Group Members:
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Roshan Jan Muhammad
Choi Jee Young
Nesreen Abdulmannan
Shalia Gregory
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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
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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.
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6.
7.
8.
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10.
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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
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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
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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)
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High number of patients are unable to communicate their needs and
wishes because of sedation, coma, delirium…..
(Beckstrand, 2005)
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In USA 60-80% time family members are involved in end of life care
decisions.
(Mularski, 2005)
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ICU doctors lack skills to provide good palliative care.
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Nurse patient ration, time constraint and assignment system pose
challenge.
Quality of death and dying in ICU (QODD)
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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)
Variables
Score
P value
Pain under control
47
0.009
Saying goodbye to loved ones
47
0.006
Unafraid of dying
39
<0.001
Keeping dignity and respect
32
0.001
Feeling at peace with dying
30
<0.001
Control of events
8
<0.001
(Mularski, Heine, Osborne, Ganzini, & Curtis, 2005)
Family/signifi
cant others
• Depression
• Guilt
Patient
• Burnout
•Syndrome of
depersonalization
•Emotional exhaustion
• Lower sense of personal
accomplishment
Health Care
System
•Financial
ramification
• Moral residue and distress
Health Care
Professionals
Mularski, 2005)
(Beckstrand & Kirchhoff, 2005, 2006)
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Death is a common phenomena in nursing practice.
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Focus of medical/ technical care digress broader efforts to improve care of those
near death.
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Terminally ill patients demand compassionate care not curative treatment.
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Nurses can bridge the communication gap between patient, family and physician
during end of life care decisions.
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Promotes and advocates for rights of dying patient.
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Play vital role in preparing patient and families for transition in treatment goal.
(Fighting death ……seeking good death).
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We have unique relational bond with the patient and family.
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Sensitive to individualized patient’s needs.
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Individualized care planning
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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.
Theoretical underpinning
standard of
Care “End of
life care”.
Empirical
evidence from
direct
experience.
Evidence
based.
Donabedian’s
model (general
system theory)
Preference theory
of Brandt
Peaceful
end of
life
(Alligood, Tomey, 2010)
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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
Experience
of Comfort
Experience
of dignity
and respect
Monitoring
and
administering
pain
medication
Preventing
monitoring and
relieving
physical
discomfort
Being attentive to
patient’s
expressed needs,
wishes and
preferences
Applying
pharmacologi
cal and non
pharmacologi
cal measures
Facilitating rest,
relaxation and
contentment
Preventing
complications
Including patient
and significant
others in decision
making
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 antianxiety 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)
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Theory covers maximum aspects of peaceful end of life.
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Derived from standard of Care that is grounded into core
value of nursing “CARING”.
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End of life care for terminally ill patients in acute care setting.
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Relates patient’s personal definition of ‘quality of life’ and
perspective of ‘Good death”.
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Interventions are, measurable, attainable and based on
scientific knowledge.
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Patient and family centered care.
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Developed by nurses and guides nursing practice.
SIGNIFICANCE
ADEQUACY
Physical, psychological, social,
spiritual dimension of care.
Addresses fear of death and
domains of good death.
Individualized care planning
Applicable to wide range of
patients regardless of diagnosis.
Standard of care as a source of
theory development.
All relational statements does not
have empirical support.
Focus of core value of nursing
“Caring”.
Belief system, religion and
spirituality is not fully integrated.
Evidence based practice.
Applicability into various setting
has not been tested.
Guides nursing practice.
Provides avenue for research in
related field.
High level middle range theory
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.
Feasible for intensive care unit
setting.
Setting and patient population is
clearly defined.
Specific boundaries to setting and
patient population.
All elements of theory (concepts,
assumptions and relational
statements) are stated clearly.
Applicability is limited in case of
patients rapidly approaching to death.
Constructs and philosophical claims
are consistent and congruent.
Applicability in pediatric patient and
with different culture is not tested.
Abstract concepts (dignity, peace) are
operationalized well.
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
Experience
of Comfort
Experience
of dignity
and respect
Monitoring
and
administering
pain
medication
Preventing
monitoring and
relieving
physical
discomfort
Being attentive to
patient’s
expressed needs,
wishes and
preferences
Applying
pharmacologi
cal and non
pharmacologi
cal measures
Facilitating rest,
relaxation and
contentment
Preventing
complications
Including patient
and significant
others in decision
making
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
Subspecialty
Consultants
Respiratory
therapist
Nurse
Pharmacist
Nutritionist
Nurse
Intensivist
Doctor
Family/friends
Nurse
Pharmaci
st
Others
Respiratory
therapist
Chaplain
Palliative
Nurse
Nutritionist
Social worker
Not being
in Pain
Closeness
to
significant
others
Being at
peace
Experience
of comfort
Experience
of dignity
and
respect
NOT BEING IN PAIN
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EXPERIENCE OF COMFORT
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
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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.
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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
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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
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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.
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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
Staffing and
scheduling
patterns
Non-availability of
advanced
directives
• Education of staff to improve communication
skills and competencies related to EOL care.
• End of life care pathway.
• Involvement and family members into care.
• Involvement of palliative care team.
• Institutional policy change.
• Primary care physician and advanced care
practitioners propagate advanced care directive.
• Brochure for advanced care directive.
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Tune into what I’m going through here. Be
present with me here and now.”
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Beckstrand, R. L., Callister, L. C., & Kirchhoff, K. T. (2006). Providing a "good
death": Critical care nurses' suggestions for improving end-of-life care. American
Journal of Critical Care : An Official Publication, American Association of CriticalCare Nurses, 15(1), 38-45; quiz 46.
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Beckstrand, R. L., & Kirchhoff, K. T. (2005). Providing end-of-life care to patients:
Critical care nurses' perceived obstacles and supportive behaviors. American Journal
of Critical Care : An Official Publication, American Association of Critical-Care
Nurses, 14(5), 395-403.
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Deeken, A. (2009). An inquiry about clinical death--considering spiritual pain. The
Keio Journal of Medicine, 58(2), 110-119.
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Fawcett, J. (2000). Analysis and evaluation of contemporary nursing knowledge.
Nursing models and theories. Philadelphia: F. A. Davis.
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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
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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
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Hayden, D. (2011). Spirituality in end-of-life care: Attending the person on their journey.
British Journal of Community Nursing, 16(11), 546-551.
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Kehls, K. (2006). Moving towards peace: An analysis of the concept of good death.
Americal Journal of Hospital Palliative Care, 23 (4), 277-286.
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Kongsuwan,W. & Locsin R.C.(2009) Promotion peaceful death in the intensive care unit
in Thailand international Nursing Review 56,116-122
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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
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Alligood, M.R,& Tomey, A.M. (2010). Nursing theories and their work. Mosbey :
Eleseiver.
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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
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Montagani, M, & Balisterieri. (2012). Assessment of self perceived End of life care
Competencies of Intensive care unit providers. Journal of Palliative Care, 15(1).
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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
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Thelen, M. (2005). End-of-life decision making in intensive care. Critical Care
Nurse, 25(6), 28-37; quiz 38.
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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