Feasibility of conducting prospective observational research on critically ill, dying patients in the intensive care unit.

Studying patients during the end of life is important, as it has the potential to lead to improvements in care for the dying. For patients who die after a controlled withdrawal of life-sustaining therapies in the intensive care unit, information about the natural history of death and the process of removing life support has additionally led to advances in practice for deceased organ donation. However, this unique population of severely critically ill and imminently dying patients has been difficult to study, largely due to assumptions made by research teams and ethics boards alike about the logistical difficulties of obtaining consent and completing research procedures before or during the process of withdrawal of life-sustaining therapies. In this paper, we describe the ethics substudy of the first prospective observational research study in Canada to obtain consent and collect clinical data on patients during the process of withdrawal of life-sustaining therapies in the intensive care unit. We describe in detail the process of protocol development, review by five institutional research ethics boards and bedside staff satisfaction with the study. We conclude that prospective research on a critically ill and imminently dying population is feasible and can be conducted in an ethical manner. Further information is needed about the experiences and motivations of families and substitute decision makers who provide consent for research on critically ill intensive care unit patients at the end of life.

Establishing and maintaining the clinical learning environment for nursing students: a qualitative study.

BACKGROUND: Experience in the clinical setting is viewed as a crucial aspect of nursing education. Evidence suggests that students experience acceptance to alienation on the clinical unit. Little is known about preceptor beliefs underlying their approach with students, and the perspective of unit management is absent. OBJECTIVES: To provide a description of the beliefs and processes that emerge at the unit level regarding the clinical learning environment for nursing students. DESIGN: Multiple case study design. SETTING: Four units from across an urban university health center who have a demonstrated ability to accept students. PARTICIPANTS: A purposive sample of four nurse managers, four assistant nurse managers, three advanced practice nurses, and six staff nurses with recent and recurrent precepting experience were recruited from across four units. METHODS: Semi-structured focus group interviews were conducted with all participants from each unit. Content analysis was used to identify major themes and categories in the interview data. RESULTS: Two overarching themes were revealed: (1) Influencing factors included cultural factors and contextual factors that either inform units' beliefs about the ideal learning environment, or affect their ability to provide it. (2) Willingness refers to a willingness to invest in students and the forms that investment takes. It includes openness, taking them under wing, and structuring to meet goals. The influencing factors provide the foundation upon which the unit's work to accommodate students is built. CONCLUSIONS: The degree to which a unit is able to manage the contextual factors determines how well they can shape the students' environment. The sturdiness of their culture with regard to hosting students determines the pervasiveness of their approach by staff on the unit.

The consultation component of the clinical nurse specialist role.

The clinical nurse specialist (CNS) role in Canada has 5 key components: clinical practice, consultation, education, research, and leadership. This study focuses on the consultation component: how it is described by CNSs and the facilitators and barriers to its implementation. A qualitative descriptive design was used to interview 8 CNSs who worked with adult populations in a university hospital setting.The findings indicate that managing crisis situations, ensuring continuity of care, and supporting other health professionals and health-care teams are key areas of consultation. Role ambiguity perceived by other professionals and constant demands and expectations due to a changing environment constitute the major challenges of CNS practice, requiring CNSs to continuously clarify their role in accordance with changes in time and place.

Building a successful DCD program: planning and leading change.

In Canada, there is a growing gap between the number of organs donated each year and the number of organs needed for transplant. This gap is forcing health care professionals to re-examine end-of-life care and donation practices. In 2005, a national forum created recommendations for the development and implementation of donation after cardio-circulatory death programs. In this article, the authors outline the multifaceted approach needed for change in interdisciplinary clinical practice. Clinical nurse specialist leadership, ethics consultation, partnerships with key physician colleagues and administrators, as well as comprehensive workshops are described as essential for success. Lessons learned throughout are shared.

National recommendations for donation after cardiocirculatory death in Canada: Donation after cardiocirculatory death in Canada.

These recommendations are the result of a national, multidisciplinary, year-long process to discuss whether and how to proceed with organ donation after cardiocirculatory death (DCD) in Canada. A national forum was held in February 2005 to discuss and develop recommendations on the principles, procedures and practice related to DCD, including ethical and legal considerations. At the forum's conclusion, a strong majority of participants supported proceeding with DCD programs in Canada. The forum also recognized the need to formulate and emphasize core values to guide the development of programs and protocols based on the medical, ethical and legal framework established at this meeting. Although end-of-life care should routinely include the opportunity to donate organs and tissues, the duty of care toward dying patients and their families remains the dominant priority of health care teams. The complexity and profound implications of death are recognized and should be respected, along with differing personal, ethnocultural and religious perspectives on death and donation. Decisions around withdrawal of life-sustaining therapies, management of the dying process and the determination of death by cardiocirculatory criteria should be separate from and independent of donation and transplant processes. The recommendations in this report are intended to guide individual programs, regional health authorities and jurisdictions in the development of DCD protocols. Programs will develop based on local leadership and advance planning that includes education and engagement of stakeholders, mechanisms to assure safety and quality and public information. We recommend that programs begin with controlled DCD within the intensive care unit where (after a consensual decision to withdraw life-sustaining therapy) death is anticipated, but has not yet occurred, and unhurried consent discussions can be held. Uncontrolled donation (where death has occurred after unanticipated cardiac arrest) should only be considered after a controlled DCD program is well established. Although we recommend that programs commence with kidney donation, regional transplant expertise may guide the inclusion of other organs. The impact of DCD, including pre-and post-mortem interventions, on donor family experiences, organ availability, graft function and recipient survival should be carefully documented and studied.

The family as window onto the world of the patient: involving patients and families in the decision-making process.

The need to involve family members as patient advocates and as surrogates when patients are unable to speak for themselves is not an issue. What continues to be debated are the methods for involving family members in the decision-making process. Such decisions can be complex and the environment in which they are made can be chaotic, while clinicians' approach to decision-making is often seen as insensitive. Families struggle with the emotional burden of their role and clinicians struggle to translate complex information into comprehensible, meaningful, and practical language. There is a need to examine clinical practice to determine which approaches to involving family members are preferable from a philosophical as well as a practical point of view. The paper explores the many facets of the surrogate decision-making role and suggests a reorientation of current models of the professional-surrogate relationship.