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Table 3 Data extraction and quality assessment of included articles divided into mixed-methods articles

From: Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

First author, publication years, country Aim of the study Participants Methodology/data gathering Main outcome Barriers Facilitators Quality assessment
Hansen, L [37]
2009/Portland USA
To examine how use of multiple interventions could improve nurses’ experience of end-of-life care. Phase 1 nurses (n = 91)
Phase 2
nurses (n = 127)
Questionnaire: a 5-subscale tool consisting of 30 items scored on a Likert scale
Qualitative data open-ended questions
In general, scores on the five subscales were exceeded, with the levels of nurse perception improving over time, particularly during the second stage when the scores were greater than the set criteria. It was evident that the pace of some improvements was consistent across units, whereas others were implemented at different times to reach the overall mean score. *Lack of written symptom control protocol
* Insufficient communication
among nurses, physicians,
and patients’ families
*Lack of spiritual care
*Physicians’ behaviours, influence palliative care
*Bereavement programme Moderate al.
To describe residents’ experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU) and to understand the possible influence of the 3 Wishes Project. Residents
(n = 33)
Semi- structured interviews
It was evident that there were three major issues. (1) Training is paramount in the care of EOL patients as a death in the intensive care unit (ICU) can create a feeling of helplessness, especially as it is difficult to form an empathetic relationship with dying patients. In particular, it is considered that there is not enough EOL training, the very quality that is valued by patients. (2) The project re-emphasizes the elements of dying, focusing more on the humanity of the practice, giving prominence to the family’s involvement, encouraging a higher level of emotional interaction and ensuring that the care is an ongoing process during and after the patient’s death. (3) Encouraging EOL dialogue and reflection, assisting residents to react in a palpable manner and employing role modelling allows the project to subscribe to experimental education. *Difficulties in communication with dying patients related to ICU culture
* Inadequate education and palliative care skills
*Facilitate palliative care dialogue
*Facilitate family engagement learning
Anderson WG
To implement and evaluate a palliative care professional development programme for ICU bedside nurses. Nurses (n = 428)
Nurse leaders
(n = 8)
Mixed methods
A survey was completed by bedside nurses
Qualitative data notes taken by nurses’ leaders
It was encouraging to learn that nurses assessed their EOL skill level to be significantly higher post-workshop; they identified 15 tasks such as making sure the family fully understood the situation when convening a family meeting and helping to alleviate family distress (P < 0.01 vs. pre-workshop) care needs. *Lack of palliative care team in ICU
*ICU is a noisy environment
*Palliative care nursing programme (hospital setting)
*Involve multi-specialty
*Palliative care nursing instructor
*Communication workshop
Wysham N.
To explore attitudes about ICU-based palliative care delivery, preferred screening practices for finding appropriate recipients of specialist consultation, and triggers themselves Nurses (n = 150) Intensivist (n = 114) physicians (n = 39) Survey included open-ended questions Three-quarters of the 225 cases reviewed stated that palliative care consultation was inadequate. The favoured method was selecting those eligible by electronic health record identification searches for specialist consultation. From 123 cases (41%), only 6% (in this instance 17 cases), considered that the present system was sufficient. Metastatic malignancy, EOL decision making, persistent organ failure and non-realizable care aims were the most identifiable triggers for consultation. *Absence of palliative care consultation in ICU
*Unrealistic goals of care, end of life decision making, and persistent organ failure.
Satomi Kinoshita
Examine why intensive care unit (ICU) nurses experience difficulties in respecting the wishes of patients in end-of-life care in Japan Nurses (n = 1158) Survey/questionnaire
The reasons were compounded, as decision making was often conducted by those who had no concept of patient wishes, even those which were often unachievable, where the death was sudden and constrained by time. It was identified that the majority of nurses sought to fulfil the wishes of a dying patient. Their manner of death in the ICU left ethical questions to be answered. However, nurses appreciated that to honour a patient’s last wishes in such a situation was frequently impracticable. It was evident from the results of the investigation that there was a lack of meaningful discussion on how to respect the wishes of dying patients. *Inability to respect patient’s wishes
*Excessive treatment in the role of the ICU *ICU environment is inappropriate for dying *Rapid deterioration and sudden death *Lack of information (patients’ wishes) and patients’ family
Zib, M [42]
This pilot audit addresses the feasibility of developing an end-of-life (EOL) decision making audit and quality improvement tool and applying it in the intensive care setting Patients records (n = 47)
(n = 15)
Charts were audited
Structured interview with the intensivist
Over half of ICU deaths (55%) followed the withdrawal of treatment. The vast majority of reasons for withdrawal were given as futility or treatment failure. There were no recorded instances of dissension between the family and the medical staff. Critical care physicians, the intensivists, had a high level of credence in making EOL decisions. *Treatment failure or futility was the reason cited for withdrawal.
*Confidence among intensivists
Strong support for advance planning and for audit of EOL decision making was highlighted.
*Consultation with ICU colleagues was rated as the most helpful factor in decision making.
*Intensivists wished for earlier and more active support from the admitting medical officers in decision making.