Nurses need guidance in enacting their roles in end-of-life decision making so that they can help alleviate suffering and ensure that end-of-life needs and goals for their patients and family members are being met. These nursing strategies should be guided by empirical evidence – research study. Understanding how nurses engage in this process is essential to the development of interventions to improve the strategies that nurses use in end-of-life decision making. Case-oriented studies that identify how nurses engage in the end-of-life decision making process are needed. Such studies would provide a systematic understanding of the strategies that nurses use. Quantitative studies that are based in the existing literature to develop valid and reliable tools are needed to measure the extent to which nurses are enacting roles, the strategies they use, and the patient and family member outcomes. With the knowledge generated from these studies, interventions could be developed that target areas identified as important to the family members and most likely to improve their well-being. (Hanna, 2004)
The application of this theory has been seen in several research studies since its inception almost 15 years ago. It is a mid range theory that can be used by nurses to assist patients as well as their significant others in dealing with death. 1
The studies include a doctoral dissertation in 2001 by Renea Lindstrom Beckstrand entitled National
Survey of Critical Care Nurses’ (CCRN) Perceptions of End- of-Life Care
and Effect of Incentives on Survey Response Rates. Here she used
this theory as a guide in formulating her questionnaire reflecting the
aspects of all five of the adapted outcome indicators and all 14 of the
nursing interventions. Knowledge on how to deal with deaths and
assisting grieving families can help critical care nurses improve their
job performance and avoid physical exhaustion in the process.
The study seeks to answer the following questions:
1.
Which obstacles to providing end-of-life care to dying patients do
critical-care nurses perceive as being the largest, most frequent, and
most severe?
2.
Which helpful behaviors (or helps) to providing end-of-life care to
dying patients do critical-care nurses perceive as being the largest,
most frequent, and most intense?
3. Which aspect of end-of-life care would critical-care nurses most like to see changed?
4.
In what ways do critical-care nurses' perceptions of obstacles and
helpful behaviors differ based upon length of I CU work experience?
5.
Do CCRN-certified critical-care nurses' perceptions of obstacles and
helpful behaviors significantly differ from the perceptions of
critical-care nurses who have never certified as a CCRN?
An
experimental, posttest-only, control group design was used. A random
sample of the American Association of Critical-Care Nurses (AACN)
yielded 861 usable responses from 1,409 eligible respondents (61 %). The
three most severe obstacles were frequent calls to the nurse, families
not understanding the term "lifesaving measures," and physicians
disagreeing about the direction of patient care. The three most intense
helps were when nurse allowed the family adequate time alone (after
death), provided a peaceful and dignified bedside scene and taught the
family how to act around the dying patient.
Other
results included nurses preferring that a patient experience a "good
death," more time be provided to care for patients, communication to
patients be more open and honest, and education in end-of-life care be
provided to physicians and nurses. Nurses reporting more ICU work
experience were older and also had cared for more dying patients (75 %)
than did nurses reporting less experience (62 %). Certified
critical-care registered nurses (CCRNs) perceive as larger obstacles
physicians being overly optimistic about the patient surviving, families
not accepting that the patient will die, visiting hours that are too
restrictive, and patients who have pain that is difficult to alleviate
or control. 2
Another
related study in the role of critical nurses in ICU’s has been
conducted back in 2009 by the group of Lee et al. in Taiwan. It is
entitled Attaining Good End of Life Care in Intensive Care Units in
Taiwan- The Dilemma and Strategy. 3 Here
they used the five main components of this theory in providing good EOL
(end-of-life) care to meet the dying patients’ need.
As with application on education, the theory was highlighted in the 2001 conference by the American Emergency Nurses Association regardingAssessment of EOL Practices with Patients with Multiple Trauma.4 Its
purpose is to describe the documentation regarding end of life (EOL)
care and test one relational statement from the middle range theory on a
peaceful EOL. The theory focuses on ways nurses can contribute toward a
peaceful and meaningful death for the patients. Medicals records back
in 1998 of trauma patients upon arrival in the ER were reviewed.
Among
the 88 deaths, 73 charts were available for review. The sample mean age
was 41.67 years and patients are mostly male (72.9%). Three factors
discussed in the theory were used in the methodology namely (1) being
attentive to the patient's expressed wishes, needs, and preferences; (2)
including the patient and family in patient care decision making; and
(3) treating the patient with empathy, respect and dignity.
The
following are outcome of the study, (1) Attention to spiritual needs
was documented for 65.8% of patients/families; (2) 43.8% had
documentation that death was the expected outcome, yet 60% of the
patients died without being resuscitated. (3) An EOL conversation with
health care providers was reported by 52% of families, with 6% of
patients meeting with their physician. Over one-half (57%) of patients
died while aggressive care was in progress and none of the records had
any documentation of conflict between the family and a health care
worker.
Nurses
documented EOL care discussions by other health care providers more
frequently than their own interactions. The study concluded that most
were treated with respect and dignity through evidence of shared
decision making and spiritual support consistent with the middle range
theory.
References:
4 http://www.nursinglibrary.org/vhl/handle/10755/162714
D. R. Hanna, “Moral distress: the state of the science,” Research and Theory for Nursing Practice, vol. 18, no. 1, 2004.
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