Family Care Rituals in the ICU to Reduce Symptoms of Post-Traumatic Stress Disorder in Family Members-A Multicenter, Multinational, Before-and-After Intervention Trial.

OBJECTIVES: To assess the feasibility and efficacy of implementing "Family Care Rituals" as a means of engaging family members in the care of patients admitted to the ICU with a high risk of ICU mortality on outcomes including stress-related symptoms in family members. DESIGN: Prospective, before-and-after intervention evaluation. SETTING: Two U.S. academic medical ICU's, and one Italian academic medical/surgical ICU. SUBJECTS: Family members of patients who had an attending predicted ICU mortality of greater than 30% within the first 24 hours of admission. INTERVENTIONS: A novel intervention titled "Family Care Rituals" during which, following a baseline observation period, family members enrolled in the intervention phase were given an informational booklet outlining opportunities for engagement in care of the patient during their ICU stay. MEASUREMENTS AND MAIN RESULTS: Primary outcome was symptoms of post-traumatic stress disorder in family members 90 days after patient death or ICU discharge. Secondary outcomes included symptoms of depression, anxiety, and family satisfaction. At 90-day follow-up, 131 of 226 family members (58.0%) responded preintervention and 129 of 226 family members (57.1%) responded postintervention. Symptoms of post-traumatic stress disorder were significantly higher preintervention than postintervention (39.2% vs 27.1%; unadjusted odds ratio, 0.58; p = 0.046). There was no significant difference in symptoms of depression (26.5% vs 25.2%; unadjusted odds ratio, 0.93; p = 0.818), anxiety (41.0% vs 45.5%; unadjusted odds ratio, 1.20; p = 0.234), or mean satisfaction scores (85.1 vs 89.0; unadjusted odds ratio, 3.85; p = 0.052) preintervention versus postintervention 90 days after patient death or ICU discharge. CONCLUSIONS: Offering opportunities such as family care rituals for family members to be involved with providing care for family members in the ICU was associated with reduced symptoms of post-traumatic stress disorder. This intervention may lessen the burden of stress-related symptoms in family members of ICU patients.

The hospitalized prisoner with a life-threatening illness: criminal first and patient second?

It is generally accepted that the Patient's Bill of Rights applies to all patients including prisoners. Yet, a prisoners' incarcerated status generally prohibits inmates from making any decision that may shorten his/her life, and as such, the de facto medical decision maker becomes the medical director of the state correctional facility. This case study highlights the challenges that arise when the ethically appropriate response to a hospitalized prisoner's terminal medical condition warrants decisions that are in conflict with that advocated by the correctional facility.

Conflicting voices: Withhold treatment or not for a patient with chronic self-destructive behavior?

Patients with a history of chronic self-destructive and self-injurious behavior present many difficulties to healthcare providers. These patients often have related substance abuse and personality disorders that complicate their medical care. Treatment encounters initially may be related to medical treatment of episodic substance intoxicated states with or without self-inflicted injuries. Patients later can develop comorbid medical illnesses associated with nonadherence of treatment or iatrogenic conditions, both of which result in complex end-of-life-care decisions. Institutional familiarity of repeat patients often leaves healthcare providers feeling responsible for the patient despite having little influence over the patients' ultimate behavioral outcomes. This article describes a patient with chronic alcohol abuse, treatment noncompliance, severe personality disorder, recurrent suicidal ideation, self-injurious behavior, alcoholic cirrhosis, and suicide attempt resulting in multisystem injuries leading to an ethical conflict regarding end-of-life care.

Respecting patient autonomy versus protecting the patient's health: a dilemma for healthcare providers.

A 74-year-old man with multiple chronic medical problems was hospitalized for respiratory distress. He experienced recurrent aspiration and required frequent suctioning and endotracheal intubation on several occasions. The patient was deemed competent and steadfastly refused feeding tube placement. The patient demanded that he be allowed to eat a normal diet despite being told that it could lead to his death. The patient wanted to go home, but there was no one there to care for him. Additionally, neither a nursing home nor hospice would accept him in his present condition. The case is especially interesting because of the symbolic value of food and the plight of the patient who has no alternative to hospitalization. The hospital staff experienced considerable stress at having to care for him. They were uncertain whether their obligation was to respect his autonomy and continue to provide food or to protect his health by avoiding aspiration, pneumonia, and possible death by denying him food. This ethical dilemma posed by the professionals' duty to do what is in the patient's best interest versus the patient's right to decide treatment serves as the focus for this case study. Ethical, legal, and healthcare practitioners' considerations are explored. The case study concludes with specific recommendations for treatment.

To Continue or to Withhold Opioid Analgesics? An Ethical Dilemma Involving a 63-year-old Cancer Patient Who 'Broke the Pain Contract'.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Factors that enable or complicate end-of-life transitions in critical care.

BACKGROUND: Nurses in medical intensive care units are routinely involved in negotiations to maintain or withdraw life support. How nurses move from aggressively attempting to extend life to letting life end is not well understood. OBJECTIVE: To explore nurses' experiences of moving from cure- to comfort-oriented care and to describe factors that inhibit or facilitate such transitions. METHOD: A descriptive qualitative research design with brief observation of participants and focus group interviews was used. Participants were 19 female and 5 male nurses in an 18-bed medical intensive care unit in a 719-bed acute care hospital in the northeastern United States. RESULTS: The transition point between cure- and comfort-oriented care was unclear. Nurses reported that the patient's age, misunderstanding of the illness by the patient's family, family discord, and shifting medical care decisions made end-of-life transitions difficult. Conversely, developing a consensus among patients, patients' families, and staff about the direction of medical therapy; exhausting treatment options; and patients' lack of response to aggressive medical interventions helped nurses move toward comfort care. CONCLUSIONS: The most distressing situations for staff were dealing with younger patients with an acute life-threatening illness and performing futile care on elderly patients. End-of-life transitions were difficult when patients' families had conflicts or were indecisive about terminating treatment and when physicians kept offering options that were unlikely to change patients' prognosis. The most important factor enabling nurses to move from cure- to comfort-oriented care was developing a consensus about the treatment.

A descriptive study of coping strategies used by Medical Intensive Care Unit nurses during transitions from cure- to comfort-oriented care.

OBJECTIVE: The aim of this study was to describe Medical Intensive Care Unit (MICU) nurses' coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort-oriented care. METHODS: The use of a descriptive qualitative research design with brief selective participant observation and focus group interviews was used to explore the coping experiences of MICU nurses. The study took place in an 18-bed MICU that was part of a 719-bed acute care hospital located in the northeastern United States. Nineteen female and 5 male nurses participated in the study. RESULTS: MICU nurses used a variety of coping strategies including cognitive, affective, and behavioral techniques to cope with end-of-life care transitions. Being a MICU nurse in and of itself provided a sense of pride for staff. Most believed that their clinical opinions were valued and that they were respected as professionals. Providing futile care, the perception of "torturing the patient," and conflict with families caused the greatest distress to staff. CONCLUSIONS: MICU nurses are dynamic and resourceful when responding to challenging end-of-life patient care situations.

Reevaluation of the critical-care pain observation tool in intubated adults after cardiac surgery.

BACKGROUND: Pain assessment in critically ill patients who are intubated, sedated, and unable to verbalize their needs remains a challenge. No universally accepted pain assessment tool is used in all intensive care units. OBJECTIVES: To examine concurrent validation of scores on the Critical-Care Pain Observation Tool for a painful and a non-painful procedure and to examine interrater reliability of the scores between 2 nurse raters. METHODS: A prospective, repeated-measures within-subject design was used. A convenience sample of 35 patients was recruited to achieve enrollment of 30 patients during a 5-month period. Observational data were collected on patients intubated after cardiac surgery during routine turning and during dressing changes for central catheters. RESULTS: Raters' mean scores did not increase significantly during dressing changes (increase, +0.25; 95% CI, -0.07 to 0.57; P = .12) but did increase significantly during turning (increase, +3.04; 95% CI 2.11-3.98; P < .001). The degree to which mean scores increased was significantly greater during turning than during dressing changes (increase, +2.80; 95% CI, 1.84-3.75; P < .001). The Fleiss-Cohen weighted κ for the inter-rater reliability of the ratings of research nurses was 0.87 (95% CI, 0.79-0.94). CONCLUSION: The results support previous research investigations on validity and reliability of the Critical-Care Pain Observation Tool for evaluating pain in intubated, critically ill adults.

Non-fatal suicide attempt by intentional stab wound: Clinical management, psychiatric assessment, and multidisciplinary considerations.

BACKGROUND: Suicide by means of self-inflicted stab wounds is relatively uncommon and little is known about this population and their management. MATERIALS AND METHODS: Retrospective review of adult trauma patients admitted to our Level-1 trauma center between January 2005 and October 2009 for management of non-fatal, self-inflicted stab wounds. RESULTS: Fifty-eight patients were evaluated with self-inflicted stab wounds. Four patients died due to their injuries (mortality, 7%). Of the non-fatal stab wounds, 78% were male ranging in age from 19-82 (mean: 45 years). The most common injury sites were the abdomen (46%), neck (33%), and chest (20%). In terms of operative interventions, 56% of abdominal operations were therapeutic, whereas 100% of neck and chest operations were therapeutic. When assessing for suicidal ideation, 44 patients (81%) admitted to suicidal intentions whereas 10 patients (19%) described accidental circumstances. Following psychiatric evaluation, 8 of the 10 patients with "accidental injuries" were found to be suicidal. Overall, 54 patients (98%) met criteria for a formal psychiatric diagnosis with 48 patients (89%) necessitating inpatient or outpatient psychiatric assistance at discharge. CONCLUSIONS: Compared to previous reports of stab wounds among trauma patients, patients with self- inflicted stab wounds may have a higher incidence of operative interventions and significant injuries depending on the stab location. When circumstances surrounding a self-inflicted stabbing are suspicious, additional interviews by psychiatric care providers may uncover a suicidal basis to the event. Given the increased incidence of psychiatric illness in this population, it is imperative to approach the suicidal patient in a multidisciplinary fashion.

Critical Care Nurse Intern program: addressing psychological reactions related to critical care nursing.

Rhode Island Hospital Critical Care Nurse Internship program prepares recent graduates to work in critical care specialty units. Despite best efforts to prepare nurse interns for immersion into the critical care arena, significant clinical challenges await, and it is unknown how individual nurse interns will react under stressful clinical encounters. With this concern in mind, it was decided to add a new lecture to the critical care curriculum to address psychological reactions related to critical care nursing. This article presents an overview of 4 major psychological reactions critical care nurse interns will likely experience including acute bereavement reactions, moral distress, secondary traumatization, and performance guilt. Specific strategies to navigate these difficult encounters are explored.