chronic or terminal illness, or caring for those with chronic or terminal illness. The review draws on Australian and relevant international literature and seeks to answer this question.Design/methodology/approach – A literature review was undertaken in preparation for an Australian study examining workplace supports for people who are grieving – because they are carers, have experienced a death, or are balancing their own illness with their work. Using a range of search terms, the literature was searched for relevant work between 1980 and 2010. The search found examples of workplace supports throughout the world and some developing Australian literature.Findings – Despite illness and death occurring at any stage of a persons life, there is little research that identifies workplace issues associated with grief and loss. And while workplace l...

Family centred care before and during life-sustaining treatment withdrawal in intensive care: A survey of information provided to families by Australasian critical care nurses

BACKGROUND A core component of family-centred nursing care during the provision of end-of-life care in intensive care settings is information sharing with families. Yet little is known about information provided in these circumstances. OBJECTIVE To identify information most frequently given by critical care nurses to families in preparation for and during withdrawal of life-sustaining treatment. DESIGN An online cross-sectional survey. METHODS During May 2015, critical care nurses in Australia and New Zealand were invited to complete the Preparing Families for Treatment Withdrawal questionnaire. Data analysis included descriptive statistics to identify areas of information most and least frequently shared with families. Cross tabulations with demographic data were used to explore any associations in the data. RESULTS From the responses of 159 critical care nurses, information related to the emotional care and support of the family was most frequently provided to families in preparation for and during withdrawal of life-sustaining treatment. Variation was noted in the frequency of provision of information across body systems and their associated physical changes during the dying process. Significant associations (p<0.05) were identified between the variables gender, nursing experience and critical care experiences and some of the information items most and least frequently provided. CONCLUSIONS The provision of information during end-of-life care reflects a family-centred care approach by critical care nurses with information pertaining to emotional care and support of the family paramount. The findings of this study provide a useful framework for the development of interventions to improve practice and support nurses in communicating with families at this time.

Transitioning from caregiver to visitor in a long-term care facility: the experience of caregivers of people with dementia.

Objectives: Transitioning from the primary caregiver to the visitor in a long-term care facility may be challenging for the caregiver; they are required to surrender their caring duties to the medical and nursing staff. The aim of this study was to explore the experiences of caregivers during their transition from day-to-day caregiver of a person with dementia to a visitor in a long-term care facility. Methods: This study utilised a qualitative descriptive design. Twenty caregivers of people with dementia were recruited from the one Aged Rehabilitation and Geriatric Evaluation and Management facility, located in Victoria, Australia. Semi-structured interviews were used to explore the caregivers experiences. Interviews were analysed using thematic analysis. Results: The interview data revealed that the participants were undergoing similar experiences. The findings revealed that it was difficult for the caregiver to transition to their new role of visitor; negative reactions of grief, loss of motivation and loneliness were also coupled with positive feelings of relief and the reassurance that their relative or friend would be well cared for and safe within the long-term care facility. Conclusion: The findings offer insight into the experiences felt by caregivers when their relative or friend with dementia is admitted to hospital. Implications of this study include the need to improve the transition process for the caregiver by allowing them to be involved in the decision-making process, keeping them informed of care decisions, and importantly, providing emotional support to help the caregiver positively adapt to this transition.