Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life—Updated§

Cassell, Joan; Buchman, Timothy G.; Streat, Stephen; Stewart, Ronald M.

doi:10.1097/00003246-200305000-00039

Cited by 141 publications

(91 citation statements)

References 9 publications

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“…In addition, the primary ethical principle governing care in the surgical ICU may be different than that in a nonsurgical ICU, with more focus on a covenantal ethic rather than an ethic of scarce resources. [33][34][35] This study has several important limitations. First, there may be misclassifi cation, with patients categorized based on the specialty of the attending physician at time of death.…”

Section: Documentation Of Palliative Carementioning

confidence: 96%

Differences in End-of-Life Care in the ICU Across Patients Cared for by Medicine, Surgery, Neurology, and Neurosurgery Physicians

Kross

Engelberg

Cuschieri

et al. 2014

Chest

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Background: Some of the challenges in the delivery of high-quality end-of-life care in the ICU include the variability in the characteristics of patients with certain illnesses and the practice of critical care by different specialties. Methods: We examined whether ICU attending specialty was associated with quality of end-of-life care by using data from a clustered randomized trial of 14 hospitals. Patients died in the ICU or within 30 h of transfer and were categorized by specialty of the attending physician at time of death (medicine, surgery, neurology, or neurosurgery). Outcomes included family ratings of satisfaction, family and nurse ratings of quality of dying, and documentation of palliative care in medical records. Associations were tested using multipredictor regression models adjusted for hospital site and for patient, family, or nurse characteristics. Results: Of 3,124 patients, the majority were cared for by an attending physician specializing in medicine (78%), with fewer from surgery (12%), neurology (3%), and neurosurgery (6%). Family satisfaction did not vary by attending specialty. Patients with neurology or neurosurgery attending physicians had higher family and nurse ratings of quality of dying than patients of attending physicians specializing in medicine ( P , .05). Patients with surgery attending physicians had lower nurse ratings of quality of dying than patients with medicine attending physicians ( P , .05). Chart documentation of indicators of palliative care differed by attending specialty. Conclusions: Patients cared for by neurology and neurosurgery attending physicians have higher family and nurse ratings of quality of dying than patients cared for by medicine attending physicians and have a different pattern of indicators of palliative care. Patients with surgery attending physicians had fewer documented indicators of palliative care. These fi ndings may provide insights into potential ways to improve the quality of dying for all patients.

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Section: Documentation Of Palliative Carementioning

confidence: 96%

Differences in End-of-Life Care in the ICU Across Patients Cared for by Medicine, Surgery, Neurology, and Neurosurgery Physicians

Kross

Engelberg

Cuschieri

et al. 2014

Chest

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“…In intensive care units (ICUs), considerable time and effort are devoted to delivering bad news, discussing the level of care (Tulsky et al 1995) and guiding patients or their close relatives through the process of deciding to withhold or withdraw life support therapy (Cassell et al 2003;Stevens et al 2002;Cook et al 2001). Physicians assume these responsibilities progressively during their medical training, in a manner that fosters both professional autonomy and patient-centred care (Mullan et al 2002).…”

Section: Introductionmentioning

confidence: 99%

Critically ill patients and end-of-life decision-making: the senior medical resident experience

Ahern

Doyle

Marquis

et al. 2011

Adv in Health Sci Educ

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In order to improve the understanding of educational needs among residents caring for the critically ill, narrative accounts of 19 senior physician trainees participating in level of care decision-making were analyzed. In this multicentre qualitative study involving 9 university centers in Canada, in-depth interviews were conducted in either English or French, and the transcripts then underwent a hermeneutic phenomenological analysis. The resident was the central figure in the narrated incident, along with the patients' relatives and other attending physicians. The vast majority of interviews recounted negative experiences that involved delivering bad news to patients' families and managing difficult communications with them and with physician colleagues. Emotional distress and suffering were often part of their decision-making process. Narrating their experiences was viewed as a positive event. Data analysis uncovered 6 general themes that were organized into 2 categories, the first one grouping together themes related to interactions with the patients' families and the second comprising themes related to interactions with physician coworkers. The findings suggest that physician trainees' narratives are a rich source of data regarding what constitutes meaningful training experiences and what they learn from them. Educational approaches that incorporate the telling of stories would allow students to express their feelings, doubts, and opinions about their work experiences and could thus foster personal and emotional learning in critical care.

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“…[5][6][7][8][9][10][11] Family members of ICU patients have high levels of depression, anxiety, posttraumatic stress disorder, and caregiver burden. [12][13][14][15] Of note, the administrative structure and culture of the surgical ICU (SICU) may contribute further unique stresses for patients and their families, as SICUs frequently involve multiple care teams and providers, and much of surgical culture is centered around what Cassell and colleagues 16 refer to as a rescue culture, that is, a surgical culture focused on saving the patient at all costs.…”

mentioning

confidence: 99%

Empowering the "Cheerers": Role of Surgical Intensive Care Unit Nurses in Enhancing Family Resilience

Ellis¹,

Gergen²,

Wohlgemuth³

et al. 2015

American Journal of Critical Care

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Background Supporting family resilience, the ability of families to rebound from stressful events, is a goal of family nursing. Critical care nurses act as liaisons between patients' families and other clinicians and thus are uniquely situated to promote family resilience. Objective To explore how nurses perceive the experiences of long-stay surgical intensive care unit patients and their families in order to gain insights on how nurses could cultivate family resilience. Methods A qualitative study including semistructured interviews (n = 13) and 4 focus groups (n = 17) with nurses in 3 surgical intensive care units in a large teaching hospital. Results Three themes were identified: expectations, support, and communication. Nurses noted that clinicians' and families' unrealistic expectations regarding the patient's recovery can foster false hope. Nurses recognized families as "cheerers" who provide support by being involved in patient care and observed how extensive family involvement can be beneficial to patients but overwhelming for families. Nurses noted that communication among providers, families, and patients is the cornerstone of creating meaningful relationships. Nurses stated that with many teams involved, discrepancies in information can occur and often confuse and disturb patients' families. Thus, nurses identified ways to enhance family resilience through routine and consistent communication.Conclusions Nurses note unique stresses faced by families of patients in surgical intensive care units. Using the family resilience model, nurses can identify and enhance key family resilience factors.

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Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life—Updated§

Cited by 141 publications

References 9 publications

Differences in End-of-Life Care in the ICU Across Patients Cared for by Medicine, Surgery, Neurology, and Neurosurgery Physicians

Differences in End-of-Life Care in the ICU Across Patients Cared for by Medicine, Surgery, Neurology, and Neurosurgery Physicians

Critically ill patients and end-of-life decision-making: the senior medical resident experience

Empowering the "Cheerers": Role of Surgical Intensive Care Unit Nurses in Enhancing Family Resilience

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