Paul, Cory

Critical-Care Nurses’ Suggestions for Decreasing End-of-Life Care Obstacles: Changes Over 17 Years

Faculty Mentor: Renea, Beckstrand, BYU College of Nursing

One in five patients in intensive care units (ICUs) dies (Angus et al., 2004). As
such, EOLC becomes an integral responsibility of ICU nurses (Attia, AbdElaziz, &
Kandeel, 2012). Critical-care nurses propose that EOLC should focus on helping
patients have dignified and peaceful deaths (Beckstrand, Callister, & Kirchoff, 2006)
because ICU deaths are often unnatural and complex (Chapple, 1999). While recent
research has been performed to assess EOLC, study is specific to other departments.
ICU nurses will likely provide different perspectives due to unique challenges of ICU
EOLC. Comparing current ICU nurses’ suggestions for decreasing EOLC obstacles with
similar data collected 17 years ago will provide insight into improvements, emerging
problems, and persistent challenges with patient EOLC. When implemented, findings
will enable ICU nurses to provide peaceful and dignified deaths for ICU patients.

Methodology

We sent out a 72-item questionnaire to 2,100 American Association of Critical
Care (AACN) members in October 2014, after receiving IRB approval. Questionnaires
were collected through March 2015, after two additional mailings and a postcard
reminder. Questionnaires measured critical-care nurses’ perceptions of the magnitude
and frequency of obstacles and effective practices during EOLC. For this particular
study we looked at one question: “If you had the ability to change just one aspect of the
end-of-life care given to dying ICU patients, what would it be?” The identical question
was asked to a similar group 17 years ago (Beckstrand, Callister, & Kirchhoff, 2005).
After coding recent ICU nurses’ responses for suggestions about EOLC improvement in
ICUs, we compared results with findings from 17 years ago.

Results

After eliminating unreadable responses, we coded 392 suggestions.
Respondents with usable suggestions were between 24 and 73 years old (M = 45). With
an average of 17 years nursing experience, 65% of the sample had cared for more than
30 dying patients. The sample was 87.9% female and 11.8% male. Study participants
had several suggestions for EOLC improvement. Suggestions were grouped into
themes according to similarity. Depending on response frequency, themes were
classified as major (n > 25) or minor (n ≤ 20). Major themes included ensuring a good
death by promoting suitable atmosphere for death (n = 74), early and honest physician
communication (n = 65), one to one nurse staffing for dying patients (n = 49), early
recognition and termination of futile care (n = 39), EOLC education (n = 34), physicians
more physically present during EOLC (n = 30), ensuring families cannot override
patients’ wishes (n = 28), and more ancillary support staff (n = 26). Minor themes for
suggestions included earlier initiation of palliative care (n = 18), involving ethics
committees (n = 6), and other miscellaneous suggestions (n = 20).
The 17-year old study utilized 485 nurses’ suggestions, which were coded
similarly. One major theme of the 17-year old study was providing patients with good
death (n = 128). ICU nurses identified time (nursing shortages preventing one to one
care) (n = 72), unrealistic physician communication a (n = 47), and physicians putting
personal needs above patients’ needs (n = 24) as barriers to providing good death. In
addition to identifying barriers, nurses identified facilitators to good death such as
making fostering an appropriate environment for death like managing pain (n = 43),
honoring patients’ EOLC decisions (n = 39), ending futile care (n = 35), and effective
interdisciplinary communication (n = 34). Other suggestions for EOLC included thorough
EOLC education, increased ancillary support, and ethics committees (n = 37).

Discussion

Results of this study identify current EOLC barriers and improvements made over
17 years in ICUs. ICU nurses are passionate about giving quality EOLC but face
obstacles to providing quality EOLC. ICU nurses have specific ideas to improve EOLC,
which could be crucial in realization of quality EOLC. In comparing current data with 17-
year old data, we found that little has changed regarding EOLC status in ICUs. Nurses
still struggle to ensure good death because ICUs are not suitable atmospheres for death
(pain management, alarms, etc.), communication and relations are lacking between
physicians and families, nurses experience lack of time to provide quality EOLC,
patients receive futile care despite wishes, families do not receive adequate EOLC
education, and there are insufficient ancillary staff for families. Little has changed
regarding EOLC in ICUs; however, progress has been made because some EOLC
suggestions made in 1999 were not mentioned in current data, such as effective
interdisciplinary communication.
While valuable, data received is limited. First, only AACN members were invited
to participate in the questionnaire, which limits generalizability. Moreover, data does not
address family or patients’ perceptions of EOLC, which would provide greater insight
into effectiveness of current EOLC efforts.

Conclusion

ICU patients are entitled to dignified and peaceful deaths. ICU nurses play crucial
roles in providing quality EOLC in order for patients to experience good death, but often
face many barriers when caring for dying patients. By identifying barriers to EOLC,
nurses can find solutions to such difficulties to improve EOLC practices.

References

Agnus, D. C., Barnato, A. E., W. T., Weissfeld, L. A., Watson, R. S., Rickert T. &
Rebenfeld, G. D. (2004). Use of intensive care at the end of life in the United
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doi:10.1097/01.CCM.00001148166. 62331.08
Attia, A. K., Abd-Elaziz, W. W., & Kandeel, N. A. (2012). Critical care nurses perception
of barriers and supportive behaviors in end-of-life care. American Journal of
Hospice & Palliative Medicine, 30(3). 297-304. doi:10.1177/10499091124500067
Beckstrand, R. L., Callister, L. C., & Kirchhoff K. T. (2005). Providing a “good death”:
Critical care nurses’ suggestions for improving end-of-life care. American Journal
of Critical Care, 15(1). 38-46.
Beckstrand, R. L., Wood, R. D., Callister, L.C., Luthy, K.E., Heaston, S. (2012).
Emergency nurses’ suggestions for improving end-of-life care obstacles. Journal
of Emergency Nursing, 38(5). 7-14. doi:10.1016/j.jen.2012.03.008
Chapple, H.S. (1999). Changing the game in the intensive care unit: letting nature take
its course. Critical Care Nurse, 19(3). 25-34.