Subscribe Publish
Subscribe Publish

Read Our Latest Issue Read Now

Barriers and facilitators in the provision of palliative care in critical care: A qualitative descriptive study of nurses’ perspectives

Lisa Vaughn, MN, RN, and Anna Santos Salas, PhD, RN

Barriers and facilitators in the provision of palliative care in critical care: A qualitative descriptive study of nurses’ perspectives

Abstract

Intensive care units are providing increasing amounts of palliative care. Accordingly, integrating palliative care as a component of comprehensive critical care has been identified as a necessity. The purpose of this study was to explore what critical care nurses perceive as barriers and facilitators in the provision of palliative care in the critical care setting.

We conducted a qualitative descriptive study between 2016 and 2017. Eleven critical care nurses working within an intensive care unit in a tertiary care western Canadian hospital participated in this study. Semi-structured individual interviews were conducted with each participant and data was interpreted using thematic analysis.

Key barriers and facilitators identified were related to communication, end-of-life decision making, the life- saving mentality of the ICU, exposure to palliative care education, and the strengths and perils of the critical care environment.

The results of this study provide insight into the initiatives and resources that are required to enhance the provision of palliative care in the critical care setting.

Implications for Nurses

  • An in-depth understanding of the critical care nurses’ perspectives from a western Canadian province.
  • Raises awareness of the importance of integrating a palliative approach to care in the critical care setting.
  • Highlights gaps and needs in the provision of palliative care based on a deep portrayal of critical care nurses’ experiences.
  • Provides insight into what can be done to facilitate palliative care in critical care within a western Canadian intensive care unit context.

The primary goals of intensive care are to help individuals survive an acute health crisis (Akgun et al., 2019). When this goal is no longer feasible, the focus of care transitions from cure to comfort (Mercadante et al., 2018). Palliative care can bridge the gap between comfort and cure (Baker et al., 2015).Palliative care is an approach that improves the quality of life of patients and their families facing the struggles associated with a life-limiting illness (World Health Organization, 2002). Caring for dying patients is an integral component of critical care (Kyeremanteng et al., 2020). However, intensive care staff report that there are barriers to quality palliative care that negatively affect patients and their families (Ganz & Sapir, 2019). These barriers and inconsistencies in the provision of palliative care to critically ill patients can potentially result in negative end-of-life experiences for the patients and their families. Commonly reported barriers in the critical care setting include communication gaps (Coelho & Yankaskas, 2017), difficult end-of-life decisions (Wiedemann et al., 2012), and minimal access to education (Wolf et al., 2019). Efforts have been underway to improve the quality of palliative critical care. Often, these are focused on the provision of palliative education to critical care staff (End of Life Nursing Education Consortium [ELNEC], 2017), adoption of useful models of care (Aslakson et al., 2014), and development of palliative critical care guidelines (National Coalition for Hospice and Palliative Care, 2018). Many studies have examined the barriers to palliative care in critical care while a few have explored the facilitators. Most studies originate in the US, Australia, and Britain, with only a few done in the Canadian context. The Canadian Association of Critical Care Nurses (CACCN, 2011) states that critical care nurses are integral to enhancing the delivery of palliative care. However, to date, few studies have examined the perspective of western Canadian critical care nurses (CCN). Canadian CCNs are an important source of wisdom in conceptualizing a good death in the care of palliative care patients and their families (Vanderspank-Wright et al., 2019). In this article, we report findings from a qualitative study that explored critical CCNs’ perspectives concerning barriers to and facilitators of palliative care in the critical care setting.

Methods

We designed a study to explore the following research question: “What do Critical Care Nurses perceive as barriers and facilitators in the provision of palliative care in the critical care setting?” The research objectives were: 1) to explore the barriers in the provision of palliative care in critical care from the perspective of CCNs, and 2) to examine the facilitators in the provision of palliative care in critical care from the perspective of CCNs. This study received approval from the University’s Health Research Ethics Board and operational approval from the local health authority.

We followed Sandelowski’s (2000; 2010) qualitative descriptive methodology, an approach that provides opportunity to describe an experience from the perspective of those experiencing it and in the context within which it occurs. Descriptive qualitative methods are ideal when description of a phenomenon is the goal (Walker, 2012). While description and interpretation are always intertwined, this research methodology is highly descriptive in its approach. Description occurs when researchers provide “an accurate accounting of events” that in the eyes of those living through the experience is accurate (Sandelowski, 2000, p.336). The strength of a qualitative descriptive approach is the knowledge that is produced from findings that are more representative of the original data and data source (Sandelowski, 2010).

Participants

Participants were CCNs from a 27 bed intensive care unit (ICU) in a large tertiary hospital from a western Canadian city. Purposive sampling was used to recruit participants with varying levels of experience and knowledge, using the following inclusion criteria: a CCN (Registered Nurse [RN] or Nurse Practitioner [NP]) who had at least one year of experience in critical care. We employed posters and invitation letters sent via email by a key contact person to accrue potential participants. The final sample consisted of 11 participants, four of whom were NPs and seven RNs. The participants’ critical care experience ranged between 1 and 15 years. The sample size was determined by data saturation, the point at which no new ideas were evident in the transcripts (Malterud et al., 2016).

Data Collection

Data collection occurred from January 2016 to June 2017. Activities included 30-to-60-minute individual face-to-face semi-structured interviews, field notes, and a reflexive journal. Interviews were conducted by the first author, an RN and former CCN, at a location that was convenient to participants. We examined the interview guides from similar studies for content and wording of open-ended questions and used these guides to inform our interview questions. The initiating interview question was, can you tell me about your experience of providing palliative care to patients in the intensive care unit? This question was followed by probing questions which were focused on identifying potential facilitators and barriers to palliative care. Interviews were digitally audio-recorded and transcribed verbatim by a transcriptionist. The files were stored in the Health Research Data Repository (HRDR) at the authors’ home institution.

Data Analysis

Data analysis occurred concurrently with data collection. NVivo© was utilized to organize data analysis processes. We used thematic analysis to identify themes and patterns among the narrative data. Thematic analysis serves to identify and report patterns within data (Vaismoradi et al., 2013). It involves taking apart raw data and converting it into meaningful data through the identification of common themes (Castleberry & Nolen, 2018). Transcripts were read as a whole followed by a detailed line by line reading to extract predominant ideas and stories. Preliminary codes were generated that were then discarded or modified until the final codes were obtained. Codes were then synthesized into main themes. The primary author performed data analysis with feedback from the second author at various stages of the study.

Methodological Rigour

Lincoln and Guba (1985) present four criteria for establishing rigour: (a) dependability, (b) confirmability, (c) credibility, (d) and transferability. Strategies that were used in this study to enhance these qualities include: maintaining an audit trail through documentation of study processes, exercising reflexivity by keeping a reflexive journal, engaging in peer debriefing and member checking, and thick description of the study process and findings. Following completion of data analysis, 9 participants were invited to participate in member checking (two had declined consent to being approached for feedback). Four participants responded and their feedback served to confirm the findings. Additionally, this study has been reported using the Consolidation Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al., 2007).

Findings

Participants articulated several barriers to and facilitators of palliative care in critical care. While the research question focused on the broader experience of palliative care, the nurses tended to focus on their experiences of providing end-of-life care. End-of-life care refers to care that is provided when a persons’ death is imminent (Health Canada, 2018). The most salient barriers and facilitators identified were related to communication, end-of-life decision making, the life-saving mentality of the ICU, palliative care education, and the critical care environment. We describe these below.

Communication 

Several nurses expressed that conversations related to palliative care in critical care are often avoided: “It seems like talking about death is a faux pas.” (P8). Others explained that when these conversations occur, they are not addressed early enough in a patient’s illness trajectory. Participating nurses also expressed a concern that palliative care related communication between the health care team and the family is often inconsistent. One nurse recounted a specific experience that had been plagued by inconsistent communication:

“And the perspective of Surgery, was that the surgery was a success. And it was a success in terms of what they expected to happen was happening. So, it didn’t necessarily mean the patient was actually going to recover, or that it did him any good…Surgery was just pleased that his ostomy was putting out stool…When everything else was falling apart. And I remember, the ICU resident went in and spoke to the family and said, “we need to change the focus of care.” And the family seemed like they were kind of on board with that…. But every once in a while, a surgeon would walk in and be like, “Oh, yeah. We’re really pleased with how this is going.” And then they’d [the family] be confused” (p.3).

Alternatively, participating nurses were adamant that effective communication is an essential facilitator of palliative care: The nurses explained that effective communication is open and honest, timely, and patient-centred. They emphasized that the goal of effective communication is to enter into a dialogue to identify what is most important to the patient in relation to end-of-life care and final wishes.

“So, he [Physician] had a conversation with her, while she was still intubated, and told her, “this is how it is,” and he’s like, “you’re probably not gonna live through this.” And she had written him a note, “can I have a beer?” So, they made a plan. The next day, they would extubate her. And he brought her out a beer. And she sat in her bed, and she was able to talk to her family a little bit. And take some sips of her beer. And she just passed away. And that was like the best death ever. ‘Cause she was perfectly in acceptance, and she got what she wanted” (p.7).

End-of-Life Decision Making

Participants reported that many palliative care discussions between patients, families, and the health care team in critical care focus on making decisions related to end-of-life care and withdrawing or withholding life-sustaining treatment. They also said that families are often heavily involved in making these final decisions. However, several nurses suggested that this responsibility can be a great burden on families because it is often unexpected and crisis driven, creating feelings of stress, guilt, and doubt (P8; P10). Participants clearly articulated that end-of-life decision making, particularly related to withdrawing and withholding treatment, can be complex and difficult. Many nurses suggested that end-of-life discussions and decision-making can be thwarted by disagreements regarding directions of care, particularly between the medical team and the patient’s family. One nurse recalled a particularly distressing confrontation with a patient’s mother: “His mother was like, shaking me. “You can’t pull the plug on [him]!” And it was awful. I felt so bad for them, but they had to understand, right? Like, there’s nothing we can do” (P2). Additionally, many of the nurses reported that a patient’s care often remains on a blurred line between resuscitation and end-of-life care, in a state of limbo per se, in which no finite decision has been made. This creates more problems:

“What we were doing for this patient was not enough to save her life but [it was] too much that it was kind of putting her in a little bit of pain….But she’s not intubated. We didn’t line her. We didn’t provide her any support for her blood pressure. She’s super hypotensive, so I couldn’t even give her pain medications. And so, I just felt like, either let’s treat her or let’s not, but I felt like we were kind of in the middle. And so, I felt very confused and distressed as to how I should proceed” (p.6).

Alternatively, many nurses emphasized the importance of supporting patients and their families through a decision-making process, particularly regarding withdrawing and withholding life-sustaining treatments. One key to supportive decision-making is to allow a family the time they require to decide what they feel is best for their family member (P6). Additionally, many of the nurses identified the positive impact that advance care planning can have on end-of-life decisions.

“They can say, “No, my mom was very adamant, you know. She wouldn’t want to be on dialysis.” Or “My dad, you know, told me, never, ever would he want to have CPR.” … I think those are the best conversations that can happen before the situation, because then that gives us a good understanding of what the patient would be comfortable with.” (p.9) 

Life-Saving Mentality of the ICU

There was a consensus among the nurses that there is an innate culture of critical care which can both facilitate and hinder end-of-life care in the ICU. For example, the nurses explained that the ICU is grounded in a life-saving mentality, which can create a hierarchy of patient priority. They explained that once a decision is made to shift the focus of care to providing end-of-life care, often it seems that the patient becomes less of a priority compared to other patients on the unit. One nurse mentioned “You’ve gotta see your resuscitations and your critically ill first or even your transfers out get seen first, like we just don’t see our palliative patients as a priority.” (P10). The nurses in the study also associated this hierarchy of priority with the reality that critically ill patients will have priority over palliative patients with regards to bed occupancy. This meant that an imminently dying patient could be transferred out of ICU to make room for a critically ill patient. One nurse recalled working with a physician who was eager to move a palliative patient out of the ICU, rushing her saying, “Get it going, let’s go, why is he is still intubated? He’s taking up a bed for people who need it more.”…We’re just waiting for the kid’s grandpa to come in. He’s gonna be here at two o’clock. [The physician said] “We don’t have ‘til two o’clock. We have people waiting for ICU beds.” (p.3).Many of the nurses said that the recent introduction of designated palliative care beds to the hospital had been beneficial, but not quite adequate to meet the needs of their palliative patients [P3]. The nurses said that they often experience substantial conflict between wanting to keep a patient who is imminently dying in the ICU versus the harsh reality of needing to free up the beds for incoming critically ill patients. One nurse explained, “It’s almost more distressing when you move someone. And then, hours later, they pass. Like, it just seems like why put them through that stress, when it was only a few hours later.” (P3).

Overall, participants said they prefer to care for an imminently dying patient in the ICU rather than transferring such a patient to another unit. Additionally, many nurses spoke about the challenges of “shifting hats” from providing aggressive lifesaving and life-prolonging interventions to providing palliative care. For instance, one nurse shared, “when you switch to a palliative patient, it’s almost like there’s the big backpack of ICU that you are carrying; you just take it off and put it in the corner” (P5). Although they often struggle with having to shift the focus of care, the nurses showed pride in their ability to do so: “I’m proud of the nurses for being able to switch hats so quickly, and move into providing comfort and basic care, to provide dignity and a good death.” (P4)

Palliative Care Education

Several of the nurses identified that minimal access to palliative care education is a barrier to palliative care in the ICU. Some of the nurses said that everything they know about palliative care is what they’ve learned on the job rather than anything they were formally taught. As one nurse said, “You know, it’s something that you just gain with experience” (P1). Several nurses expressed a desire for education on how to engage in serious illness conversations with patients and their families [P1;P7;P9]Another nurse suggested putting a component of palliative care education into the ICU school education:

“I think if they did even just a small little tidbit of, “Okay, sometimes you’re gonna be withdrawing on your patient, and this is what you should be expecting”… When you’re new, you’re all gung-ho, caring for like the super sick patients that you’re trying to provide all the interventions for…But then, you’ll get the one patient that you’re withdrawing on, and… it’s hard to make that transition quickly.” (p.7)

The Critical Care Environment

Many of the nurses said that specific components of the ICU environment can both impede and improve palliative care. They highlighted that the heavy use of technology, lack of privacy, and the noisy bustling atmosphere of the ICU environment can hinder palliative care experiences [P4]. One nurse pointed out “there is nothing particularly warm or comfortable in the ICU, but the biggest problem isn’t comfort, it’s lack of familiar surroundings” (P1). Nurses emphasized the importance ofoffering comfort to patients and their families such as refreshment carts. They also supported the need to personalize the space by decorating a patient’s room with family photos and personal mementos. Additionally, they noted that it is important to create an environment that enables family presence at end-of-life. One nurse recalled caring for a particular patient:

“She was quite a young woman who had epilepsy for most of her life. She had a prolonged grand mal seizure, and as a result her brain was just not functioning. So, her husband, who was fantastic, -just wanted to be close to her. So, my colleagues and I made it so that we could scootch her over in bed enough so that he could crawl beside her… I don’t know if she could feel that he was there, but I think it made it better for him” (p.4).

Additionally, nurses identified that the innate interdisciplinary nature of the ICU creates an environment that facilitates palliative care. The nurses frequently referred to the strengths of specific members of the multi-disciplinary team, such as NPs, spiritual care practitioners, social workers, and respiratory therapists. For instance, one nurse recalled a young Indigenous woman who had lived a hard life and was dying of liver failure:

“She was estranged from all of her family, and one of our aboriginal counsellors stayed at her bedside all night and sang to her, and sang to her while she died, and that just had such a profound impact, that nobody else was really even going in the room. But this woman sat with her. She didn’t know her and sang to her all night” (p.10).

Several of the nurses identified that the one-to-one nurse-patient ratio of ICU facilitates nurses to form strong therapeutic emotional connections with many of the palliative patients and their families. They shared many experiences of bonding and crying with families over the loss of a loved one. Participants recalled the strong impact made on them by some patients and families, often describing them as unforgettable. For instance, one nurse explained, “I have this little group of patients that follow me around in my head, both goods and bads that help me adjust how I approach things now. They’re like my teachers with palliative care” (P10). This profound connection between nurse and patient, has deep implications for nurses who provide palliative care in any setting.

Overall, participating nurses had a clear understanding of what impedes and what facilitates palliative care in critical care. They were adamant that for the sake of patients and their families, the barriers to palliative care need to be addressed.

Table 1. Barriers and Facilitators in the Provision of Palliative Care in Critical Care Overview of Themes
ThemeExamples of BarriersExamples of Facilitators
CommunicationDoesNot occur early enough, inconsistentOpen, honest, timely, patient and family-centred
End-of-Life Decision MakingThe burden of decision-making on family, disagreements regarding the direction of careAdvance care planning, family support,appropriate timing
Life-Saving Mentality of ICU  Life-saving mentality, hierarchy of patient priority, moral distressDebriefing sessions, access to counselling, “shifting hats”
Palliative Care EducationLack of palliative care education and trainingAccess to palliative care education and training
The Critical Care EnvironmentNoise, technology, lack of privacy  One-on-one nursing care, family presence, extra comforts, interdisciplinary nature of the ICU

Discussion

Study findings revealed that participating nurses were highly committed to improving the quality of palliative care provided in critical care. The themes in this study mirror similar findings reported in the critical care literature. Additionally, the findings of this study support that efforts must be focused on developing and engaging in processes that serve to enhance palliative care in critical care. Although not an exhaustive list, such efforts should include, early integration of the palliative approach, supporting effective communication and decision making, providing palliative education to critical care staff, and promoting an environment that is conducive to quality end-of-life experiences. Below, we discuss each of these implications.

Early Integration of a Palliative Approach

Early integration of a palliative approach in critical care promotes quality of care, enhances quality of life, and improves the experiences of patients, families and health care providers (Lakin et al., 2016). Processes need to be in place to assist ICU clinicians to proactively identify patients and families who would benefit from a palliative approach. Several evidence-based palliative screening tools have been developed to identify people who would benefit from palliative care services (McCarroll, 2018). These screening questions focus on criteria such as the onset of a new or advanced diagnosis, presence of co-morbidities and chronic illness, frequency of hospital and ICU admissions, complex symptom and care needs, lack of social supports.

Another strategy to support early integration of palliative care in the ICU is to garner support from local palliative care leaders. This could manifest in the form of collaboration with local health authorities and governmental bodies to establish strategic planning and goals that would address the palliative care needs of critical care. Other palliative care leaders who can support critical care include the interprofessional palliative specialist team. The nurses in this study said that, more frequent consultations with palliative care specialists would improve the quality of palliative care provided to critical care patients. These teams have the expertise to support intensive care teams in developing their primary palliative skills and recognizing when specialist palliative care support is required (McAndrew et al., 2021). Other strategies to support palliative care in the ICU include: establish designated ICU palliative care champions and mentors to support ICU staff; and utilize a palliative care checklist to serve as a reminder to ICU healthcare providers to address palliative care topics during treatment planning (Kyeremanteng et al., 2019; McAndrew et al., 2021).

Supporting Effective Communication and Decision-Making

Active participation in health care decisions is impossible for many critically ill patients because of their impaired capacity (Goldfarb et al., 2017). As such, the health team often relies heavily on direction from the patient’s family. Effective communication between the health care team and families is a crucial (Hinkle et al., 2015). Families who participate in frequent family conferences and collaborative decision-making experience greater satisfaction with care, less conflict, and are more often able to reach a consensus regarding the direction of patient care (Hwang et al., 2014). Effective communication with patients and their families is a well-documented challenge in the ICU that has been further exacerbated by the recent pandemic. For instance, current visitation restrictions in response to the COVID-19 pandemic prevent families from being actively engaged in communication and hinder their ability to advocate and be a potent reminder of the patient as a whole person (Akgun et al., 2019). The COVID-19 pandemic has brought to light how essential it is to establish and leverage effective communication strategies that support quality palliative care in the ICU (McAndrew et al., 2021).  Such strategies include: conduct an initial assessment of communication preferences and needs (Akgun et al., 2019); assign a team member(s) to act as the primary outreach representative each day (Kerckhoffs et al., 2019); hold family meetings as early as possible and at regular intervals thereafter (Akgun et al., 2019); use internet-based solutions, such as video conferencing (however, it is important to identify situations in which family members lack access to reliable internet access, devices, or technological literacy) (Hart et al., 2020; Neville, 2020;); and engage palliative care specialists as partners in communication. Another important strategy is to leverage the communication skills of ICU nurses. For instance, O’Donnell et al., (2020) established a successful Critical Care Nurse Communicator Program in the Trauma Life Support Center at the University of Wisconsin, in which an experienced ICU nurse with additional palliative care training staffs the ICU 7 days per week to support effective communication and allocation of resources for patients and families.

Palliative Care Education

Health care providers need to be adequately trained to provide the highest standard of palliative care to patients and their families (Canadian Institute for Health Information [CIHI], 2018). The COVID pandemic has resulted in high volumes of severely ill patients requiring advanced life sustaining treatments in intensive care units, further highlighting that every clinician needs knowledge and skills in the fundamentals of palliative care (Akgun et al., 2019; Rosa et al., 2020. Many authors suggest that palliative education should be introduced earlier within the nursing undergraduate programs so that palliative care is not a foreign concept as nurses begin their careers (Kaasalainen et al., 2015). Health Canada (2018) identifies that palliative care education targeting the continuum of care across all settings is crucial for effective delivery and sustainability of palliative care in Canada. Additionally, the CACCN (2011) has mandated that CCNs be able to support patients in their transition to end-of-life. This is a gap that needs to be addressed as many CCNs report that they have inadequate palliative care training to meet the needs of patients and families (Anderson et al., 2016).  There are several challenges to providing palliative care education to health care providers including a lack of standardization, funding, and staffing shortages (CIHI, 2018). Health Canada’s (2019) Action Plan on Palliative Care calls us to make palliative care education a priority, “to support health system quality by improving palliative care skills and supports for health care providers, families, caregivers, and communities” (p. 3).

CCNs should receive palliative care education specifically related to communication skills, inter-professional collaboration, and palliative symptom management (ELNEC, 2017). In the United States, programs to address the palliative education needs of CCNs have been developed (ELNEC, 2017). Similar ICU specific educational programs have yet to be developed in Canada. However, there are valuable palliative care educational opportunities available in Canada, such as educational resources offered through the Canadian Virtual Hospice, Pallium’s Learning Essential Approaches to Palliative Care courses, and several courses offered through Victoria Hospice. There are also several palliative care guidelines that CCNs can refer too, such as the Registered Nurses Association of Ontario’s (2020) “A palliative approach to care in the last 12 months of life”, and the palliative care competency frameworks developed by the Nova Scotia Health Authority (2017), British Columbia Center for Palliative Care (2018, Ontario Palliative Care Network (2019), and the Covenant Health Palliative Institute (2020).

Critical Care Environment

The balance between technology and calm, interventions and presence, isolation and vigilance, efficiency and time for pause, and communication and silence make critical care a challenging environment for palliative care (Fournier, 2017). CCN’s have repeatedly demonstrated their skills of navigating these environment-related challenges by minimizing as much of the ICU as possible, such as removing unneeded medical equipment, discontinuing invasive lines, and slowing the overall tempo and pace of activity in a patient’s room (Efstathiou & Walker, 2014). Establishing a supportive environment that is conducive to end-of-life care has been further complicated by the isolating effects of the COVID-19 restrictions. To counter the negative impact of COVID-19, one hospital ICU introduced a video-conferencing strategy to promote patient-family connection. This consisted of adding to every patient’s room a computing device with video-conferencing capabilities. During morning rounds, the last item on the ICU checklist was to make sure videoconferencing between patients and their families had occurred once a day, even if it was just five minutes long and all the family members could see is their loved one intubated, sedated, and prone (Neville, 2020). This is a strategy that can be used to support quality palliative care in the ICU even beyond the pandemic, particularly for families who are unable to visit their loved one due to geographical, health, or financial constraints.

Other supportive environmental elements that promote quality end of life have been identified, these include: ensuring that the patient’s room is clean and devoid of clutter; making the patient’s bed a space of comfort through the use of extra pillows and blankets; ensuring that the patient is accessible to the family so that they can visit with and be encouraged to touch and to support the patient; maintaining an environment that is calm; eliminating distressing sounds such as alarms; providing a private room to accommodate larger numbers of visitors and to ensure privacy; encouraging family members to bring in photographs and other special objects to transform the space into a personalized environment; and ensuring that there are adequate locations for the family to sit and rest with the patient (Fournier; 2017; McCallum & McConigley, 2013;). Additionally, several of the nurses in this study stressed that greater effort needs to be placed on providing “extra little comforts” to family members of imminently dying patients. For this purpose, many health care locations have developed comfort carts that are brought to the rooms of imminently dying patients. 

There is a delicate balance between providing life-saving technology and providing comfort and peace when it is the right time. The resource-intensive services of critical care are extremely costly to the health care system and, as such, are generally reserved for patients in dire need of critical care interventions (CIHI 2016). If an imminently dying patient is occupying a critical care bed, this means that another critically ill patient’s admission to the ICU is either being refused or delayed, which has been shown to increase a patient’s risk of mortality (Robert et al., 2012). The recent strains on health system capacity due to the pandemic has further compounded this issue raising ethical questions about rationed care (Rosa et al., 2020). This raises an ethical dilemma related to the principle that all patients should have equitable access to healthcare (Bandrauk et al., 2018). Several of the nurses said that the recent introduction of designated palliative care beds to the hospital had been beneficial, but not quite adequate to meet the needs of their palliative patients. Many of the nurses in this study expressed concerns over having to transfer imminently dying patients out of the ICU to other units. Study findings reveal the importance that critical care environments be able to accommodate the needs of patients requiring end-of-life care. As such, this is an issue that requires further exploration.

Limitations

The scope of this study was limited to understanding the perceptions of CCNs within the local context and before the outset of the COVID-19 pandemic. Our results may not reflect the perceptions of nurses working in other settings or the pandemic-related nurses’ experiences concerning palliative and end-of-life care. Also, the perspectives of other members of the interdisciplinary team and family members were not explored and might differ from the ones found in this study. There is also a potential for researcher bias in interpreting the data. Strategies were in place to strengthen the rigour of this study. We hope these findings will create opportunities for reflection among critical care nurses and allied health providers concerning actions that can be taken to improve the end-of-life experiences of patients and their families.

Conclusion

The need to deliver palliative care is increasingly common in critical care. However, there are many barriers and facilitators that influence palliative care experiences in the critical care setting. Understanding these barriers and facilitators from the perspective of the CCNs provides insight and direction into what supports are required to improve the quality of palliative care in the critical care context and in the midst of the current pandemic and beyond. For end-of-life care, the range of our capabilities has become restricted. With a little effort and courage, we can still perform the small acts of kindness that we already know make a big difference (Neville, 2020). This study will provide some direction and insight into this very important component of critical care.

Author Notes

Lisa Vaughn, MN, RN, Faculty of Nursing, University of Alberta, Edmonton, AB

Anna Santos Salas, PhD, RN, Faculty of Nursing, University of Alberta, Edmonton, AB

Corresponding Author

Lisa Vaughn, MN, RN, Faculty of Nursing, University of Alberta, 3rd Floor Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9

Telephone:    7809186678  Email:  lweisger@ualberta.ca

Acknowledgments

We gratefully acknowledge the contributions of study participants. We thank them for their generosity to take part in the study. We thank Lisa Vaughn’s Master of Nursing Thesis Committee members for their helpful suggestions in the development of this work

Ethics Approval

The research project received research ethics approval from the University of Alberta Research Ethics Board, Barriers and Facilitators in the provision of Quality Palliative Critical Care, No. Pro00058038, November 17, 2015.

Funding and conflict of interest statement

The authors have no funding or conflict of interest to disclose.

References

Akgun, K. M., Gruenewald, D., Wertheimer, D., Gabriel, M., Rizzon, D., Zuccaro, M., & Luhrs,

C. (2019). A national VA palliative care quality improvement project for improving intensive care unit family meetings (icu-Fms). Journal of Pain and Symptom Management, 58(6). 1075-1080. https://doi.org/10.1016/j.jpainsymman.2019.08.015

Anderson, W.G., Puntillo, K., Biyle, D., Barbour, S., Turner, K., Cimino, J., Moore, E., Noort, J.,

MacMillan, J., Pearson, D., Grywalski, M., Liao, So., Ferrell, B., Meyer, J., N’Neil-Page, E., Cain, J., Herman, H., Mitchell, W., & Pantilat, S. (2016). ICU bedside nurses’ involvement in palliative care communication: A multicenter survey. Journal of Pain and Symptom Management, 51(3), 589-596. https://doi.org/10.1016/j.jpainsymman.2015.
11.003

Aslakson, R.A., Curtis, R.J., & Nelson, J.E. (2014). The changing role of palliative care in

the ICU. Critical Care Medicine, 42(11), 2418-2428. https://doi.org/10.1097/ccm.
0000000000000573

Baker, M., Luce, J., & Bosslet, G.T. (2015). Integration of palliative care services in the

intensive care unit: A roadmap for overcoming barriers. Clinics in Chest Medicine, 36(3), 441-448. http://doi.org/10.1016/j.ccm.2015.05.010

Bandrauk, N., Downar, J., & Paunovic, B. (2018) Withholding and withdrawing life-sustaining

treatment: The Canadian Critical Care Society position paper. Canadian Journal of Anesthesiology;65(1),105-122. 10.1007/s12630-017-1002-1.

British Columbia Center for Palliative Care. (2018). Inter-professsional palliative competency             framework: Nurse Practitioners, RNs, LPNs, and RPNs. https://bc-cpc.ca/wp-            content/uploads/2019/09/1-Nurse-Competencies-May2019.pdf

Canadian Association of Critical Care Nurses. (2011). Providing end of life care in the ICU.

https://caccn.ca/wp-content/uploads/2019/10/PS2011End-of-Life-Care.pdf

Canadian Institute for Health Information. (2016). Care in Canadian ICUs.

https://secure.cihi.ca/free_products/ICU_Report_EN.pdf

Canadian Institute for Health Information. (2018). Access to palliative care in Canada.

https://www.cihi.ca/sites/default/files/document/access-palliative-care-2018-en-web.pdf

Castleberry, A., & Nolen, A. (2018). Thematic analysis of qualitative research data: Is it as             

           easy as it sounds? Currents in Pharmacy Teaching & Learning, 10(6), 807-815.               

https://doi.org/10.1016/j.cptl.2018.03.019

Coelho, C., B., & Yankaskas, J. R. (2017). New concepts in palliative care in the intensive care

unit. Revista Brasileira de Terapia Intensiva. 29(2): 222-230. https://dx.doi.org
/10.5935%2F0103-507X.20170031

Covenant Health Palliative Institute. (2020). Alberta Palliative Care Competency Framework.

https://www.albertahealthservices.ca/info/Page17398.aspx

End of Life Nursing Education Consortium. (2017). End of life nursing education consortium

(ELNEC) fact sheet. http://www.aacn.nche.edu/ELNEC/factsheet.htm.

Efstathiou N, Walker W. (2014). Intensive care nurses’ experiences of providing end-of-life-      care after treatment withdrawal: a qualitative study. Journal of Clinical Nursing, 23(21),3188–3196. https://doi.org/10.1111/jocn.12565

Fournier, A.L. (2017). Creating a sacred space in the intensive care unit at the end of life.

Dimensions of Critical Care Nursing, 36(2), 110-111. https://doi.org/10.1097/dcc
.0000000000000231

Ganz, F. D. & Sapir, B. (2019). Nurses’ perceptions of intensive care unit palliative care at end

of life. Nursing in Critical Care, 24(3), 141-148. https://doi.org/10.1111/nicc.12395

Goldfarb, M.J., Bibas, L., Bartlett, V., Jones, H., & Khan, N. (2017). Outcomes of patient-and-

family centered care interventions in the ICU: A systematic review and meta-analysis. Critical Care Medicine, 45(10), 1751-1761. https://doi.org/10.1097/CCM.0000000
000002624

Hart, J.L., Turnbull, A.E., Oppenheim, I.M., Courtright, K.R. (2020). Family-centered care

during the COVID-19 era. Journal of Pain and Symptom Management, 60(2), e93-e97. https://doi.org/10.1016/j.jpainsymman.2020.04.017

Health Canada. (2018). Framework on palliative care in Canada. https://www.canada.ca

/en/health-canada/services/health-care-system/reports-publications/palliative-care/framework-palliative-care-canada.html

Health Canada. (2019). Action plan on palliative care: Building on the framework of palliative

care in Canada https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/palliative-care/action-plan-palliative-care.html

Hinkle, L.J., Bosslet, G.T., & Torke, A.M. (2015). Factors associated with family satisfaction

with end-of-life in the ICU: A systematic review. Chest, 147(1), 82-93. https://doi.org/10.1378/chest.14-1098

Hwang, D.Y., Yagoda, D., Perrey, H., Tehan, T.M., Guanci, M., Ananian, L., Currier, P. F.,

Cobb, J. P., Rosand, J. (2014). Assessment of satisfaction with care among family members of survivors in a neuroscience intensive care unit. Journal of Neuroscience Nursing, 46(2), 106-116. 10.1097/JNN.0000000000000038

Kaasalainen, S., Willison, K., Wickson-Griffiths, A., & Taniguchi, A. (2015). The evaluation of

a national interprofessional palliative care workshop. Journal of Interprofessional Care, 29(5), 494-496. https://doi.org/10.3109/13561820.2014.998364

Kerckhoffs, M.C., Kant, M., van Delden, J.J.M., Hooft, L., Kesecioglu, J., & van Dijk, D. (2019).

Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review. Journal of Critical Care, 51, 39-45. https://doi.org/10.1016
/j.jcrc.2019.01.029

Kyeremanteng, K., Beckerleg, W., Wan, C., Vanderspank-Wright, B., D’Egidio, G., Sutherland,             S., Hartwick, M., Gratton, V., & Sarti, A.J. (2020). Survey on barriers to critical care and             palliative care integration. American Journal of Hospice & Palliative Care, 37(2), 108-      116. 10.1177/1049909119867658. 

Lakin, J.R., Isaacs, E., Sullivan, E., Harris, H.A., McMaha, R.D., & Sudore, R.L. (2016).

Emergency physicians’ experience with advance care planning documentation in the electronic medical record: Useful, needed, and elusive. Journal of Palliative Medicine, 19(6), 632-638. https://doi.org/10.1089/jpm.2015.0486

Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Sage Publications.

Malterud, K., Siersma, V.S., & Guassora, A.D. (2016). Sample size in qualitative interview

studies: guided by information power. Qualitative Health Research, 26(13), 1753-1760. https://doi.org/10.1177/1049732315617444

McAndrew, N. S., Guttormson, J.; Marks, S., Rhodes, M.; Patel, J.; & McCracken, C. (2021).

Intensive care unit nurse: could we call a palliative care consult? Intensive care unit provider: it’s too early. Palliative care integration in the intensive care unit: The struggle to translate evidence into practice. Dimensions of Critical Care Nursing, 40(1), 51-58. 10.1097/DCC.0000000000000451

McCallum, A. & McConigley, R., (2013). Nurses’ perceptions of caring for dying patients in an   open critical care unit: a descriptive exploratory study. International Journal of Palliative           Nursing, 19(1), 25-30. 10.12968/ijpn.2013.19.1.25. PMID: 23354430.

McCarroll, C.M. (2018). Increasing access to palliative care services in the intensive care unit.

Dimensions of Critical Care Nursing, 37(3), 180-192. https://doi.org/10.1097/DCC
.0000000000000299

Mercadante, S., Gregoretti, C., & Cortegiani, A. (2018). Palliative care in intensive care units:

why, where, what, when how. BMC Anesthesiology, 18(1): 106. https://doi.org/10.1186/s12871-018-0574-9

National Coalition for Hospice and Palliative Care. (2018). Clinical Practice Guidelines for

Quality Palliative Care (4th ed.). https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf

Neville, T.H. (2020). COVID-19: A time for creative compassion. Journal of Palliative

Medicine, 23(7), 990-991. http://doi.org/10.1089/jpm.2020.0242

Nova Scotia Health Authority. (2017). The Nova Scotia palliative care competency framework:

A reference guide for health professionals and volunteers. http://www.spiritualcare
.ca/uploads/PPC/2017/NS%20Palliative%20Care%20Competencies%20%20Framework%20v6.pdf

O’Donnell, A., Buffo, A., Campbell, T.C., & Ehlenbach, W.J. (2020). The critical care nurse

communicator program: An integrated primary palliative care intervention. Critical Care Nursing Clinics, 32(2), 265-279. https://doi.org/10.1016/j.cnc.2020.02.008

Ontario Palliative Care Network. (2019). The Ontario palliative care competency framework.

https://www.ontariopalliativecarenetwork.ca/sites/opcn/files/OPCNC ompetencyFramework.pdf

Rosa, W. E., Ferrel, B. R., & Wirncek, C. (2020). Increasing critical care nurse engagement of

palliative care during the COVID-19 pandemic. Critical Care Nurse, 1(40), e28-e36. https://doi.org/10.4037/ccn2020946

Registered Nurses’ Association of Ontario. (2020). A palliative approach to care in the last 12             months of life: Best practice guideline. https://rnao.ca/sites/rnao-            ca/files/bpg/PALLATIVE_CARE_FINAL_WEB_2.pdf” https://rnao.ca/sites/rnao-            ca/files/bpg/PALLATIVE_CARE_FINAL_WEB_2.pdf

Robert, R., Reignier, J., Tournoux-Facon, C., Boulain, T., Lesieur, O., Gissot, V., Sunday, V.,

Hamrouni, M., Chapon, C., & Gouello, J.P. (2012). Refusal of intensive care unit admission due to a full unit: impact on mortality. American Journal of Respiratory Critical Care Medicine, 185(10), 1081-7. 10.1164/rccm.201104-0729OC. Epub 2012 Feb 16. PMID: 22345582.

Rosa, W.E., Ferrell, B.R., Mason, D.J. (2021). Integration of palliative care into all serious             illness care as a human right. Journal of the American Medical Association, 2(4). 1-3            10.1001/jamahealthforum.2021.1099

Sandelowski, M. (2000). What ever happened to qualitative description? Research in Nursing

& Health, 23(4): 334-340. https://doi.org/10.1002/1098-240X(200008)23:4%3C334::AID-NUR9%3E3.0.CO;2-G

Sandelowski, M. (2010). What’s in a name: Qualitative description revisited. Research in

Nursing & Health, 33(1), 77-84. https://doi.org/10.1002/nur.20362

Tong A, Sainsbury P, Craig J. (2007). Consolidated criteria for reporting qualitative research

(COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349 – 357. https://doi.org/10.1093/intqhc/mzm042

Vaismoradi, M., Turunen, H., & Bundas, T. (2013). Content analysis and thematic analysis:

implications for conducting a qualitative descriptive study. Nursing & Health Sciences, 15(3), 398-405. https://doi.org/10.1111/nhs.12048

Vanderspank-Wright, B., Wright, D.K., & McMillan, K. (2019). Thinking about strengths in end- of-life nursing practice: the case of intensive care unit nurses. International Journal of          Palliative Nursing, 25(8), 378-385. 10.12968/ijpn.2019.25.8.378. PMID: 31437107

Walker, J. L. (2012). The use of saturation in qualitative research. Canadian Journal of

Cardiovascular Nursing, 22(2), 37-41

World Health Organization. (2002). National cancer control programmes: policies and

managerial guidelines (2nd ed). http://www.who.int/cancer/media/en /408.pdf.

Wiedemann, C.J., Lehner, G.F., & Joannidis, M. (2012). From persistence to palliation: Limiting

active treatment in the ICU. Current Opinion in Critical Care, 18(6), 694-699. https://doi.org/10.1097/MCC.0b013e328358d417

Wolf, A.T., White, K.R., Epstein, E.G., & Enfield, K.B. (2019). Palliative care and moral   distress: An institutional survey for critical care nurses. Critical Care Nurse, 39(5), 38-   49. https://doi.org/10.4037/ccn201964

Return to Spring 2022 Journal

Find an Article

Includes all articles in the Canadian Jounral of Critical Care Nursing (CJCCN).

View our Journals

Publish with Us

The CJCCN invites submissions on the following critical nursing topics: Clinical, Education, Management, Research and Professional Issues. Original articles on any aspect of critical care nursing are welcome.

Learn More

Recent Publications

Archive >

Become a Member

CACCN membership recieve complimentary Journal Subcription Access

Join Now Already a member? Sign In

Advertising Opportunities

Advertise with the CACCN. Vitrine promotionelle de l'ACIISI

Learn More