Abstract
BackgroundAs an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting. Most of these studies are centered on the patient’s and/or the relatives’ experience. Our study aimed to develop an instrument designed to assess the experience of physicians and nurses of patients who died in the ICU, using a mixed methodology and validated in a prospective multicenter study.MethodsPhysicians and nurses of patients who died in 41 ICUs completed the job strain and the CAESAR questionnaire within 24 h after the death. The psychometric validation was conducted using two datasets: a learning and a reliability cohort.ResultsAmong the 475 patients included in the main cohort, 398 nurse and 417 physician scores were analyzed. The global score was high for both nurses [62/75 (59; 66)] and physicians [64/75 (61; 68)]. Factors associated with higher CAESAR-Nurse scores were absence of conflict with physicians, pain control handled with physicians, death disclosed to the family at the bedside, and invasive care not performed. As assessed by the job strain instrument, low decision control was associated with lower CAESAR score (61 (58; 65) versus 63 (60; 67), p = 0.002).Factors associated with higher CAESAR-Physician scores were room dedicated to family information, information delivered together by nurse and physician, families systematically informed of the EOL decision, involvement of the nurse during implementation of the EOL decision, and open visitation. They were also higher when a decision to withdraw or withhold treatment was made, no cardiopulmonary resuscitation was performed, and the death was disclosed to the family at the bedside.ConclusionWe described and validated a new instrument for assessing the experience of physicians and nurses involved in EOL in the ICU. This study shows important areas for improving practices.
Highlights
As an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting
The score was higher when a decision to withdraw or withhold treatment was made, when no cardiopulmonary resuscitation was performed, and when the death was disclosed to the family at the bedside rather than by phone or upon arrival at the ICU
The nurse CAESAR-N score (Table 2) was significantly higher in the absence of conflict with physicians, when pain control was handled by physicians rather than by nurses alone, when the death was disclosed to the family at the bedside rather than by phone or upon arrival at the ICU, and when invasive care such as surgery, chest tube, or bronchoscopy was not performed
Summary
As an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting Most of these studies are centered on the patient’s and/or the relatives’ experience. A study comparing QODD ratings by relatives and by healthcare professionals [9] shows that relatives and attending physicians give the most favorable ratings of death, while nurses and residents provide less favorable ratings. Significant differences between these groups are notable on items related to patient autonomy. This tool was designed and validated in the USA, where hospital and end-of-life culture, and physicians’, nurses’, relatives’, and patients’ roles are different than in Europe [4, 13]
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