Group Members:

   

Roshan Jan Muhammad Choi Jee Young Nesreen Abdulmannan Shalia Gregory

    

Describe the practice issue, its magnitude and significance.

Discuss relevance of the issue to nursing and potential consequences if the problem is not resolved. Describe nursing theory used to solve the problem. Evaluate theory using established criteria and discuss the limitations.

List solutions to the problem using identified nursing theory

.

What is Good death?

What it means to individual patients and how do we offer peaceful death in Intensive Care Setting?

Theory: Peaceful End of life

• • 540, 000 deaths occur per year in ICU, which corresponds to 20% of all deaths in USA. Approximately half of the patients who die in hospitals are cared for in ICU within 3 days of death.

(

Montagani, 2012)

Death trajectories: (a) Sudden Death, (b) Cancer Deaths, (c) Death from advanced non-oncological disease (COPD, cardiac insufficiency, HIV-AIDS), (d) Death from dementia.

BACK GROUND

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Fear and anxiety in patients confronting death. Fear of death Fear of pain (physical, mental, social, psychological, spiritual) Fear of unpleasant experiences and appearance.

Loss of self determination Fear of loneliness and isolation Quality of life during end of life Fear of becoming burden to the family and society Fear of death as a feeling that ones life tasks are still incomplete Loss of meaning Guilt/regret Fear of death as a fear of extinction Anxiety of death as anxiety towards unknown Fear of death as a fear of judgment and punishment after death (Deeken, 2009),(Goldsteen, Houtepen, Proot, Abu-Saad, Spreeuwenberg, & Widdershoven, 2006a ),

(Hayden, D. (2011).,

(Lunder, Furlan, & Simonic, 2011)

• • • • • • • • • • • • • •

GOOD DEATH Highly individualized experience

Being in control Being comfortable and free of pain Having a sense of closure and completion of final responsibilities Having trust in care providers Recognizing the impending death Avoid inappropriate prolongation of dying Leaving a legacy.

Minimizing burden Optimizing relationships with lovedones Affirming/recognizing the value of the dying person Living one’s life till end Honoring beliefs and values Caring for family Acknowledging the level of appropriateness of the death

(Kehl, 2006 )

DEATH IN ICU

http://www.youtube.com/watch?v=F6xPBmkrn0g

 Critical care environment does not adequately foster compassion that dying patients need . (Beckstrand, Callister, & Kirchhoff, 2006)  They continue to suffer pain and other distressing symptoms and receive aggressive therapies until the moment of death. Patient satisfaction with pain control is worse in ICU than other hospital setting. (

Montagani, 2012)

 High number of patients are unable to communicate their needs and wishes because of sedation, coma, delirium….. (

Beckstrand

, 2005)  In USA 60-80% time family members are involved in end of life care decisions.

(Mularski, 2005 )  ICU doctors lack skills to provide good palliative care.

 Nurse patient ration, time constraint and assignment system pose challenge .

   

Quality of death and dying in ICU (QODD)

24% patients were not aware they were dying 34% patients were aware of dying only during last 7 days of life.

Mean ICU QODD score = 60 (0-100) ICU as a place of death = 61 (0-100) Pain under control Variables Saying goodbye to loved ones Unafraid of dying Keeping dignity and respect Feeling at peace with dying Control of events Score P value 47 47 39 32 30 8 0.009

0.006

<0.001

0.001

<0.001

<0.001

(Mularski, Heine, Osborne, Ganzini, & Curtis, 2005)

Patient Family/signifi cant others • Depression • Guilt • Burnout •Syndrome of depersonalization •Emotional exhaustion • Lower sense of personal accomplishment • Moral residue and distress Health Care Professionals Health Care System •Financial ramification Mularski, 2005) (Beckstrand & Kirchhoff, 2005, 2006)

 Death is a common phenomena in nursing practice.  Focus of medical/ technical care digress broader efforts to improve care of those near death.  Terminally ill patients demand compassionate care not curative treatment.

 Nurses can bridge the communication gap between patient, family and physician during end of life care decisions.

 Promotes and advocates for rights of dying patient.

 Play vital role in preparing patient and families for transition in treatment goal. (Fighting death ……seeking good death).

 We have unique relational bond with the patient and family.

 Sensitive to individualized patient’s needs.  Individualized care planning  Help terminally ill patients and families find closure and peace during the final time of life treat them with dignity, respect and empathy.

Developed by Cornelia M. Ruland and Shirley M. Moore. standard of Care “End of life care”.

Empirical evidence from direct experience.

Evidence based .

Theoretical underpinning Donabedian’s model (general system theory) Preference theory of Brandt

Peaceful end of life

(Alligood, Tomey, 2010)

 The occurrence and feelings at the EOL experience are personal and individualized.

 Nursing care is crucial for creating a peaceful EOL experience.  Family that includes all significant others play important part in EOL care.  The goal of EOL care is to maximize treatment that is best possible care provided through judicious use of technology and comfort measure to enhance quality of life and achieve a peaceful death and not overtreatment.

(Alligood, Tomey, 2010)

(Alligood, Tomey, 2010)

Not Being in Pain Monitoring and administering pain medication Experience of Comfort Preventing monitoring and relieving physical discomfort Experience of dignity and respect Being attentive to patient’s expressed needs, wishes and preferences Applying pharmacologi cal and non pharmacologi cal measures Facilitating rest, relaxation and contentment Including patient and significant others in decision making Preventing complications Treating patient with dignity, empathy and respect Being at peace Providing emotional support Monitoring patient’s needs for antii- anxiety medications Inspiring trust Providing patient and significant others with guidance in practical issues Providing physical assistance to another caring person Closeness of significant others Facilitating opportunities for family closeness Facilitating participation of significant others in patients care Attending to significant others grief, worries and questions

1) 2) 3) 4) 5) 6) Monitoring and administering pain relief and applying pharmacologic and nonpharmacologic interventions contribute to the patient's experience of not being in pain .

Preventing, monitoring, and relieving physical discomfort, facilitating rest, relaxation, and contentment, and preventing complications contribute to the patient's experience of comfort .

Including the patient and significant others in decision making regarding patient care, treating the patient with dignity, empathy, and respect, and being attentive to the patient's expressed needs, wishes, and preferences contribute to the patient's experience of dignity and respect .

Providing emotional support, monitoring and meeting the patient's expressed needs for anti anxiety medications, inspiring trust, providing the patient and significant others with guidance in practical issues, and providing physical presence of another caring person if desired contribute to the patient's experience of being at peace.

Facilitating participation of significant others in patient care, attending to significant other's grief, worries, and questions, and facilitating opportunities for family closeness contribute to the patient's experience of closeness to significant others or persons who care .

The patient's experiences of not being in pain, comfort, dignity, and respect,being at peace, closeness to significant others or persons who care contribute to peaceful end of life

(Alligood, Tomey, 2010)

 Theory covers maximum aspects of peaceful end of life.  Derived from standard of Care that is grounded into core value of nursing “CARING”.

 End of life care for terminally ill patients in acute care setting.  Relates patient’s personal definition of ‘quality of life’ and perspective of ‘Good death”.

 Interventions are, measurable, attainable and based on scientific knowledge.  Patient and family centered care.

 Developed by nurses and guides nursing practice.

SIGNIFICANCE

Physical, psychological, social, spiritual dimension of care.

Individualized care planning Standard of care as a source of theory development. Focus of core value of nursing “Caring”.

Evidence based practice. Guides nursing practice. Provides avenue for research in related field. High level middle range theory

ADEQUACY

Addresses fear of death and domains of good death.

Applicable to wide range of patients regardless of diagnosis.

All relational statements does not have empirical support.

Belief system, religion and spirituality is not fully integrated. Applicability into various setting has not been tested. Fawcett, J. (2000) Alligood, M.R., & Tomey, A.M. (2010)

CLARITY AND CONSISTENCY FEASIBILTY

Use of simple and uncomplicated terms and clear expression of ideas.

Setting and patient population is clearly defined.

All elements of theory (concepts, assumptions and relational statements) are stated clearly.

Constructs and philosophical claims are consistent and congruent.

Abstract concepts (dignity, peace) are operationalized well. Feasible for intensive care unit setting. Specific boundaries to setting and patient population. Applicability is limited in case of patients rapidly approaching to death. Applicability in pediatric patient and with different culture is not tested. Fawcett, J. (2000) Alligood, M.R., & Tomey, A.M. (2010 )

“I am not afraid of death, I just don't want to be there when it happens”

Woody Allen

What is Good death?

What it means to individual patients and how do we offer peaceful death in Intensive care setting?

Anticipatory Phase Dying Phase Care following Death

Not Being in Pain Monitoring and administering pain medication Experience of Comfort Preventing monitoring and relieving physical discomfort Experience of dignity and respect Being attentive to patient’s expressed needs, wishes and preferences Applying pharmacologi cal and non pharmacologi cal measures Facilitating rest, relaxation and contentment Including patient and significant others in decision making Preventing complications Treating patient with dignity, empathy and respect Being at peace Providing emotional support Monitoring patient’s needs for antii- anxiety medications Inspiring trust Providing patient and significant others with guidance in practical issues Providing physical assistance to another caring person Closeness of significant others Facilitating opportunities for family closeness Facilitating participation of significant others in patients care Attending to significant others grief, worries and questions

ADVANCED CARE DIRECTIVE (Code, Care limits, proxy) COMMUNICATION

Intensivist Nurse Subspecialty Consultants Pharmacist Respiratory therapist Nutritionist

Nurse Intensivist Family/friends Nurse Doctor Others Pharmaci st Palliative Nurse Respiratory therapist Nutritionist Chaplain Social worker

Not being in Pain Closeness to significant others Experience of comfort Being at peace Experience of dignity and respect

                             NOT BEING IN PAIN Conduct pain assessment every 1-2 hourly.

Use behavioral pain scale and critical care pain observation tool to quantify pain. Involve family members in assessing pain Morphine infusion for pain management. Discuss and define goal of pain management.

Beware of double effect. Prophylaxis pain management before painful procedure, aggressive physical activity like bathing, suctioning, wound care. Minimize invasive painful procedure.

Physiotherapy and massage.

Therapeutic touch Palliative sedation also known as total sedation, terminal sedation for intractable suffering EXPERIENCE OF DIGNITY AND RESPECT            EXPERIENCE OF COMFORT Symptoms management for dyspnea, agitation, delirium, nausea, vomiting.

Withdrawal of ineffective or burdensome therapy.

Minimize invasive painful procedure.

Hygiene care, positioning.

Provide intermittent rest.

Physiotherapy and massage.

Music Care of wounds and devices Clean, odor free environment Undistracted calm environment Palliative sedation also known as total sedation, terminal sedation for intractable suffering.

BEING AT PEACE Respect patient desires for aggressive treatment and resuscitation.

Reassess patient ongingly for expressed wishes Involve patient in decision making if competent. Ongoing communication with patient to keep him informed.

Shared decision making process with family.

Visit patient frequently to avoid feeling of abandonment. Arrange sitter to avoid restraint.

Coordinate organ donation as per patient’s desire. Observe moment of silence with family when patient die. Funeral arrangement as per patients desire.

         Provide emotional support and empathy. Wheel patient outside ICU in sunlight, fresh air.

Share good memories Add sensitive humor to the care.

Facilitate opportunities to forgive and being forgiven Care sensitive to their belief system Allow patient/family to offer prayers/hollywater offer rituals.

Involve chaplain or religious representative in care. Respect patient preference for place of death CLOSENESS OF SIGNIFICANT OTHERS Flexible visiting hours.

Involve family members in assessing pain. Undistracted calm environment Brief interruption of sedation or analgesia to allow interaction of patient and family if possible. Provide opportunity for private patient and family interaction Facilitate family complete unfinished business Remind family that hearing stays longer than any other sense and encourage them to continue talking to patient and offer prayer.

Allow/encourage family to be with patient at the time of death . (

Watts, T. (2012), (Beckstrand, 2006)

     Respect and dignity for the body.

Cultural and religion sensitive last offices.

Involve family members.

Facilitating organ donation process.

Support for family and friends.

Communication Competencies of doctor and nurses

• Education of staff to improve communication skills and competencies related to EOL care.

Staffing and scheduling patterns

• End of life care pathway.

• Involvement and family members into care.

• Involvement of palliative care team.

Non-availability of advanced directives

• Institutional policy change.

• Primary care physician and advanced care practitioners propagate advanced care directive. • Brochure for advanced care directive .



Tune into what I’m going through here. Be present with me here and now.”

 Beckstrand, R. L., Callister, L. C., & Kirchhoff, K. T. (2006). Providing a "good death": Critical care nurses' suggestions for improving end-of-life care.

Care Nurses, 15

(1), 38-45; quiz 46.

American Journal of Critical Care : An Official Publication, American Association of Critical-

 Beckstrand, R. L., & Kirchhoff, K. T. (2005). Providing end-of-life care to patients: Critical care nurses' perceived obstacles and supportive behaviors.

Nurses, 14

(5), 395-403.

American Journal of Critical Care : An Official Publication, American Association of Critical-Care

 Deeken, A. (2009). An inquiry about clinical death--considering spiritual pain.

Keio Journal of Medicine, 58

(2), 110-119.

The

 Fawcett, J. (2000).

Analysis and evaluation of contemporary nursing knowledge

.

Nursing models and theories

. Philadelphia: F. A. Davis.  Goldsteen, M., Houtepen, R., Proot, I. M., Abu-Saad, H. H., Spreeuwenberg, C., & Widdershoven, G. (2006a). What is a good death? terminally ill patients dealing with normative expectations around death and dying.

Patient Education and Counseling, 64

(1-3), 378-386. doi:10.1016/j.pec.2006.04.008

 Goldsteen, M., Houtepen, R., Proot, I. M., Abu-Saad, H. H., Spreeuwenberg, C., & Widdershoven, G. (2006b). What is a good death? terminally ill patients dealing with normative expectations around death and dying.

Patient Education and Counseling, 64

(1-3), 378-386. doi:10.1016/j.pec.2006.04.008  Hayden, D. (2011). Spirituality in end-of-life care: Attending the person on their journey.

British Journal of Community Nursing, 16

(11), 546-551.  Kehls, K. (2006). Moving towards peace: An analysis of the concept of good death. Americal

Journal of Hospital Palliative Care,

23 (4), 277-286.  Kongsuwan,W. & Locsin R.C.(2009) Promotion peaceful death in the intensive care unit in Thailand international Nursing Review 56,116-122  Lunder, U., Furlan, M., & Simonic, A. (2011). Spiritual needs assessments and measurements.

Current Opinion in Supportive and Palliative Care, 5

(3), 273-278. doi:10.1097/SPC.0b013e3283499b20

 Alligood, M.R,& Tomey, A.M. (2010). Nursing theories and their work. Mosbey : Eleseiver.  Mazor, K. M., Schwartz, C. E., & Rogers, H. J. (2004). Development and testing of a new instrument for measuring concerns about dying in health care providers.

Assessment, 11

(3), 230-237. doi:10.1177/1073191104267812  Montagani, M, & Balisterieri. (2012). Assessment of self perceived End of life care Competencies of Intensive care unit providers.

Journal of Palliative Care

, 15(1).

 Mularski, R. A., Heine, C. E., Osborne, M. L., Ganzini, L., & Curtis, J. R. (2005). Quality of dying in the ICU: Ratings by family members.

Chest, 128

(1), 280-287. doi:10.1378/chest.128.1.280  Thelen, M. (2005). End-of-life decision making in intensive care.

Nurse, 25

(6), 28-37; quiz 38.

Critical Care

 Watts, T. (2012). End-of-life care pathways as tools to promote and support a good death: A critical commentary.

European Journal of Cancer Care, 21

(1), 20-30. doi:10.1111/j.1365-2354.2011.01301.x; 10.1111/j.1365-2354.2011.01301.x