Suboptimal End-Of-Life (EOL) Care in The Intensive Care Unit (ICU)
Question
This is a outline of the paper it need to be 15 pages and I outline in three sections for sub optimal care
Section 1 : reason for sub optimal end of lie care in the icu
-Barrier to goal of care discussion
- complexity of substitute decision maker
- difficult of implementing palliative care in icu
Second 2: consequence when getting sub optimal end of life care I. Icu
- consequence of barrier of goal discussion
- consequence of complexity of substitute decision maker
- consequence of poor implementation of palliative care in icu
Section 3 : intervention that improve end of life care in icu
- intervention. To improve goal of care discussion
- intervention to help the choice of substitute decision maker as well as help substitute deiciosn maker make patient Centered care
- intervention to improve palliative care in icu
Below is are more details outline with associated reference but i need more references regarding implement of palliative care in icu and how to improve them .
Paper instructions
My thesis statement is: Death and Dying is a reality in the intensive care unit, however, however the litterature reports there IS suboptimal end-of-life (EOL) care in the Intensive care unit (ICU) A review of the literature identifies three common themes that contribute to poor EOL care in the ICU, barriers to the goal of care discussion, complexities of surrogate decision-making, and poor integration of palliative care in the ICU.
This is the style I want my paper
Section one of the barrier to end of life care in the Intensive care unit 6 pages
part one of section 1 :barrier of goal of care discussion addressing these two themes
( 2 pages )
1)barrier from the heatlh care worker prospective
You, J. J., Downar, J., Fowler, R. A., Lamontagne, F., Ma, I. W. Y., Jayaraman, D., Kryworuchko, J., Strachan, P. H., Ilan, R., Nijjar, A. P., Neary, J., Shik, J., Brazil, K., Patel, A., Wiebe, K., Albert, M., Palepu, A., Nouvet, E., des Ordons, A. R., … Heyland, D. K. (2015). Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families. JAMA Internal Medicine, 175(4), 549. https://doi.org/10.1001/jamainternmed.2014.7732
Wilson, M. E., Akhoundi, A., Krupa, A. K., Hinds, R. F., Litell, J. M., Gajic, O., & Kashani, K. (2014). Development, validation, and results of a survey to measure understanding of cardiopulmonary resuscitation choices among ICU patients and their surrogate decision makers. BMC Anesthesiology, 14(1), 15. https://doi.org/10.1186/1471-2253-14-15 Wilson, M. E., Kaur, S., Gallo De Moraes, A., Pickering, B. W., Gajic, O., & Herasevich, V. (2015). Important clinician information needs about family members in the intensive care unit. Journal of Critical Care, 30(6), 1317–1323. https://doi.org/10.1016/j.jcrc.2015.07.028
2) 2) 2 barrier from the patient and family prospective
You,
J. J., Dodek, P., Lamontagne, F., Downar, J., Sinuff, T., Jiang, X., Day, A. G., & Heyland, D. K. (2014). What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. Canadian Medical Association Journal, 186(18), E679–E687. https://doi.org/10.1503/cmaj.140673 Aleksova, N., Demers, C., Strachan, P. H., MacIver, J., Downar, J., Fowler, R., Heyland, D. K., Ross, H. J., & You, J. J. (2016). Barriers to goals of care discussions with hospitalized patients with advanced heart failure: feasibility and performance of a novel questionnaire. ESC Heart Failure, 3(4), 245–252. https://doi.org/10.1002/ehf2.12096 Note : always tie it back to this negatively impact goals of care
2a) complexity of substitue decision maker using these 4 reference addressing the following complexity of substitute decision makers focusing on these three thems 1)
1)Difficult of picking a Substiture decision maker 2) 2)Diffuculty of making a desicion when the subtitue decision maker is a trustee of the government 3) 3)Difficult of substitue decision maker of making goal of care decision.
Kryworuchko, J., Strachan, P. H., Nouvet, E., Downar, J., & You, J. J. (2016). Factors influencing communication and decision-making about life-sustaining technology during serious illness: a qualitative study. BMJ Open, 6(5), e010451. https://doi.org/10.1136/bmjopen-2015-010451
Quinn, T., Moskowitz, J., Khan, M. W., Shutter, L., Goldberg, R., Col, N., Mazor, K. M., & Muehlschlegel, S. (2017). What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients. Neurocritical Care, 27(2), 154–162. https://doi.org/10.1007/s12028-017-0427-2 https://www.scu.edu/ethics/focus-areas/bioethics/resources/conserved-patient/medical-decision-making-for-publicly-conserved-/
Part 3 : barrier to integration of palliative care in the ICU : use this one article to outline the 3 theme of barrier to inter gratuit of palliative care in icu but then find more article
article. Article 1: Kyeremanteng, K., Beckerleg, W., Wan, C., Vanderspank-Wright, B., D’Egidio, G., Sutherland, S., Hartwick, M., Gratton, V., & Sarti, A. J. (2020). Survey on Barriers to Critical Care and Palliative Care Integration. American Journal of Hospice and Palliative Medicine®, 37(2), 108–116. https://doi.org/10.1177/1049909119867658
Section 2 the consequences of poor end of life care in the ICU
using these 4 articles focusing on these three themes Seciton 3
Consequence resulting from poor goal of care discussion Decreased quality of care particularly end of life care (EOLC) (Secunda et al., 2020; Suen et al., 2020a; Turnbull et al., 2019).
Unwanted intervention medical intervention resulting in suffering Emiloju et al., 2020)
. Poor understand of prognosis of prognosis and diagnosis (Howard et al., 2021; Wilson et al., 2014).
Complexity of substitute decision maker
Increase family conflict (Scheunemann et al., 2019; Secunda et al., 2020; Suen et al., 2020a; Turnbull et al., 2019).
Increased incidence of anxiety, depression for patient and substitute decision makers (Quinn et al., 2017; Wilson et al., 2015).
Intevention to improve GOAL of care discusion
Early Timing of goal of care discussion
Implement strategies to facilitate, more time-responsive GOC discussions by
-implementing daily prognostic assessments, such as the Clinical Frailty Scale, which can then be used to trigger earlier GOC discussions between the patient or SDM and the HCP (Orford et al., 2019).
-In addition, the use of mortality prediction scores such as “DeepSOFA: A Continuous Acuity Score for Critically Ill” (Shickel et al., 2019, p.1) can help the HCP clarify the patient diagnosis and prognosis during GOC discussions.
Shickel, B., Loftus, T. J., Adhikari, L., Ozrazgat-Baslanti, T., Bihorac, A., & Rashidi, P. (2019). DeepSOFA: A Continuous Acuity Score for Critically Ill Patients using Clinically Interpretable Deep Learning. Scientific Reports, 9(1), 1879. https://doi.org/10.1038/s41598-019-38491-0
Orford, N. R., Milnes, S., Simpson, N., Keely, G., Elderkin, T., Bone, A., Martin, P., Bellomo, R., Bailey, M., & Corke, C. (2019). Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study. BMJ Supportive & Palliative Care, 9(1), e21–e21. https://doi.org/10.1136/bmjspcare-2016-001231
Orr, S. (2020). The Acceptability and Feasibility of Using Mortality Prediction Scores for Initiating End-of-Life Goals-of-Care Communication in the Adult Intensive Care Unit. Journal of Pain and Symptom Management, 59(1), 121–129. https://doi.org/10.1016/j.jpainsymman.2019.09.0
Intervention to help substitute decision maker
Emiloju, O. E., Djibo, D. A. M., & Ford, J. G. (2020). Association Between the Timing of Goals-of-Care Discussion and Hospitalization Outcome's in Patients With Metastatic Cancer. American Journal of Hospice and Palliative Medicine®, 37(6), 433–438. https://doi.org/10.1177/1049909119882891 Intervention to improve SDM decision making. 1) developing a decision aid to assist SDMs in setting goals of care for patients with traumatic brain injuries.
2) can also evaluate such tools and frameworks for their acceptability and feasibility to positively contribute to GOC discussions for patient, SDM, families, and HCP (Muehlschlegel et al., 2020; Quinn et al., 2017)
. 3)Finally, develop working groups with representatives from all stakeholders to evaluate and continuously improve implementation methods (Scheunemann et al., 2019). Scheunemann, L. P., Ernecoff, N. C., Buddadhumaruk, P., Carson, S. S., Hough, C. L., Curtis, J. R., Anderson, W. G., Steingrub, J., Lo, B., Matthay, M., Arnold, R. M., & White, D. B. (2019). Clinician-Family Communication About Patients’ Values and Preferences in Intensive Care Units. JAMA Internal Medicine, 179(5), 676. https://doi.org/10.1001/jamainternmed.2019.0027 Improve they have a comprehensive, collaborative empathetic approach that promotes open lines of communication between the health care providers and family (Wilson et al., 2015). Ahrend (2013) concluded that early, frequent, and scheduled discussions led by APNs improve support of patient and SDM establishing GOC.
3) I need more intervention to improve palliative care integration in the ICU use I neee more reference but you can find some interventions in this paper
Conclusion


Solution
Suboptimal End-Of-Life (EOL) Care in
The Intensive Care Unit (ICU)
Reason
For Sub Optimal End of Lie Care in the ICU
Barrier
From the Health Care Worker Prospective
There are numerous potential
roadblocks to discussing goals of treatment with families and their patients.
Health care workers may feel that they lack the necessary skills or knowledge
to initiate these discussions (You et al., 2015). They may also feel
uncomfortable to discuss the end-of-life problems with patients and their relatives,
especially if they are still relatively young and appear to have a good quality
of life (Wilson et al., 2005). Health care workers may feel they are being too
pushy or demanding if they bring up the topic of discussion about prognosis and
treatment options. They may be afraid to ask patients or their loved ones what
their wishes will be in an emergency because it could cause guilt or distress
if they cannot communicate their wishes (You et al., 2015). Such discussion
could also make them feel like they are abandoning the patient or giving up on
them (Silliman et al., 2014). Suppose patients and families do not express
interest in discussing treatment options. In that case, health care workers may
assume that they do not wish to have such discussions and therefore refrain
from initiating the conversation (Wilson et al., 2005).
Health care workers may also assume
that patients and their families assume they know what the patient and family
will want and do not initiate the goal of care discussion (Wilson et al.,
2005). Health care workers may be aware of a patient’s advance directive but
feel that it is unlikely to be relevant because they do not appear to have any
life-limiting conditions (Wilson et al., 2005). Or, they may be aware that
their patient has an advance directive but does not know where the document is
located or what it contains.
Health care workers are responsible
for providing patients with information about their health issues and treatment
options, but this information must also include clear explanations of the benefits
and burdens of each treatment option (Wilson et al., 2005). When patients
receive this information, they can make fully-informed decisions based on their
value. Suppose a patient is not able to choose a particular treatment option.
In that case, they can specify who in their family should be included in the
process of decision-making and when in life the course of their illness they
would like their family to be made aware of their health condition (Wilson et
al., 2005).
For both the patient and the care
practitioner, the objective of the therapy talk is critical. To make rational
choices regarding their care, patients must have a comprehensive grasp of their
diagnosis and the treatments that are accessible to them. According to health
care experts, clients must be provided with the necessary information to make
these decisions. However, since both patients and their families may be unaware
of the value of having this dialogue, health care personnel frequently do not
start the purpose of service conversation (Wilson et al., 2005).
2 Barriers from The Patient and
Family Perspective
Surrogates must make difficult
judgments when patients cannot engage in the decision-making process. The
clinical literature contains many examples where surrogate caregivers for
critically ill patients have been inadequately prepared and supported in this
role (You et al., 2014). Most studies on advance care planning in ICUs have
focused on surrogate decision-making for patients with do-not-resuscitate
orders rather than goals of care discussions (Aleksova et al., 2016). Studies
that have looked specifically at surrogate decision-making for patients focusing
on care have found that surrogates often feel unprepared in making decisions
and have little knowledge on patient’s prognosis and treatment options (You et
al., 2014). In a qualitative study that involved family members with patients in
the ICU, 37% of participants felt that they had no enough information to make
decisions on behalf of their loved ones (Aleksova et al., 2016).
Surrogates frequently express a lack
of knowledge regarding the patient’s prognosis and treatment alternatives, in
addition to feeling unprepared. Surrogates for patients in the ICUs typically
feel ignorant about their prognosis (49%) and treatment alternatives (44%)
according to one study (12). Other studies have found similar results, notably
that relatives who cannot make decisions for their loved ones in the ICU
perceive a lack of information about their loved one’s prognosis and treatment
options (Aleksova et al., 2016). According to Aleksova et al., surrogates felt
more insufficiently educated about the patient’s diagnosis, clinical features,
and intended results with various therapies than the patients or professionals’
caregivers.
There is poor communication and lack
of knowledge amongst caregivers and patients in the EOL treatment decision-making
process. These results indicate that ICU patients and their surrogates will not
always be well-informed or ready to handle EOL choices, implying that
physicians and carers need to communicate more effectively (Aleksova et al.,
2016). Furthermore, family members might require additional knowledge regarding
the diagnosis and therapy alternatives to feel comfortable initiating decisions
about the future of their family members. If a client has a bad outlook, for
example, professionals should tell them about pain management and other
end-of-life options that could be beneficial.
The impediments to aim talks
observed in this study imply that adequately explained among clients,
relatives, and doctors. Furthermore, more research is wanted to create
treatments that will assist surrogates in feeling knowledgeable and equipped to
act on behalf of the family members. Clinicians who communicate this
information to surrogates could also ask questions on these topics. Another
option would be to provide more support and education to surrogates to increase
their knowledge about EOL decision-making.
The
Complexity of Substitute Decision Maker
1.
Difficult picking a Substitute
decision-maker
Patients who don’t have an advance instruction
or a healthcare proxy often don’t know who should speak for them. In such
cases, the decision of who will speak for the patient is often left to hospital
staff or friends and family members who may be struggling with their emotional
turmoil. For example, in a study of family members who had been asked to make
decisions for a critically ill loved one, nearly two-thirds felt unprepared or
uncomfortable with the responsibility (Quinn et al., 2017). Family members may
also disagree about what the patient wanted, leading to conflict and further
frustration.
In addition, surrogates may have
difficulty interpreting medical information and making decisions about complex
treatments. For example, a study of surrogates caring for patients with
traumatic brain injury found that many had difficulty understanding information
about the patient’s prognosis and treatment options (Quinn et al., 2017). Because
of this, surrogates and medical personnel may disagree over the best course of
action.
The
difficulty of making a decision when the substitute decision-maker is a trustee
of the government
Publicly conserved patients present
a unique challenge for surrogate decision-makers. In order to make resolutions
on the account of a patient under government cared, surrogates must often
navigate complex bureaucracies and legal systems. This can be very difficult,
especially if the surrogate is unfamiliar with the legal process or the medical
terminology used in court proceedings. For example, in a study of surrogate
decision-making for organ donation after cardiocirculatory death, both
surrogates and healthcare providers reported that the legal process was
difficult to navigate and often frustrating (Kryworuchko et al., 2016).
Also, surrogates may lack access to details
concerning the patient’s potential health outcomes during legal proceedings
because hospital staff is not always comfortable sharing this information with
surrogates who have no medical background. In one study, for example, surrogate
decision-makers reported being surprised by prognostic information during court
proceedings and said that they would have preferred to have had more time to
discuss the information with healthcare providers (Quinn et al., 2017).
2.
Difficult of the substitute
decision-maker of making the goal of care decision
Surrogates may also have difficulty
making decisions about the best course for a severely sick patient. Should the
goal, for example, be to prolong life at any costs, even if it means the
patient won't be able to return home or have any quality of life? Or is it more
important to focus on providing comfort and palliative care, even if it means
that the patient will no longer be alive in a few days or weeks? These
complicated questions require surrogates to consider complex information and
make difficult tradeoffs. For example, a study of surrogates of patients who
had died in the ICU found that many felt that they had made the wrong decision
about the goal of care (Quinn et al., 2017).
These are just a few examples of
surrogate decision-makers’ challenges when making decisions for a critically
ill loved one (Quinn et al., 2017). Several factors can contribute to poor
surrogate decision-making, including lack of data about the patient’s treatment
and prognosis choices, inability to understand medical information, lack of
access to information during legal proceedings, or conflicting opinions among
family members. Addressing these challenges will require collaboration between
surrogates, healthcare providers, and legal professionals. If there is adequate
communication and training on the patient's illness and potential therapies,
surrogates will be more equipped to make knowledgeable judgements that
represent the patient's needs.
Part
3: Barriers to the integration of palliative care in the ICU.
There are numerous obstacles to
palliative care inclusion inside the ICU. The first roadblock is a shortage of
knowledge about palliative care amongst medical providers. Many clinicians are
hesitant to provide palliative care because they assume it is reserved for
patients near death (Kyeremanteng et al., 2020). Clients may well not obtain
the hospice support they deserve as a consequence. Dillworth et al. observed,
for instance, that doctors rarely bring up the subject of end-of-life care with
patients and caregivers, even when the clients are terminally sick.
The additional stumbling block is
the ICU’s shortage of palliative capabilities. Only a few healthcare
professionals have received particular training in hospice care, and palliative
facilities have a limited number of rooms. Clients may be relocated to other
hospitals or units due to this, which can be inconvenient and unpleasant for
patients and family members. For instance, Alshehri et al. (2020) discovered
that a shortage of palliative care facilities in the ICU was an essential
aspect in implementing palliative care into the department. This can make
patients and family members feel rushed and stressed at an already stressful
moment.
The attitude of healthcare
practitioners regarding dying is the third obstacle. Many clinicians believe it
is their responsibility to save each person’s life, irrespective of the expense
or the severity of the patient’s pain. Patients may be kept on life support even
though they are anticipated to die, or they may be given therapies that may not
enhance the quality of life. For example, Suen et al. (2020) discovered that
several relatives believed their physicians were more concerned with saving the
patient’s life than with guaranteeing that they would have a high quality of
life. This is aggravating for families because it stops people from making the
greatest choice for their loved ones.
The
Consequences of Poor End of Life Care in the ICU
Consequence resulting from the poor purpose
of care discussion
One of the most serious issues that
develop during end-of-life care is poor end-of-life (EOL) care in the intensive
care unit (ICU); it is associated with delirium and poor surrogate decision-making
and has been a common event (Suen et al., 2020a). In a study by White et al.,
end-of-life discussions in the ICU were associated with higher family
satisfaction and low rates of surrogate discord. Secunda et al. discovered that
patients who received documents about EOL treatment in their medical records
before the termination of life support had much reduced family surrogate
discord and better family satisfaction in a retrospective cohort study.
1. Decreased quality of care,
particularly end-of-life care (EOLC).
Decreased quality of care can be
defined as suboptimal care or provision of care that does not meet the
patients’ needs. In the context of EOLC, decreased quality of care may lead to
a shortened life or an experience that is less than optimal (Secunda et al.,
2020). Suen et al. found that lower care quality was significantly associated
with less family satisfaction with end-of-life (EOL) care outside the hospital
setting (Suen et al., 2020a). Turnbull et al. also showed decreased surrogate
decision making in favor of life support when discussing prognoses that are not
documented in the medical record. Suen et al. also reported that poor surrogate
decision-making was associated with family satisfaction. Similarly, Secunda et
al. found that families who had their concerns documented in the medical record
before the withdrawal of life support had significantly lower family surrogates’
surrogate discord and higher family satisfaction.
2. Unwanted intervention medical
intervention resulting in suffering
Unwanted medical intervention can be
defined as medical care or treatment that the patient does not want or is unnecessary.
Emiloju et al. found that patients who did not have a do-not-resuscitate (DNR)
order was more likely to experience unwanted intervention in the ICU, which
often resulted in suffering. This suffering could be from medical procedures or
treatments that the patient found invasive and painful. All three articles
identified unwanted intervention due to poor goal of care discussion. Turnbull
et al. found that when the prognosis was not documented in the medical record,
there was an increase in life support interventions. Emiloju et al. also showed
that patients who did not have a DNR order were more likely to experience
unwanted intervention in the ICU. Lastly, Secunda et al. found that families
who had their concerns documented in the medical record before a withdrawal of
life support had significantly lower family surrogates’ surrogate discord and
higher family satisfaction.
3. Poor understanding of the prognosis
and diagnosis
Poor prognosis and diagnosis can be
defined as patients and families not fully understanding the prognosis and
diagnosis. This leads to a higher level of stress, anxiety, uncertainty and
fear. All three articles identified the poor understanding of prognosis and
diagnosis due to poor goal of care discussion. Wilson et al. demonstrated that
when families had concerns documented in the medical record, they reported a greater
understanding of prognosis and diagnosis. Secunda et al. found that families
who had their concerns documented in the medical record before the withdrawal
of life support had significantly lower family surrogates’ surrogate discord
and higher family satisfaction. Finally, Turnbull et al. showed that increased
decisional conflict was significantly associated with increased use of life
support interventions and decreased surrogate decision making in favor of life
support when discussing prognosis is not documented in the medical record.
Consequence of the Complexity of
Substitute Decision Maker in the ICU.
The complexity of surrogate
decision-making is the second factor contributing to poor EOL treatment in the
ICU. Surrogates might be friends, family members or medical substitutes. Surrogate
decision-making is often driven by the idea of substituted judgment, which
assumes that if surrogates were intelligent to participate in the verdict-making
process themselves, they would make a reasonable conclusion about what the
patient would want. For surrogates, this principle is controversial. Instead of
relying on substituted judgment, surrogate decision-makers frequently consider
what the patient would desire if they could make the decision themselves (23).
This results to increase family conflict and increased incidence of anxiety,
depression for patients and substitute decision-makers.
1. Increase family conflict
The literature has consistently
shown that family conflict is a common consequence of ICU surrogate
decision-making. In one study, Scheunemann et al. (2019) found that family
members frequently disagreed about the best course of action for their loved
ones. This disagreement often led to increased stress and tension within the
family. In a more recent study, Suen et al. (2020a) found that surrogate
decision-makers who were uncertain about what their loved one would want
experienced increased stress and anxiety levels. In another study, Turnbull et
al. (2019) found that family members frequently disagreed about the best course
of action. Differences in surrogate preferences and values, as well as
arguments concerning the patient’s prognosis, were the most common causes of
disagreement. These disagreements often led to increased stress and tension
within the family.
2. Increased incidence of anxiety,
depression for patient and substitute decision-makers
In addition to family conflict,
there is also evidence that anxiety and depression are common among patients
and surrogate decision-makers in the ICU. For example, Quinn et al. (2017)
found that patients approaching the end of life in the ICU had higher rates of depression
and anxiety than patients who were not nearing the end of life. In addition,
surrogate decision-makers were also found to experience higher rates of
depression and anxiety in a recent study (Wilson et al., 2015). For example,
surrogate decision-makers who were uncertain about what their dear one would
want had greater anxiety and sadness levels. The findings show the significance
of providing support to patients and surrogate decision-makers in the ICU.
Implement Strategies to Facilitate,
More Time-Responsive GOC Discussions
The use of a validated scoring
system, such as the SOFA score or the Acute Physiology and Chronic Health
Evaluation II (APACHE II) score, can help to provide an objective measure of a
patient’s clinical status and prognosis, which can then be used to inform
timely discussions about goals of care (Orr, 2020). For example, a daily
prognostic assessment of the patient’s mortality risk may serve as a trigger to
facilitate earlier GOC discussions (Orr, 2020). Also, the use of validated
scoring systems for patients with “do not resuscitate” (DNR) orders, such as
the Richmond Agitation-Sedation Scale (RASS), may facilitate timely discussions
related to GOC (Orford et al., 2019; Orr, 2020). Nurses and physicians often
overestimate an individual patient’s prognosis, even in patients who are
critically ill (Shickel et al., 2019). Thus, standardizing prognostic
assessments can help to facilitate earlier discussions about GOC.
The use of mortality prediction
scores such as “DeepSOFA: A Continuous Acuity Score for Critically Ill” (Shickel
et al., 2019, p.1) can help the HCP during GOC discussions in clarifying the
patient diagnosis and prognosis. DeepSOFA is a machine learning algorithm that
uses clinical data to predict mortality in critically ill patients (Shickel et
al., 2019). The DeepSOFA score has been found to be more accurate in predicting
mortality than the APACHE II score (Shickel et al., 2019). The “DeepSOFA” score
can be used to better quantify clinical status during daily rounds,
facilitating earlier GOC discussions (Shickel et al., 2019). For example,
DeepSOFA is a continuous acuity score, which is not a prognostic predictor but
can provide a metric of patient status during daily rounds and serve as a
trigger to facilitate GOC (Shickel et al., 2019). Another way to implement
strategies to facilitate more time-responsive GOC discussions by implementing
daily prognostic assessments is to implement the Clinical Frailty Scale (Orford
et al., 2019). The Clinical Frailty Scale has been found to be an accurate
measure of mortality risk in critically ill patients (Orford et al., 2019).
Additionally, communication training curriculums have successfully improved
communication between HCPs and SDMs during GOC discussions (Orford et al.,
2019; Simpson et al., 2019).
Intervention To Help Substitute
Decision Maker
When a patient is reaching the end
of their life and is unable to make decisions on their own, a surrogate
decision-maker is chosen to act on their behalf. This can be a difficult task,
as there are many factors to consider when making care decisions. A study
published in the Journal of Palliative Medicine looked at how best to support
surrogates in the ICU. The study found that providing support to surrogates
through a palliative care consultation service improved decision making and
increased patient satisfaction. The consultation service helped surrogates better
understand the patients’ care goals and made it easier for them to make
decisions that aligned with those goals.
Intervention To Improve SDM Decision
Making
1. Developing a decision aid to assist
SDMs in setting goals of care for patients with traumatic brain injuries.
According to Emiloju et al. (2020),
a decision aid is an intervention that helps individuals make informed
decisions. It is a structured tool that provides information in a clear and
concise format, intending to facilitate decision making” (p. 433). In their
study, Emiloju et al. (2020) investigated whether using a decision aid could help
surrogates set goals of care for patients with traumatic brain injuries. They
found that the use of the decision aid helped strengthen communication between
surrogate and health care team, resulting in improved decision making around
patient treatment. Patients suffering from traumatic brain injuries often have
a poor prognosis, and difficult choices need to be made about their care. In
this situation, a decision aid can assist the SDMs in ensuring that the
patient's desires are honored and that the best possible treatment is provided.
Intervention to improve SDM decision
making
Intervention to improve SDM decision-making
can also be used to evaluate such tools and frameworks for their acceptability
and feasibility so that they can be positively used to contribute in GOC
discussions for a patient, families, SDM, and HCP (Muehlschlegel et al., 2020).
The goal of Muehlschlegel et al. (2020) was to assess the effectiveness and
feasibility of a tool created by an interdisciplinary team meant to help
surrogate decision-makers set goals of care for their loved ones. The
investigators found that the decision aid helped strengthen communication between
SDMs and health care teams, resulting in improved patient treatment decisions.
However, they also found it difficult to create incentives for health care
teams to use the decision aid. Quinn et al. (2017) found that an intervention
to improve SDM decision-making in the setting of goals of care for patients
with the chronic obstructive pulmonary disease could be effective, but the
investigators also discovered the need for further training and education for
surrogates.
2. Develop working groups with
representatives from all stakeholders
Developing working groups with
representatives from all stakeholders can help evaluate and continuously
improve the methods of implementation (Scheunemann et al., 2019). Scheunemann
et al. (2019) found that using a tool created by an interdisciplinary team
designed to help SDMs make decisions was effective and feasible, but the investigators
also reported that more work is necessary to continually improve its
implementation methods. An example of such a working group is the National
Quality Improvement Program for End-of-Life Care in the ICU (Quinn et al.,
2017). The purpose of this program was to develop and evaluate an intervention
designed to improve communication between surrogates and health care teams,
resulting in improved decision-making about patient treatment (Quinn et al.,
2017). Patients suffering from chronic obstructive pulmonary disease often have
a poor prognosis, and difficult decisions need to be made about their care (Quinn
et al., 2017). The intervention developed by Quinn et al. (2017) successfully
improved SDM decision-making, but more work is needed to ensure that it is
successfully implemented in clinical practice.
3. Improve a comprehensive,
collaborative, empathetic approach
Improving a comprehensive,
collaborative, empathetic approach can help promotes open lines of
communication between the health care providers and family (Wilson et al., 2015).
Early, scheduled, and frequent discussions led by APNs help in improving patient
support and SDM establishing GOC (Wilson et al. 2015). According to Wilson et
al. (2015), all members of the health care team should work together to improve
the quality of GOC discussions. Wilson et al. (2015) also identified strategies
for improving communication during these discussions, including making sure all
members of the health care team are present during the discussion and using
open-ended questions, paraphrasing, and reflective listening. Furthermore, they
stress the importance of having a compassionate and collaborative approach that
promotes open lines of communication between the health care providers and
family (Wilson et al., 2015).
Intervention
To Help the Choice of Substitute Decision Maker and Help Substitute Decisions
Maker, Make Patient-Centered Care.
An intervention designed to help
surrogate decision-makers make better patient-centered decisions about care was
found to be effective and feasible, but more work is needed to improve its
implementation methods (Scheunemann et al., 2019). The study by Scheunemann et
al. (2019) looked at using a tool created by an interdisciplinary team designed
to help SDMs make decisions. The investigators found that the tool was
effective and feasible, but more work is still necessary to improve its
implementation methods (Scheunemann et al., 2019). Patients suffering from
chronic obstructive pulmonary disease often have a poor prognosis, and
difficult decisions need to be made about their care (Wilson et al., 2015). Wilson
et al. (2015) discovered that members of the health care team should
collaborate to guarantee optimal communication during GOC meetings.
Intervention To Improve Palliative
Care In ICU
Intervention To Improve Palliative
Care is an intervention that was successful in improving SDM decision making,
but more work is needed to ensure that it is successfully implemented in
clinical practice (Quinn et al., 2017). The study by Quinn et al. (2017) looked
at using a tool created by an interdisciplinary team designed to help SDMs make
decisions about EOL care. The investigators found that the tool was effective
and feasible, but more work is still necessary to improve its implementation
methods (Quinn et al., 2017). This shows that additional work is needed to
guarantee that treatments aimed at assisting SDMs in making better
patient-centered care decisions are implemented successfully in clinical
practice. To offer the best care for patients reaching the end of their lives,
all members of the health-care team must collaborate.
Conclusion
The literature reports suboptimal
EOL care in the ICU. There are many barriers to providing optimal EOL care,
including suboptimal SDM decision making, complexities of surrogate
decision-making, and poor integration of palliative care into all aspects of
patient care (Emiloju et al., 2020). Interventions that focus on helping
surrogates make better patient-centered decisions about care need to be
successfully implemented to improve the quality of EOL care for ICU patients.
The investigators found that the tool was effective and feasible, but more work
is still necessary to improve its implementation methods (Quinn et al., 2017).
This suggests that more work is needed to ensure that interventions designed to
help SDMs make better patient-centered decisions about care are successfully
implemented in clinical practice settings. This study provides valuable
information about the barriers to providing optimal EOL care in the ICU. The
investigators identified three common themes that contribute to poor EOL care
in the ICU: barriers to the goal of care discussion, complexities of surrogate
decision-making, and poor integration of palliative care into the ICU (Emiloju
et al., 2020). These themes present an area that needs further investigation to
improve EOL care in the ICU. This study has several limitations, including that
it was conducted with a very small group of patients and surrogates. Larger
sample size would provide more accurate results that suggest how EOL care could
most effectively be improved for ICU patients.
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