2241.ppt

End-of-Life Care in the Critically Ill; a description of knowledge, attitudes

and practices of physicians and nurses from Karachi, Pakistan.

End-of-Life Care in the Critically Ill; a description of knowledge, attitudes

and practices of physicians and nurses from Karachi, Pakistan.

Muhammad Naeem, Nawal Salahuddin, Sulaiman Mapara, Roshan Manasia RN, Shahla Siddiqui, Aasim Ahmad, Saad

Shafqat

Department of Pulmonology & Critical Care Medicine, The Aga Khan University Hospital, Karachi, Pakistan

Background (1)Background (1)

• Not all patients admitted to an intensive care unit will benefit from life-sustaining treatments

• Practitioners are then faced with decisions to limit care so as to not prolong the process of Dying

Inabilities to recognize Dying results in:

• Overspending of health care resources

• Undue suffering to the patients and their families

• A ‘steal’ of limited intensive care facilities


Limitations in providing quality end-of-life care can occur due to:

• Lack of formal training about end-of-life issues

• Inadequate communication skills • Heightened emotions of patients, their

families and healthcare providers • Inconsistent understanding of legal and

ethical issues


ObjectivesObjectives

• We carried out this study to determine the actual End-of-Life Care knowledge and practices of clinicians routinely involved in the care of patients admitted to Intensive Care Units (ICU)

Methods: Outline (1)Methods: Outline (1)

Design:• Cross Sectional study in May 2006

Sample:• Trained & certified critical care nurses

(only from AKUH)

• Physicians (attending and physicians-in-training) currently involved in the care of ICU patients

Study Sites:• The Aga Khan University Hospital

(AKUH), Karachi

• Liaqat National Hospital (LNH) Karachi

• National Institute of Cardiovascular Disease (NICVD) Karachi

Methods: Outline (2)Methods: Outline (2)

Methods: Questionnaire development (1)Methods: Questionnaire development (1)

A 13 question instrument was developed with specific attention to assessing:

• Recognition of End-of-Life in the ICU patients

• Knowledge of commonly used terms to describe limitations of care (DNR, Comfort measures)

• Attitudes and practices towards withdrawal and limitation of life support measures

• Organ harvest for transplantation


• The questions were fixed-response with 2 best-choice and the others multiple choice

• The questionnaire was locally developed after reviewing similar, validated instruments used in earlier surveys on end-of-life assessment in the intensive care


• The questionnaire was then pilot tested on 10 clinicians (5 nurses and 5 physicians) which were not included in the final sample

• Based on their feedback the final

instrument underwent grammatical modifications to maximize clarity

• The final instrument required 15 minutes to fill


Methods: Survey techniques (1)Methods: Survey techniques (1)

• A research officer delivered & collected the self-administered questionnaire

• The questionnaire did not solicit any personal information that could link the responses to specific persons

• Each questionnaire contained a cover letter from the investigators explaining our interest in understanding the recognition, attitudes and practices towards end-of-life care

Methods: Survey techniques (2)Methods: Survey techniques (2)

• A Chi square analysis was used to determine significant differences in responses between the nurses, attending physicians & physicians-in-training

• Fisher’s Exact Test was used where the individual cell counts was < 5

• A one-way ANOVA was used to compare differences in age and years of practice

Data Analysis (1)Data Analysis (1)

• A 2-sided p value of <0.05 was considered statistically significant

• Statistical analysis was performed using version 14.0 of the Statistical Program for Social Sciences (SPSS)

Data Analysis (2)Data Analysis (2)

• Of the 200 questionnaires sent to nurses and physicians, 137 (68.5%) completed the survey

• There were 100 physicians (medicine, surgery, anesthesia, critical care physicians) and 37 (ICU,CICU,CCU) nurses in this final study group

Results (1)Results (1)

Respondents:

The Aga Khan University Hospital 60%

Liaqat National Hospital 30%

National Institute of Cardiovascular Disease 10%


Respondent Characteristic Physiciansn = 100

Nursesn = 37

p value

Age (yrs) Mean ± SD 34.86 ±8.43 26.08 ± 4.43 < 0.001

Gender Male (%) Female (%)

70 (70%)30 (30%)

29.770.3

< 0.001

Generalists (%)Specialists (%)

40 (40%)60 (60%)

-100%

Years of independent Practice * Median Range

5 yrs1 – 37

4 yrs1- 7

<0.001


* excludes physicians in training


Respondent Characteristic Physiciansn = 100

Nursesn = 37

p value

Place of Certification & post-graduate Training Pakistan (%) USA (%) United Kingdom (%)

61 (61%)13 (13%)26 (26%)

35 (95%)02 (5%)

-

Percentage answering ‘yes’ to the following questions:

Consultantsn= 52

Nursesn= 37

Physicians-in-

Trainingn= 48

pvalue

Braindeath is defined as: ‘Irreversible cessation of brainstem function’ 88.5% 97.3% 72.9% 0.01

Eligible organ donors for transplantation: Cadavers Brain dead (heart beating) Persistent Vegetative states

55.8%78.8%15.4%

21.6%51.4%5.4%

62.5%66.7%6.3%

<0.0010.025

0.4

Responses on questionnaireResponses on questionnaire



Consultantsn= 52

Nursesn= 37

Physicians-in-

Trainingn= 48

pvalue

‘Comfort measures’ includes:

Surgery under GA

Noninvasive ventilation

Enteral feeding

Total parenteral nutrition

Antibiotics

Dialysis

11.5%

17.3%

69.2%

32.7%

48%

13.4%

18.9%

13.5%

18.9%

13.5%

8%

2.7%

0%

16.7%

70.8%

58.3%

43.7%

8.3%

0.004

0.63

<0.001

<0.001

<0.001

0.20




Consultantsn= 52

Nursesn= 37

Physicians-in-

Trainingn= 48

pvalue

In which circumstances would you withdraw life support?End stage of a chronic disease

Acute multi-organ failure with no expectation of meaningful recovery

Family’s request

44.2%

34.6%

34.6%

24.3%

40.5%

21.6%

22.9%

50%

29.2%

0.07

0.56

0.65

Results (7)Results (7)Responses on questionnaireResponses on questionnaire


Consultantsn= 52

Nursesn= 37

Physicians-in-

Trainingn= 48

pvalue

Which measure do you usually withdraw first? Mechanical ventilation Vasopressors Artificial airway

48.1%28.8%1.9%

13.5%62.2%

0%

54.2%31.3%2.1%

<0.0010.006NS

Hospital Ethics Committee consultations in decisions to withdraw life support 55.8% 73% 87.5% 0.01




Consultantsn= 52

Nursesn= 37

Physicians-in-

Trainingn= 48

pvalue

Who usually initiates the discussion to withdraw life support? Primary physicians Critical care physicians ICU nurses Family

65.4%23.1%

2%9.6%

56.8%8.1%0%

16.2%

68.8%12.5%

0%14.5%

0.520.07NS0.65

Results (9)Results (9)Responses on questionnaireResponses on questionnaire




Consultantsn= 52

Nursesn= 37

Physicians-in-

Trainingn= 48

pvalue

For care givers who do not consider withdrawal of life support in any circumstances, the reasons were: Not allowed by religion Must sustain life at all cost Medicolegal implications Family’s reactions

3.8%30.8%11.5%26.9%

5.4%29.7%

0%29.7%

14.6%37.5%16.7%29.2%

0.260.290.03NS

Summary of the main results (1)Summary of the main results (1)

• Brain Death is generally well recognized by all care givers

• The indications to Withdraw already established Life Support are not well understood and the decision is infrequently initiated by clinicians

• The eligibility for organ donation is variably understood

• What kinds of care is included in ‘Comfort measures’ is unclear

Summary of the main results (2)Summary of the main results (2)

Discussion (1)Discussion (1)

• Though Death in the critically ill patient, appears to be recognized by most care-givers, the Dying process may not

• Care givers are poorly equipped to deal with End-of-Life issues in the ICU

Reliance on Ethics Committee consultation to assist in Withdrawal of care issues suggests that though a need to limit care is recognized, care givers are:

• Inadequately prepared to deal with families

• Personally conflicted with the limitation of life sustaining treatment

Discussion (2)Discussion (2)

• There are confusions in the definition of Brain Death, End-of-Life recognition and indications and processes of withdrawal of life support

• Discrepancies exist between physicians and nurses perceptions and attitudes

• Clearly teaching programs will need to incorporate cultural and religious differences in their Ethics curricula

ConclusionConclusion

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2241.ppt