Nurse-Perceived Barriers to Effective Communication Regarding Prognosis and Optimal End-of-Life Care for Surgical ICU Patients: A Qualitative Exploration

Abstract

Background: Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting. Methods: We developed a focus group guide to identify barriers to two key components of palliative careoptimal communication regarding prognosis and optimal end-of-life care-and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses. Results: Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, clinician discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. For optimal end-of-life care, the groups identified 24 barriers in four domains: logistics, inability to acknowledge an end-of-life situation, inadequate skill and training, and cultural differences relating to end-of-life care. Conclusions: Nurses providing bedside care in SICUs identify barriers in several domains that may impede optimal discussions of prognoses and end-of-life care for patients with surgical critical illness. Consideration of these perceived barriers and the underlying SICU culture is relevant for designing interventions to improve palliative care in this setting.

Palliative Care Professional Development for Critical Care Nurses: A Multicenter Program

“…[15][16][17][18][19]21,24 Our findings indicate that IMPACT-ICU prepared nurses As a result of the training received through the IMPACT-ICU program, a nurse in one of our ICUs facilitated a family meeting that allowed a patient to make a decision to go home instead of continuing therapy in the ICU. The patient did not know his true prognosis.…”

“…Our program, IMPACT-ICU, was designed to address identified barriers to integration of palliative care into the ICU and to increase bedside nurses' engagement in palliative care. 3,17,18,21,[25][26][27][28][29] A combination of learner-centered communication training workshops and bedside coaching rounds led by advanced practice palliative care nurses and nurse educators helped bedside nurses to feel more skilled to engage in palliative care communication, as well as to be more involved in identifying and addressing palliative care needs.…”

“…26 We organized factors found in previous work to influence bedside nurses' involvement in palliative care 17,18,21,25,[27][28][29] on the basis of whether they predisposed, enabled, or reinforced bedside nurses to perform daily palliative care assessments and develop plans to address identified needs (Table 1). An overview of the initiative follows.…”

“…3 Families, physicians, and nurses identify involvement of bedside nurses as a key factor in the quality of ICU palliative care. [15][16][17][18][19][20] Nurses' training and constancy at the bedside position them to identify palliative care needs, coordinate communication among families and an array of clinicians, and support and educate families. 15,16,19,21 Despite the success of palliative nursing education programs, 22,23 we found at our centers and in the literature that ICU nurses perceived a number of barriers to their involvement in palliative care, including lack of clarity about their role and inadequate communication training.…”

“…Our program, IMPACT-ICU, was designed to address identified barriers to integration of palliative care into the ICU and to increase bedside nurses' engagement in palliative care. 3,17,18,21,[25][26][27][28][29] A combination of learner-centered communication training workshops and bedside coaching rounds led by advanced practice palliative care nurses and nurse educators helped bedside nurses to feel more skilled to engage in palliative care communication, as well as to be more involved in identifying and addressing palliative care needs.The initiative was focused on nurses, to address the gap between their actual and potential involvement in palliative care communication. [15][16][17][18][19]21,24 Our findings indicate that IMPACT-ICU prepared nurses As a result of the training received through the IMPACT-ICU program, a nurse in one of our ICUs facilitated a family meeting that allowed a patient to make a decision to go home instead of continuing therapy in the ICU.…”