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Family and Cultural Care of the Critically Ill Patient 173

reminders of the loss; disbelief over the person’s death; guidance and support to critical care nurses as they
feeling lonely since the loss; feeling that the future holds develop better organisational and emotional support for
no purpose; and feeling stunned or shocked by the loss. 153 each other. 160 Effective palliation occurs when the multi-
These symptoms can result in elevated morbidity and disciplinary team, including senior management, collec-
mortality levels associated with depression, cardiac events tively develops a philosophy for palliative care and
(including a higher risk of sudden cardiac death), hyper- bereavement services. 151,139
tension, neoplasms, ulcerative colitis, suicidal tendencies, Nurses depend on colleagues and friends for support
and social dysfunction (including alcohol abuse and vio- when patients die, and value debriefing sessions. 156
lence). 154 These potentially harmful outcomes provide ‘Debriefing’ sessions can have a number of interpreta-
strong motivation for critical care clinicians to initiate tions. For example, ‘debriefing’ in critical care often takes
family support mechanisms such as bereavement ser- the form of an opportunity to share feelings. Alterna-
vices. 139 Bereavement programs aim to reduce the imme- tively, it may be for a procedural clinical review of events
diate physical and emotional distress for those grieving, where the objective is to understand and learn from the
while improving the long-term morbidity associated with situation. 160 Both components of debriefing are impor-
unresolved grief. 155
tant, together with the opportunity to provide mutual
156
Although critical care clinicians in the UK, USA, 139 support within the multidisciplinary team. The effective-
Europe and Canada 145 are conducting dialogue and devel- ness of sessions should be evaluated.
oping guidelines for bereavement care in critical care,
little evidence-based research has been conducted on A ‘grief team’ provides more formalised support from
bereavement care strategies. 139 An exception is a bereave- colleagues that have been given additional education on
158
ment program developed by a group of nurses from a grief, dying and death. This enables a program of care,
British ICU, who instituted a booklet on ‘coping with and may include such strategies as assessing the welfare
bereavement’, an after-care form for the clinical nurse to of the staff immediately after the death of the patient;
complete with details for follow-up with the family, and being present for staff members to express their feelings;
a sympathy card and letter inviting family to participate providing follow-up and information on coping mecha-
158
in support group meetings. 156 Although initial evaluation nisms during grief. Accessing experts from outside the
of the program through feedback from participating unit’s usual resources may be helpful with de-briefing in
160
family members was positive, the team acknowledges especially challenging situations. Dealing with death is
that this does not constitute rigorous research. Evaluation never easy; however, an awareness of colleagues’ needs is
of bereavement services in Australian adult ICUs was also a key to providing the support they require.
reported to be inadequate, as no data could be located
concerning bereavement services in other areas of critical SUMMARY
care. Only 30% of ICUs provided some follow-up care, The psychosocial, cultural and religious needs of critically
and only four units had any evaluation other than anec- ill patients and their families are just as important as their
dotal evidence. 157 It is imperative to assess new and exist- physical needs, and care needs to be taken not to overlook
ing bereavement interventions and how well they meet these. This chapter presents a holistic and patient- and
the needs of families through rigorous evaluation. Legiti- family-centred approach to practice, which enables indi-
mising research on this vulnerable group is required to vidualised plans of care that includes specific psychoso-
improve end-of-life care for families and patients. 156
cial, cultural and religious needs of critically ill patients
and their families. Indigenous Māori, Aboriginal and
CARE OF THE CRITICAL CARE NURSE Torres Strait Islander patients generally have a holistic and
The two previous sections have focused on care for the spiritual world view, and consequently have specific cul-
dying patient and the patient’s family. Critical care nurses tural practices that are vital to their spiritual wellbeing.
who care for both patients and families also require care Culturally and linguistically diverse patients and families
in bereavement situations. Caring for dying patients is also have specific cultural values, beliefs and practices that
emotionally draining and highly demanding of the critical critical care nurses need to determine, which may involve
care nurse, who often fails to notice or acknowledge the the assistance of an interpreter. These patients require the
need to grieve. 158,159 In addition, critical care nurses may critical care nurse to interact with them in a manner that
not have the knowledge and understanding of palliative facilitates the identification of their needs on an indi-
care and death in the critical care environment and a vidual basis. The old adage ‘actions speak louder than
specific educational program and unit guidelines on pal- words’ is worthy of consideration when working with
liative care may provide support and reduce burnout. 137,139 these patients in the critical care setting. It is important
that individual plans of care be developed that include
Once the patient has died, nurses may not have the the participation of Māori, Aboriginal and culturally and
opportunity to mourn publicly and may feel they are linguistically diverse patients and whānau or family,
acting unprofessionally if they show overt signs of grief. 158 reflecting the beliefs and practices that need to be included
Dealing with the death of patients may be exacerbated in in their critical care experience. In order to meet the needs
some critical care environments, particularly in the rural of the critically ill patient and family, the critical care
setting, where the nurse may know the patient outside nurse is advised to identify personal beliefs, practices and
the work environment. Collaboration with colleagues expectations that may influence professional decision
from oncology areas or palliative care teams will provide making and interactions with the patient and family.