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Table 4 Influencing factors of the palliative care approach in the ICU

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

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].
- Inappropriate environments for dying patients [27, 41].
- 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].