Research paper
Barriers, enablers and challenges to initiating end-of-life care in an Australian intensive care unit context

https://doi.org/10.1016/j.aucc.2016.08.001Get rights and content

Abstract

Background

Patients admitted to Australian intensive care units are often critically unwell, and present the challenge of increasing mortality due to an ageing population. Several of these patients have terminal conditions, requiring withdrawal of active treatment and commencement of end-of-life (EOL) care.

Objectives

The aim of the study was to explore the perspectives and experiences of physicians and nurses providing EOL care in the ICU. In particular, perceived barriers, enablers and challenges to providing EOL care were examined.

Methods

An interpretative, qualitative inquiry was selected as the methodological approach, with focus groups as the method for data collection. The study was conducted in Melbourne, Australia in a 24-bed ICU. Following ethics approval intensive care physicians and nurses were recruited to participate. Focus group discussions were discipline specific. All focus groups were audio-recorded then transcribed for thematic data analysis.

Results

Five focus groups were conducted with 11 physicians and 17 nurses participating. The themes identified are presented as barriers, enablers and challenges. Barriers include conflict between the ICU physicians and external medical teams, the availability of education and training, and environmental limitations. Enablers include collaboration and leadership during transitions of care. Challenges include communication and decision making, and expectations of the family.

Conclusions

This study emphasised that positive communication, collaboration and culture are vital to achieving safe, high quality care at EOL. Greater use of collaborative discussions between ICU clinicians is important to facilitate improved decisions about EOL care. Such collaborative discussions can assist in preparing patients and their families when transitioning from active treatment to initiation of EOL care. Another major recommendation is to implement EOL care leaders of nursing and medical backgrounds, and patient support coordinators, to encourage clinicians to communicate with other clinicians, and with family members about plans for EOL care.

Section snippets

Background and literature review

Patients admitted to Australian intensive care units (ICUs) are critically unwell and present challenges related to increased mortality. Several ICU patients require withdrawal of active treatment and commencement of end-of-life (EOL) care.1, 2 To provide optimal EOL care ICU clinicians must be sufficiently prepared and supported by healthcare organisations.3 Many barriers exist in transitioning patients to EOL care, including a lack of education and limited emotional and organisational support

Aims

The aim of the study was to explore the experiences and perspectives of physicians and nurses when providing EOL care in the ICU. The study addressed the following research question: What are the barriers, enablers and challenges that clinicians encounter when initiating and delivering EOL care within the ICU? An enabler is defined as something that enables achievement of an end point. A challenge is a problem or difficulty associated with initiating and delivering EOL care, whereas a barrier

Methods

An interpretative, qualitative inquiry framework was employed. Focus groups were conducted, with a semi-structured format. A focus group approach was used as it was perceived that deep reflections and discussion among clinicians who provided EOL care in ICU would be encouraged. This study was granted ethics approval by the participating health service.

Results

Five focus groups were conducted, two involving physicians and three involving nurses. Eleven physicians and seventeen nurses participated in the study. Table 2, Table 3 present a summary of the demographic and qualification characteristics of participating physicians and nurses. Quotes from transcripts have been used to support the themes relating to barriers, enablers and challenges. These quotes have been coded using the nomenclature of PG and NG to indicate physician group and nursing group

Discussion

This study shows there is a gap in the current education delivered to nurses and physicians in communicating with patients and their families at EOL. There was a lack of education and training opportunities for clinicians identified in this study. The ANZICS Statement on Care and Decision-Making at the EOL for the Critically Ill (2014) recommends that ICU staff involved with dying patients should undertake education in how to communicate effectively with patients and their families around EOL

Conclusion

Insights from this study contribute to a growing body of Australian literature on EOL care. The results will assist in improving multidisciplinary EOL care practices in the ICU. A major recommendation is to develop a structured education program, individually tailored to nurses and physicians, so all clinicians who engage in EOL care discussions are adequately prepared. Despite communication education being one of the recommendations of the ANZICS Statement on Care and Decision-Making at the

Authors’ contributions

All authors have made substantial contributions to all of the following: (1) the conception of the work; the interpretation of data for the work, drafting the article and revising it critically for important intellectual content, final approval of the version to be submitted, and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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