Page 195 - ACCCN's Critical Care Nursing

172 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

END-OF-LIFE ISSUES patient by speaking and touching as this can have a
AND BEREAVEMENT calming influence. Comfort measures to enhance holistic
care delivery should continue and may include:
Over 80,000 Australians are admitted to critical care areas ● hygiene care
each year with a critical illness and although around 92% ● position changes
survive the critical illness, many still die in these areas. 133 ● foot and hand massages
End-of-life questions and bereavement in critical care ● hair washes and other individual preferences
areas are therefore important issues involving patients, ● artificial nutrition and hydration. 139
families and staff. Death can occur as a result of sudden
decline in the patient’s condition, or as a result of with- Patient dignity should be a priority, with gowns or per-
drawal of life support in anticipation of demise. Patient sonal attire essential elements of care. The management
death in critical care areas is found to have a significantly of symptoms further allows patients to maintain their
different effect on family members from a death in dignity. Privacy for patients and their families allows an
another in-hospital area. 134 This is perhaps due to the opportunity for them to communicate without the con-
heightened anxiety associated with a critical care environ- straints of observers. 143 As indicated in previous sections
ment 134 or due to the perception of an ability to cure in of this chapter, patient and family culture, beliefs and
highly medicalised areas. 135 Where possible, family- spiritual values are important considerations that under-
centred decision making with patient involvement, pin care. 137
together with effective communication and attention to
symptom management, is optimal. Practical and emo-
tional support for family and patients is important and FAMILY CARE
scrutiny of the way we manage these important areas Care of the family is supported by proactive palliative
provide quality indicators for critical care areas. 31,136 care interventions that include empathic, informative
communication with interdisciplinary team meetings
and family conferences that are not rushed where families
PATIENT COMFORT AND PALLIATIVE CARE are integral to decision making and goal planning. 31,52,144
Maintaining patient comfort and support for families and The desire to participate in decision making varies from
staff are primary requirements of nursing patients during family to family, and cannot be assumed. Ascertaining
the end stages of life. Advanced directives and ‘not for individual families’ needs for decision making is there-
resuscitation’ orders should be in place to prevent mis- fore recommended 145 as families are best placed to have
management and understanding of patient care (see an understanding of patients’ wishes, which can be taken
146
31
Chapter 5). Maintenance of patient comfort through into account when decisions are made. Structured com-
137
care guidelines to facilitate a ‘good death in ICU’ are munication between the health care team and families
designed to control symptoms such as agitation, pain and can assist with earlier decisions and goal formation about
breathlessness and are extremely important from the care. 147 Emotional and practical support can be given to
patient, family and nurses’ perspective. 138-140 Although families by providing written material about the critical
this may seem fundamental, there is evidence to suggest care area, local facilities and specific information on
52
this is not always achieved, with 78% of over 900 North bereavement. Privacy is not always possible in the busy
American critical care nurses perceiving that patients critical care environment, but maximising efforts in this
received inadequate pain medications ‘sometimes’ or ‘fre- regard for dying patients and their families provides a
quently’ during end-of-life nursing in critical care areas. 141 more conducive environment for strengthening patient–
family relationships and communication. 148
Collaboration and early involvement by palliative care
teams is one way to integrate end-of-life care for patients While the family grapple with some or all of the five
who either remain in critical care areas or are transferred stages of grief defined by Kubler-Ross: denial, anger, bar-
from the unit to other areas. 139 Withdrawal of mechanical gaining, depression, and acceptance, nurses need to
149
ventilatory support requires adequate provision for provide the physical and psychological care for patients
150
management of potential agitation, pain and hypoxia. 140 and families. This can be achieved when there is patient
Opioid and benzodiazepine agents should be considered and family-centred decision making, good communica-
for administration before and after extubation to prevent tion, continuity of care, emotional and practical support;
agitation and pain. Choices of bolus or infusion admin- and spiritual support can assist with this. Individualis-
151
istration need to be based on patient comfort issues. ing the care to the family is essential, and support mea-
Oxygen therapy is continued in the most appropriate sures should be instituted after a full assessment of their
form, and an oral airway may improve patient comfort needs. Without support, abnormal grief reactions can
and aid secretion clearance. Atropine and scopolamine occur, which decreases the family’s ability to cope with
have been reported to successfully reduce copious oral everyday needs and may progress to unresolved grief. 152
secretions and enhance comfort. 142
The detrimental effects of long-term unresolved grief after
The attainment of humane nursing care must include the death of a loved one are well documented. Current
heightened efforts in achieving quality indicators, such as terminology favours the term of prolonged grief disorder
mentioned above – adequate management of pain and (previously called complicated grief) which has clinically
nausea, agitation and restlessness. Both critical care staff disabling grief symptoms including, amongst others: a
and families should continue to communicate with the preoccupation with thoughts of the loss; avoidance of