End-of-Life Care in Intensive Care Units: An Annotated Bibliography

Desklib provides past papers and solved assignments for students. This annotated bibliography explores end-of-life care in ICUs.

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Annotated bibliography
Clarke, E.B., Curtis, J.R., Luce, J.M., Levy, M., Danis, M., Nelson, J. and Solomon, M.Z., 2003.
Quality indicators for end-of-life care in the intensive care unit. Critical care medicine, 31(9),
pp.2255-2262.

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End of life experience in itself is a very drastic experience and for a person to be breathing last in
intensive care unit makes it more difficult. The person at the end stage of his life requires a
comfortable environment with care and support and not to be dying alone in pain in the intensive
care unit. In order to provide a supportive environment to a patient at the end stage, it is
necessary to bring improvement in the support and care provided in the intensive care unit. This
study focuses on identifying deficiencies in the intensive care unit and preparing a team or
specific clinicians and changing organisational behaviour to improve support and care for a
person in the end stage. It aims to identify the end of life care indicators through a consensus
process in the intensive care unit. It also aims at developing organisational behaviour and
specific clinician for improvement of the end of life care indicators. This study involved 36
members of the Robert Wood Johnson Foundation with 15 nurses and physician team selected
from 15, Intensive Care unit affiliated to the group members. 14, adult surgical, medical and
mixed intensive care unit was selected from Canada, Columbia, and 13 states. Consensus on end
of life domains was constructed based on literature review and interactive sessions with the
members. The collaborative process of nurses and physician was established to discuss and
identify the end of life quality indicators from the domains. The result suggested the
development of 7 ends of life domains 1. Family or patient centred decision 2.Communication 3.
Care continuity 4. Practical and emotional support 5.Comfort and management 6.Spiritual
support 7.Organisational support for clinicians. All of the 7 domains involved quality indicators
thus a total of 53 End of life care indicators was developed. Along with this 100 examples were
proposed on organisational behaviour and specific clinicians for improving end of life quality
indicators.

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Ray, D., Fuhrman, C., Stern, G., Geracci, J., Wasser, T., Arnold, D., Masiado, T. and Deitrick,
L., 2006. Integrating palliative medicine and critical care in a community hospital. Critical care
medicine, 34(11), pp.S394-S398.
End of life care focuses on caring and supporting a person physiologically but not many people
focus on the psychological and spiritual aspect of care that is required at the end stage of life.

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Caring of a person through a physiological aspect is not enough and care providers or
professionals need to focus on the psychological and spiritual approach which strengthens the
person emotionally and provides them with both emotional and practical support. Psychological
and spiritual support can be provided through communication with family and patient and
making them comfortable in the environment. There has to be a psychological and spiritual
understanding between professionals and patient to enhance the quality of care and make the
patient comfortable in the environment. This study focuses on the importance of psychological
and spiritual support to patients in the intensive care unit at the end stage of life. The rationale of
the study was to improve palliative care in a community hospital by implementing education,
environment, communication, and clinical interventions. The aim was to incorporate patient
centred quality care to relive the physical, emotional, psychological and spiritual suffering of
patients. The quality care indicators developed by the Robert wood Johnson care foundation was
taken into consideration for the chosen interventions. 3-year intervention plan from 2003-2006
was established at Lehigh valley hospital with 600 beds and 16 beds in the intensive care unit.
The monthly assessment was done through nurses and bimonthly assessment through physicians.
It suggested that new technologies created both barrier and opportunity and thus these
interventions were adapted except for family centred care as it required the approval of family.
The results of the study of implementing interventions match up to the quality standards
established by Robert wood Johnson care. These interventions involved educating the clinicians,
patients, and family about psychological and spiritual understanding, changing a clinical practice
which means changes in practical approaches to make the environment comfortable and to
establish communication and enhance to attain quality palliative care at the end stage of life.

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Mosenthal, A.C., Murphy, P.A., Barker, L.K., Lavery, R., Retano, A. and Livingston, D.H.,
2008. Changing the culture around end-of-life care in the trauma intensive care unit. Journal of
Trauma and Acute Care Surgery, 64(6), pp.1587-1593.
In the intensive care unit, most of the patients die a traumatic and painful death with their
injuries. For a person in the end stage of life, caring and supporting environment is required in
the intensive care unit. Decisions in such settings need to be taken quickly to decrease the pain of
a patient and to lead them towards an easy death. Changes or interventions in the care system
will not affect the mortality rate but it will definitely provide ease and comfort to the dying

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patient. It is suggested that communication between the family and professionals can enhance
care and support to a patient with easy and quick decisions regarding the patient and the care
plan. This study aims to implement interventions to enhance decision making and care provided
in the intensive care unit. It emphasizes on improving end of life care with trauma patients in the
intensive care unit with structure care and communication. In this study observational pre and
post study was conducted on trauma patients in ICU before intervention implementation and
after intervention implementation. It involved 2 parts with the first part focusing at the time of
admission with implementation on support to the family, assessing prognosis and considering
patient preferences. In part 2 which is assessed after 72 hours of patient admission involved
implementation of a family meeting. Data was collected from physician rounds, medical records,
and family meetings. The results suggested 83% of a patient receiving part 1 intervention and
69%patient with part 2 interventions. Discussion of goals for care increased among physicians by
4% but the mortality rate was stagnant along with DNR and withdrawal of life support which
was stagnant as well but the implications of DNR and WD were done at the earliest. Also, there
was a decrease in the stay of patients in ICU suggesting improvement in services with
communication between family and professionals.
The end stage of life is a crucial time for the patient and the patient requires extensive support
and care to relieve the pain and ease the suffering. Most of the patient in the end stage of life is
seen in the intensive care unit with pain and require palliative support and care from the
clinicians. It is often observed that patient preferences are not considered when taking care of
patients in their end stage. Many patients prefer having family and friends at the end stage of life
to provide support and love but this protocol cannot be accepted for patients in the intensive care
unit. To stick to the protocol of the hospital and to maintain safe environment health

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professionals don't allow the family to be with the patient for a longer time which is important as
well. But it is important for health centres to consider the preferences and requirements of
patients as well. For this nurses play an important role in making the patient comfortable and
support them to ease their pain.
The responsibility of nurses is not just to take care of patient physiologically but it is also
important to understand them psychologically and spiritually. As described by the article above
psychological and spiritual support to a patient is essential for mental stability and support to
patients. Nurses should be given training and knowledge about a psychological and spiritual
understanding with the patient. There needs to be strong communication between patients and
nurses to develop and understand and to provide support and ease to patients. Nurses should
follow the protocol and principles of the hospital at the same time provide support and care to the
patients by considering patient preferences. It is important for nurses to discuss the condition of
patients to the family members so that effective results and discussion process can result in a
quick decision. As described in the article that discussion and conversation between family and
professionals are necessary to bring effective and quick decisions.
Nursing practice should involve effective treatment planning and palliative care for patients in
the end stage of life in the intensive care unit. Nurses should ensure that the environment in the
intensive care unit is positive and should take it as a responsibility of care and support for every
patient. It is important for the nurses to take into consideration about patient preferences and
respect patient choices. Patients in the end stage of life have preferences to be treated and cared
in a certain way and also they need support and care of family members and need to be loved.
Nurses should develop a positive environment for patients and interact with them in a way to
ease their problems and be psychologically supportive. It is the responsibility of nurses to gain

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such psychological and spiritual knowledge so that it can be implemented in patient care to
support them to enhance the quality of life and care at the end stage. Thus nurses play an
important role in providing support to patients and care to patients at the end stage of life.