Table 4 Influencing factors of the palliative care approach in the ICU
Type of influencing factors | Specific factors | Barriers | Facilities |
|---|---|---|---|
1. Organizational structures | Management resources | - Lack of time, resources and staff shortages to care for palliative patient in ICU [19, 34]. - Simultaneous requirement to care for other patients while staff work with patients’ palliative need [32]. - Lack of time to develop and implement strategies [36]. - Lack of training and education as a result of time and resource constraints [19, 41]. - Lack of spiritual support (assistance is unavailable at weekends) [37, 42]. - Inadequate support of junior nurses from team leaders [23]. - Absence of palliative care physicians and senior nursing staff in relation to advance directive (AD), orders in ICU and difficulties within the palliative care process [32]. | - Staff ratios. For example, in ICU nurses work in patient/nurse ratios of either one to one or one to two. This allows time to be devoted to dying patients [27]. - Assign a nurse for the patient in late palliative stage, for example, patient and family should be cared for by a nurse who is known to them [28]. - A bereavement programme to support patients and families (use bereavement material) [37]. - Facilitating palliative care dialogue (standardized tools) [38]. |
Policies and guidelines | - Lack of protocol and policies guiding palliative care in ICU [22, 23, 34]. - Lack of written protocol for palliative care nursing such as pain management, dyspnoea, etc. [37]. - Doctor resistance to applying policy [37, 38]. - Physicians unfamiliar with the guidelines and resistant to using them, plus difficulties encountered in the removal of all mentors [26]. - Insufficient standardization of care [25] and the presence of procedural difficulties [32]. | - Strong leadership and management team support (supportive factors) [36]. - Guideline recommendations regarding both direct care for palliative patients and palliative care decisions [26]. - employing guidelines and care policy designed for a humanistic approach for example, medication guidelines designed to improve symptom control [26]. - An integrated care system (clear guidance, reduced paperwork, adequate structure) [27]. - Formulating the physician’s strategy [19]. - Open visiting times for family and friends [28]. | |
Knowledge and skills | - Inadequate education and knowledge of palliative care among nursing staff responsible for delivering care to patients in ICU [21, 38]. - Inadequate training for physicians and nurses regarding communication skills [35]. - Lack of understanding about the complexities involved in providing palliative care in ICU [23]. - Lack of requisite knowledge, skills and experience among physicians [37, 38]. - Lack of skill in the provision of care for dying patients [23]. - Inadequate information relating to palliative care issues within both current nursing curriculums or courses and hospital orientation [32]. - Insufficient preparation for palliative care decision-making (inadequate professional training) [29, 32]. - Unpreparedness of ICU nurses for shifting from curative to palliative care models [19]. | - Involving training teams in specialized palliative care while providing care for patients in ICU [25]. - Hospital training and the development of a palliative nursing programme [39]. - Specialist palliative nursing coaching [39]. - Training workshop communication programme for bedside nurses [39]. - Trial and error are useful ways to learn from nurses’ experiences [19]. - Education and professional support while implementing improvements to guidelines [36]. | |
Multidisciplinary team involvement | - Lack of nursing staff involvement in palliative care decision making [28, 29, 42]. - Lack of palliative care team integration within the ICU [37, 40]. | - Involvement of stakeholders from different levels and specialties [39]. - Direct palliative care team involvement in care for patients in ICU [34]. | |
2- Working environment | Physical environment | - Absence of infrastructure in the ICU to facilitate family involvement in palliative care (insufficient space for meetings) [20, 25, 35]. - Inadequate organizational support in promoting humanistic environment in ICU [23] - The challenging, hectic and noisy nature of ICU culture [20, 21, 37, 38]. | - Modified bedside environment and use single room for dying patients [23, 36]. |
Psychosocial environment | - Moral distress acts as barrier to providing palliative care in the ICU [19]. - Distress experienced by nursing staff due to lack of help from managers [27]. - Colleagues’ unwillingness to appreciate the complexity of palliative care (staff compliance with changes) [23, 36]. - Insufficient emotional support for nurses during and after their providing palliative care for patients in ICU [27, 32]. | ||
3-Patient and Family involvement | Conflict | - Disagreements, unwillingness to discuss them and conflict between families and physicians regarding palliative care process [22, 23, 32, 35]. - Family’s refusal of care on the grounds of religious belief [35]. | - To tailor and adapt the object of care in collaboration with the patients and families [22]. |
Participation | Lack of family involvement in any documented wishes that have been expressed by the patient [42]. - Language and culture barriers relating to patients and/or their families [35]. - Lack of understanding and education among patients and family concerning the prognosis and the continuity of palliative care [22, 31]. - Patient inability to participate in palliative care decision-making [35]. - Patient’s wishes regarding palliative care were insufficiently documented prior to their admission to ICU [42]. | - Family participation and involvement in patient care and decision-making (family-centred care [23, 28, 36, 38]. - Patient and family wishes considered prior to actual decision-making [38]. - The establishment of a patient advocate and medical translation team by nurses involved in family meetings [32]. - Respect for patients’ wishes [38]. | |
Information/ communication | - Lack of effective communication with family members [20, 34]. - Family’s requests for updates on patient’s prognosis [31]. - Insufficient information provided to patients and families about death [41]. | - Using multiple means to communicate medical information regarding patients’ prognoses to their families [20]. - The allocation of a single point of contact for all family members [31]. | |
4. Palliative Care Decision-Making | Transition of care objectives | Fragmentation of care objectives by different physicians [19]. - Discrepancies between the care objectives of the medical team and the family [34]. -Disagreement between team members about comfort care decisions and inconsistencies in palliative care [27, 36]. - Continuation of aggressive and life-supporting treatments [31, 41]. - Absence of a care plan for palliative care [31]. - Inconsistent attitudes, approaches and beliefs among physicians providing palliative care [37, 42]. - ICU patient decision-making potentially negated by incapacity [41]. | - Clear and defined goals for providing comfort and care [24]. - Consensus regarding objectives among varices involved in health care teams [24]. - Clear information and documentation about patient’s history, background, status and prognosis [24]. -Empowered and skilled staff involved in the care process [24]. - Locating physician participation as central during the establishment of comfort care for patients [31]. - Establishing a consensus around decision concerning comfort care [24]. |
Withholding or withdrawal of life-sustenance | - Ethical factors influencing doctors’ decision-making processes [33]. - Lack of patients’ advance directives at the time of admission [22, 34, 35, 42]. - Difficulties with palliative care treatment decisions [26]. | - Ethics consultations [30]. | |
Prognostication | - Lack of understanding concerning the assessment of prognostication efforts and pre-death symptoms [24, 25]. - Critical delays in palliative care prognostication and decision-making [28]. | - Use numeric prognostic scale [20]. | |
Multidisciplinary team communication | - Lack of communication and team interaction act as core barriers to providing adequate palliative care in ICU [19, 22]. - Inadequate communication about identification of care objectives between ICU team members and other clinicians [35]. | - Multidisciplinary meetings with families to improve communication [22, 34]. - Multidisciplinary team meetings [36]. |