Browsing by Subject "critical care"

Background/importance

Objective

Evidence review

Findings

Conclusions

Problem: Family members of patients dying in the ICU are faced with agonizing dilemmas, the consequences of which might haunt them for a lifetime. Providing these family members with meaningful support and information is imperative. Nurses, by virtue of the time spent at the bedside and knowledge of patient and family needs, are in a unique position to support family members. The literature provides ample studies of how nurses perceive they are involved in EOL decision-making and several studies describing what family members perceive that they need from health care professionals in general. What is lacking is literature that describes the family members' perceptions of the specific strategies that nurses use to support their decision-making and how family members respond to these strategies. Because nurses might act on instinct, the strategies they use might or might not be helpful to family members. This study builds on prior work by exploring in greater depth the involvement of nurses in EOL decision-making, the specific strategies that family members perceive nurses using, and how family members respond to these strategies. This study aims to explore how family members respond to nursing strategies to support EOL decision-making, including family members perceptions of the strategies nurses use, how these strategies change over the trajectory of decision-making, and how these strategies affect their ability to make decisions consistent with the goals of the patient and their ability to cope with the stress of making EOL decisions.

Methods: Chapter two describes a systematic review of the literature that was conducted to define areas where research is needed. Chapter three describes a pilot case study that was conducted to determine the feasibility of conducting a prospective longitudinal study of family members making EOL decisions for their loved one in an ICU. Chapter four describes a prospective, longitudinal, qualitative descriptive study. In this study, the PI identified ICU patients who were likely to need complex decision-making and used narrative style interviewing techniques to explore the family members' perceptions of the strategies nurses use and the effectiveness of these strategies. Participants were recruited from a 16 bed adult medical ICU and a 16 bed surgical ICU at Duke Hospital, a tertiary care university hospital system.

Results: These studies identified three roles enacted by nurses: information broker, supporter, and advocate. While enacting these roles, nurses used a myriad of strategies categorized into five approaches: Demonstrate concern, build rapport, demonstrate professionalism, provide information, and support decision-making. This study provides empirical evidence that when interacting with family members of patients who were transitioning from curative to palliative care in the ICU, nurses used strategies that helped family members cope, to have realistic hope, to have confidence and trust, to prepare for the impending loss, to accept that their loved one was dying, and to make decisions. These findings also suggest that nurses were able to demonstrate flexibility in the use of the strategies, responding to the needs of the family members.

Although nurses used many helpful strategies to support family members, some nurses used strategies that negatively affected the family members' trust and confidence in the nurses, increased their difficulty coping, and, in some cases, might have delayed decision-making. Few of these strategies have been previously described in the nursing literature.

Summary: Knowledge from this study will pave the way for developing expert nursing practices for intervention studies targeting the areas identified as important by family members, most likely to improve their ability to make decisions on behalf of their loved one and to improve their well-being, and feasible in ICU environment.

Background: Sepsis is a leading cause of death and disability globally. Despite a high burden of sepsis in sub-Saharan Africa, clinical data for sepsis in that setting are limited. We sought to describe the clinical characteristics, management, and outcomes in a cohort of adults and adolescents with sepsis in northern Tanzania. We also assessed for associations between clinical factors and in-hospital mortality.

Methods: We carried out a prospective observational cohort study at Kilimanjaro Christian Medical Centre in Moshi, Tanzania. We collected data on demographics, baseline clinical characteristics, and management, with an emphasis on hours 0-6 after arrival to the Emergency Department. Log risk regression was carried out to assess for associations between demographic and clinical factors and our primary outcome of in-hospital death. Separate multivariable regression analyses were conducted for both antimicrobial administration by hour 6 and administration of intravenous (IV) fluids >1L by hour 6 and the outcome of in-hospital mortality.

Results: Fifty-eight participants were included in our analysis. Seventeen (29.3%) participants died in-hospital. Baseline characteristics associated with inpatient mortality included inability to drink unassisted, respiratory rate >30 breaths per minute, hypoxia, and altered mentation. Less than half of participants received any antimicrobial by hour 6, and most participants received <1L of IV fluids. HIV antibody testing was performed for only one participant in the first 6 hours. On multivariable analysis, neither antimicrobial administration nor IV fluids >1L by hour 6 was associated with inpatient mortality.

Conclusion: Sepsis in northern Tanzania carries a high risk of in-hospital mortality. Further research is urgently needed to establish the highest-yield interventions suited to the unique characteristics of sepsis in sSA.