Roles and Responsibili-es of ICU Nurses in End-of-Life Decisions Making Cheryl Carter Durban
Context -Distribu-on of beds Majority of beds 86% Limpopo < 100 beds North West Gauteng Mpumalanga Northern Cape Free State KwaZulu Natal Western Cape Eastern Cape < 300 beds Bhagwanjee. S, Scribante. J. Na-onal audit of cri-cal care resources in South Africa unit and bed distribu-on. SAMJ. 2007 97(12)1311-1314
Public Sector Bed : Popula-on Ra-o < 1:20 000 Limpopo 1:82 000 North West Gauteng Mpumalanga Northern Cape Free State KwaZulu Natal Western Cape Eastern Cape 1:32 1:62 000
Defini-ons End-of-life-decisions refers specifically to the DNR order which precedes withdrawing or withholding treatment DNR /AND the decision taken when further treatment is deemed fu-le. It incorporates either withdrawing or withholding treatment.
Defini-ons Withholding treatment Treatment is maintained at the level it was when the DNR decision was taken Withdrawing treatment Life-sustaining treatment Analgesia and seda-on are maintained, and all nursing care is rendered as usual.
Background EoL decision making is a difficult and complex process When should the decision be made? When and how should discussions begin with the family? Who should communicate with the family? Who makes the decision? How are EoL decisions implemented and by who? Lack of clarity of roles of various health professionals
Roles and Responsibili-es Who should carry out the order? No guidelines available Individual units à policies and procedures Individual level of comfort à no-one should be required to carry out an order with which they are uncomfortable Each to the level of their individual conscience
Impact of DNR Nurses Experiences Grief, Sadness, Depression Need to be involved in the decision making process Our opinion should count Importance of communica-on Mul-disciplinary team Present for all communica-on with the family Carter. CA, Bhengu. BR: Lived experience of ICU Nurses in KZN: EoL decision making KZN. 2010
Nurses Experiences Taking the brunt of the process and communica-on once the decision was made Lack of support system Informal support from senior colleagues Shared experience No formal support systems Carter. CA, Bhengu. BR: Lived experience of ICU Nurses in KZN: EoL decision making KZN. 2010
What role do nurses play? Nursing Research and Prac-ce Volume 2011 1. Informa-on broker 2. Supporter 3. Advocate
1. Informa-on Broker Important role in facilita-ng communica-on: - Between various family members Between various members of the health care team Strategies employed 1.1 Giving informa-on to Dr s 1.2 Giving informa-on to family 1.3 Mediate
1. Informa-on Broker 1.1 Giving informa-on to Dr s Clinical status of the pa-ent Pa-ent and families emo-onal and psychological status Pa-ent and families expressed wishes Obtain informa-on from many sources, synthesise the informa-on providing an holis-c over view
1. Informa-on Broker 1.2 Giving informa-on to Family Members Explaining equipment Pa-ents condi-on and prognosis Transla-ng medical informa-on into lay terms Explaining, educa-ng and clarifying medical terms e.g. DNR Important not to just provide facts but need to interpret the meaning to prevent false hope
1. Informa-on Broker 1.2 Giving informa-on to Family Members Explaining equipment Pa-ents condi-on and prognosis Transla-ng medical informa-on into lay terms Explaining, educa-ng and clarifying medical terms e.g. DNR Important not to just provide facts but need to interpret the meaning to prevent false hope
1. Informa-on Broker 1.3 Mediate Bring people together to exchange informa-on directly Facilitate communica-on Encourage ques-ons during mee-ngs Bring mul-disciplinary team together for family mee-ngs Bring in other members of mul-disciplinary team Social Worker / Religious figures
Facilita-ng the Role of Informa-on Broker Ill prepared to deal with death an dying Basic training ICU Curriculum DNR process unique to ICU New staff entering units period of induc-on Explana-on of process Ra-onale for decisions Mentoring Guide through the process
Facilita-ng the Role of Informa-on Broker Communica-on is the most important aspect of DNR process Family members Healthcare workers End-of-life decision à involvement of nurses Holis-c perspec-ve and valuable insights Insight into amtudes and emo-onal response of family Encouraged to voice opinions and have those opinions heard
Facilita-ng the Role of Informa-on Broker Responsibility to have solid up to date theore-cal knowledge : - Substan-ate and jus-fy opinions Confidence Credibility
2. Supporter Nurses enact the role of the supporter during the DNR process. Roles 2.1 Building trus-ng rela-onships 2.2 Demonstra-ng empathy
2. Supporter 2.1 Building trus-ng rela-onships Building a rela-onship of trust with family members provides support Family members trust nurses who: - Introduced themselves Explained the equipment Were willing to talk
2. Supporter 2.1 Building trus-ng rela-onships Nurses support family by:- Allowing them to par-cipate in daily care Allowing important rituals Establishing what is important to them Storytelling Helping with prac-cal needs Maintaining a sense of hope Preparing them for bad news
2. Supporter 2.2 Empathy Trying to understand how the family see the situa-on Being present Taking -me to listen Allowing family -me to process informa-on Acknowledging feelings
2. Supporter 2.2 Empathy Extending empathy to colleagues involved in the decision making process Physicians should not feel alone in making the decisions
Facilita-ng the Role of Supporter Involved in all levels of communica-on with the family United front Consistent informa-on Prevent confusion Promote trust in healthcare team
Facilita-ng the Role of Supporter If nurses are supporters they need support Senior nurses Awareness of the impact of DNR process Be able to recognize staff with coping problems Apprecia-on of the value of the shared experience Mentoring systems Formal support programmes Focus groups Grief teams Stress management programmes Trust and understanding
3. Advocate Expecta-on of the family of ICU ooen that of providing a cure What aggressive treatments that maybe fu-le Nurses role ooen to challenge the status quo Role 3.1 Speaking to the medical team on behalf of the pa-ent 3.2 Speaking to the family on behalf of the pa-ent
3. Advocate Advocate to the Physician Direct Communica-on with Dr to express wishes of the family Ques-oning Dr about plans of care Challenges points of care against pa-ents / family wishes Indirect Plan-ng seeds Coaching on -ming of EoL decisions
3. Advocate Advocate to the Family Advoca-ng on EoL decision making with family when in the interests of the pa-ent Gentling telling family that the pa-ent is dying Helping family to clarify goals of care Challenge them to consider what the pa-ent would have wanted Explaining implica-ons of decisions Presen-ng a realis-c picture of what is happening Helping them accept the inevitability of death
Facilita-ng the Role of Advocate Willingness to be an advocate comes with confidence and experience Mentorship Encourage nurses to express their opinion Listen Doctors be aware of levels of knowledge and experience à Clear explana-ons and ra-onale Knowledge base Senior nursing staff ensure that decisions are fully discussed àclear ra-onale and understanding
Facilita-ng the Role of Advocate Involvement of nurses in the decision making process Nurses are then fully informed à able to provide adequate complete informa-on à enhances trust rela-onship Helps the family to understand and accept the prognosis, prepare for and cope with the death Adequate informa-on provided to meet family needs àmore sa-sfied with care
Facilita-ng the Role of Advocate Trus-ng rela-onship Fear of crea-ng false hope When provide informa-on need to interpret that informa-on Informa-on provided needs to be Adequate Truthful Consistent
Conclusion EoL decision making is a complex and difficult process Nurses have 3 important roles to play Informa-on broker Supporter Advocate In order to be effec-ve in these roles Involved in the decision making process Empowered Provided with support