Evidence Digest

Recent Evidence to Guide Clinical Practice andFuture Research in Critical and End-of-Life Care

Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP

The purpose of Evidence Digest, a recurring section inWorldviews on Evidence-Based Nursing, is to provide

concise summaries of well-designed and clinically impor-tant recent studies along with the implications for practice,research, administration, and/or health policy they high-light. Articles summarized may include quantitative andqualitative studies, systematic and integrative reviews aswell as consensus statements by expert panels. Along withrelevant implications, the level of evidence generated by thestudies or reports highlighted in this column (Figure 1) isincluded at the end of each summary so that readers canintegrate the strength of evidence into their health caredecisions.

Yaguchi R., Truog R.D., Curtis J., Luce J., Levy M., MelotC., et al. (2005). International differences in end-of-lifeattitudes in the intensive care unit: Results of a survey.Archives of Internal Medicine, 165(17), 1970–1975.

Purpose. The purpose of this study was to describephysicians’ end-of-life decisions in the intensive care unit(ICU).

Sample. The sample comprised 1,961 physicians from21 countries, a 56% participation. The sample was drawnfrom an e-mail list of addresses of physicians who had re-quested information on the International Symposium onIntensive Care and Emergency Medicine. The largest num-bers of subjects came from the United Kingdom, Belgium,the United States, and Germany.

Design. Descriptive survey.Measures. The questionnaire used comprised a case sce-

nario and four questions with three to five optional an-swers, written in English. The case scenario described apatient in a vegetative state due to anoxic encephalopa-thy after cardiac arrest who had no family and no advancedirectives.

Methods/Procedure. Subjects who requested informa-tion about the International Symposium on Intensive Careand Emergency Medicine were e-mailed the survey. Re-minders were sent twice to those physicians who did not

Copyright ©2006 Sigma Theta Tau International1545-102X1/06

reply to the first e-mail requesting completion of the sur-vey. The participants were informed that this was an anony-mous survey.

Findings. The respondents from the United States com-prised the largest proportion (45%) of physicians who re-ported that they would ask for an ethical consultant in thehospital or make a court referral. Fewer physicians in theUnited States (27%) and Canada (29%) than from otherregions reported that they would make the decision aloneor with other physicians only. In contrast, 62% of partici-pants from northern and central Europe reported more of-ten than other countries that they would involve nurses inthese discussions. Specifically, physicians from the UnitedKingdom, France, and Switzerland reported the greatestinvolvement of nurses in decision making (83%, 80%, and78%, respectively). Percentages of physicians who reportedinvolving nurses in the decision-making process were thelowest for Turkey (41%), Japan (39%), Brazil (38%), andthe United States (29%).

The greatest majority of physicians (over 80%) in north-ern and central Europe, North America, and Australia saidthat they would likely apply written “do not resuscitate”(DNR) orders in the hypothetical case. In southern Europe,Turkey, and Brazil, oral DNR orders were preferred.

Regarding the question about treatment of the patientin a vegetative state, subjects from Japan and Turkey mostoften responded that they would continue full supportthan the participants from other countries. Physicians fromAustralia and Canada chose terminal withdrawal of me-chanical ventilation more commonly than the participantsfrom other countries. Participants from northern Europehad a greater tendency to transfer patients to a generalward.

In Question 4, physicians were asked about the treat-ment of the patient if septic shock developed. The op-tion to give antibiotics was the most common responseby physicians in Japan (96%), Turkey (81%), the UnitedStates (65%), southern Europe (62%), and Brazil (59%),whereas it was more common for physicians in northernEurope, central Europe, Canada, and Australia to reportthat they would choose terminal withdrawal of mechani-cal ventilation.

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• Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical

practice guidelines based on systematic reviews of RCTs

• Level II: Evidence obtained from at least one well-designed RCT

• Level III: Evidence obtained from well-designed controlled trials without randomization

• Level IV: Evidence from well-designed case-control and cohort studies

• Level V: Evidence from systematic reviews of descriptive and qualitative studies

• Level VI: Evidence from a single descriptive or qualitative study

• Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Modified from Guyatt & Rennie (2002) Harris et al. (2001)

Figure 1. Rating System for the Hierarchy of Evidence (from

Melnyk & Fineout-Overholt, 2005).

Commentary With Implications for Clinical Practice andFuture Research. Although this sample was not drawnrandomly, which limits generalizability to all ICU physi-cians from these countries, the large number of physi-cians from the 21 countries allows greater generalizabil-ity than if the sample was restricted to a conveniencesample of physicians from only a few countries. Thelarge numbers of countries involved allowed a good com-parative analysis on this issue. Another limitation ofthis study was that no demographic information on thephysicians was collected. Information about the demo-graphics of this sample would have allowed for interest-ing analyses regarding the relationships among certaincharacteristics of the physicians (e.g., age, gender, num-ber of years in practice) and end-of-life decision making.In addition, although the authors reported that the sur-vey was anonymous, e-mail method of data collectiondoes not guarantee anonymity.

This international survey indicates a wide variation inresponses by ICU physicians regarding how they wouldtreat an adult patient in a vegetative state who was with-out family and advance directives. Legal environmentsin some countries may have contributed to the variationin responses.

It is interesting to note that certain countries in-volved nurses in the decision making to a greater extentthan others and disconcerting that physicians from somevery well-developed, technologically advanced countries(e.g., United States) reported low involvement of nursesin their decision-making process. Evidence from priorstudies has indicated that patient outcomes are substan-tially better with interdisciplinary collaboration betweenphysicians and nurses than those without collaboration(Baggs et al. 2004). Further study is needed to determinethe rationale for why physicians choose not to involvenurses in the decision-making process. Findings from

this study should pave the way for open discussions be-tween nurses and physicians regarding end-of-life deci-sion making, as nurses assume around-the-clock respon-sibility for the care of patients and should be involved inthese decisions.

Level of Evidence: VI.

Browning G. & Warren N.A. (2006). Unmet needs offamily members in the medical intensive care waiting room.Critical Care Nursing Quarterly, 29(1), 86–95.

Purpose. The purpose of this study was to determine theunmet needs of family members with loved ones who werehospitalized in a medical intensive care unit (MICU).

Sample. The convenience sample comprised 30 fam-ily members selected from the waiting room of a 20-bedMICU in a large urban hospital in the southern region ofthe United States. Criteria for study participation included(a) age between 18 and 73; (b) designation as the signif-icant other (e.g., spouse, parent, adult child, sibling); (c)willingness to meet with the researchers for 45 minutes at24–36 hours after admission of the patient to the ICU; (d)able to read, understand, and write English; and (e) thepatient admitted to the ICU for an acute illness that wasconsidered life-threatening and was or had been on me-chanical ventilation. The mean age of family members was48.5 years. The relationship of the family member to thepatient include husband (n = 4), wife (n = 10), son (n =5), daughter (n = 8), and granddaughter (n = 3). Familymembers perceived the status of their loved ones’ conditionas critical (n = 20); serious (n = 8); and stable (n = 2). Themean age of the patients was 68.6 years, and the patientsincluded 19 males and 11 females.

Design. Exploratory descriptive study.Measures. The measures included two questionnaires:

(i) a demographic questionnaire and (ii) the Needs Met In-ventory (NMI), a 45-item self-administered questionnairewith established validity and reliability. The NMI has fivesubscales including support, comfort, information, prox-imity, and assurance. Subjects responded to each of theitems on a 4-point Likert scale that ranges from 1 = nevermet to 4 = always met.

Methods. Family members who met study criteria wereapproached for study participation in the MICU waitingroom by the investigator. Informed consent was obtained.Data were collected over a 6-month period of time.

Findings. Family members reported that informationwas the need most highly met. The greatest unmet needsincluded (a) talking about negative feelings, such as guiltand anger; (b) talking about the possibility of the pa-tient’s death; (c) expectations of the environment beforegoing to the MICU for the first time; (d) visiting anytime;

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(e) talking to the same nurse every day; (f) having explana-tions that are understandable; (g) feeling that there is hope;(h) having good food available; (i) being assured that it isall right to leave the hospital for a while; and (j) feelingaccepted by the staff. As family members’ level of educa-tion increased, perceptions of the importance of supportand comfort items on the NMI decreased.

Implications for Clinical Practice and Future Research. Amajor limitation of this study was the small conveniencesample that does not allow the findings to be generalizedto all family members of critically ill patients. Despite thislimitation, the data gathered are valuable in terms of as-sisting health care providers in understanding the needsof family members when their loved ones are criticallyill.

Findings from this study reinforce the importance offamily-centered care in ICU. Specifically, it is importantfor nurses to provide a venue for family members to talkabout the emotions that they are experiencing as wellas the possibility of their loved ones’ death. Preparingfamilies for what they will see the first time they enterthe ICU is important and should reduce their level ofanxiety.

As family members in this study reported that theywanted to visit more often, it is important for ICUs toallow as much open visitation as possible. Conversely,nurses can reassure family members that it is all rightfor them to leave the unit for a while and that they willbe contacted for any significant changes in their lovedones’ conditions. Continuity of care with the same pa-tient over time by nurses also can help reduce stress forfamily members, especially in the area of familiarity andcommunication.

This study is important because it highlights the im-portance of attending to the needs of family members, asthey can experience negative psychological effects fromtheir loved ones’ illness and hospitalization. Thus, thereis an urgent need for more randomized controlled tri-als that develop and test theory-based interventions toreduce the stress and anxiety of family members of crit-ically ill adult patients.

Level of Evidence: VI

Jacoby L.H., Breitkopf C.R. & Pease E. (2005). A qual-itative examination of the needs of families faced with theoption of organ donation. Dimensions of Critical Care Nurs-ing, 24(4), 183–189.

Purpose. The purpose of this study was to examinedonor and non-donor family members’ perceived needs forsupport while in the hospital intensive care setting.

Sample. The convenience sample consisted of 11 indi-viduals who agreed to donate their loved ones’ organs and5 who did not consent to the donation of organs. The sub-jects were primarily Caucasian and females, with a posthigh school education. Their mean age was 43 years, rang-ing from 31 to 65 years. Donor family members were amean of 9 years younger than non-donor family members.All had experienced the sudden and traumatic death oftheir loved ones (e.g., motor vehicle accident, brain hem-orrhage). The deceased included 4 females and 12 males,ranging from 20 months to 66 years.

Design. Qualitative study.Methods/Procedure. Focus groups were conducted to

obtain respective accounts of the peri-donation hospitalexperiences of donor and non-donor families in order toanswer the following research questions:

1) How do donor and non-donor families describe andinterpret the communications and behaviors of peo-ple they interact with during the donation requestand decision-making processes and how do these de-scriptions differ?

2) What can we learn from families’ accounts of theirperceived needs for support in relation to their do-nation decision and how do the two groups differ inthis respect?

3) What are the implications for care and interven-tions that would effectively address families’ per-ceived needs for support?

Ninety-eight family members were identified (50 donorand 48 non-donor family members) and contacted by tele-phone to recruit into the study. Of 17 individuals in thedonor group and 6 in the non-donor group who agreedto participate, 7 of them (i.e., 1 non-donor individual and6 donor family members) did not attend the group meet-ings. Separate focus group sessions with the donor andnon-donor family members were conducted. Focus groupsessions were taped and an independent reviewer verifiedthe written transcriptions against the recorded material.Themes were then identified.

Findings. All subjects reported satisfaction with nurses’behaviors and care. However, comments about the medi-cal staff indicated that subjects perceived them on a con-tinuum from cold, distant, and unavailable to caring andcompetent. Both donor and non-donor families expressedneeds for clear information about their loved ones’ statusand about organ donation. Another need expressed by thefamily members was emotional support and the desire tohave someone who had been in their situation to talk withthem about it. They wanted someone to “be there” for themand to listen to them. These individuals also had a strongneed for respectful and compassionate care for their loved

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ones. A key characteristic of the donor group was that theyhad a friend or relative who served as an intermediary andtranslator of information.

There was a difference in timing of approach betweenthe groups. The non-donor group felt that they had notbeen told that their loved ones were brain dead before be-ing approached about organ donation, whereas the donorgroup felt that the timing was as good as it could have been.Family members wanted to see concrete evidence confirm-ing brain death of their loved ones.

Pace and tone of the approach and information aboutorgan donation was highly important. Non-donor respon-dents reported that the information was provided in arushed manner and that they felt hurried to make a de-cision. Donors also emphasized that it was important notto feel rushed or pressured to make a decision. The tone inwhich the information was delivered was very importantto both groups. Having privacy in a comfortable settingto make the decision was also important to both groups.Faith and spiritual support were important to nearly alldonor families, but less so in the non-donor group.

Commentary With Implications for Clinical Practice andFuture Research. Although this was a convenience smallsample, which does not allow generalizability of thestudy’s findings, this study provides a prior understand-ing of the experience of organ donation by family mem-bers and factors influencing donors’ decisions. It is clearthat providing accurate information in a sensitive, car-ing manner and treating family members’ loved onesin a respectful manner are very important to individ-uals who are facing a decision of organ donation. Tim-ing of the approach is also critical to families, includ-ing not feeling pressured about the decision. Makingsomeone available who has been through the experi-ence before and a friend or relative present who can helpfamilies process the information are also important aswell as having a comfortable environment to make thedecision.

Physicians and nurses should be well educated re-garding the stress and emotions, which family mem-bers experience when they face the death of their lovedones. Intervention studies in this field are greatly neededso that health care providers can implement effectiveevidence-based interventions to reduce anxiety and pro-mote coping in these families. Larger studies also areneeded to determine if these same factors influence de-cision making in a more diverse sample. Factors couldvary by type of relationship with the loved ones (e.g.,spouse, daughter, parent); therefore, further study iswarranted.

Level of Evidence: VI

Dunne K., Sullivan K. & Kernohan G. (2005). Palliativecare for patients with cancer: District nurses’ experiences.Journal of Advanced Nursing, 50(4), 372–380.

Purpose. The purpose of this study was to explore dis-trict nurses’ experiences of providing palliative care for pa-tients with cancer and their families.

Sample. The convenience sample comprised 25 femaledistrict nurses. Inclusion criteria consisted of being willingto participate in a lengthy interview, one year experience ofworking in a district nursing team, and a caseload in whichat least 20% of patients required palliative care and haveactively cared for patients in the palliative phase of theirillness in the past 6 months.

Design. Qualitative study.Methods/Procedure. A Husserlian phenomenological ap-

proach was used in order to describe the human experienceas lived by district nurses caring for cancer patients duringpalliative care. Nurses, as potential participants, were pro-vided by clinical coordinators in the community trusts. Thepotential subjects were approached by an informational let-ter. A total of 25 of 166 potential subjects agreed to par-ticipate in the study, however, 38 of these individuals didnot meet inclusion criteria. Unstructured interviews wereused with the nurses to gather the data. One session, whichaveraged approximately 60 minutes, was conducted witheach participant. The data were analyzed using Colaizzi’sseven stages of data analysis.

Findings. Four themes emerged from the data.

1) The communication web (e.g., referrals not beingmade at the appropriate time in the course of the pa-tient’s illnesses; lack of one person to coordinate thecare of the patient and family; difficulty in commu-nicating with the patients about dying; dealing withanger; disclosure of information);

2) the family as an element of care (e.g., challenges withhelping all family members to deal with the impedingdeath, especially children and adolescents);

3) challenges for the district nurse in symptom man-agement (e.g., the complexity of controlling pain ina holistic manner, diminishing breathlessness and fa-tigue); and

4) the personal cost of caring (e.g., dealing with termi-nally ill patients and their family members is highlystressful).

Commentary With Implications for Clinical Practiceand Future Research. Although this was a small con-venience sample, the findings are insightful regardingthe challenging experiences that district nurses face

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when caring for palliative care patients. The study hasmany strong clinical implications, including (a) theneed to provide educational and skills-building ses-sions with nurses in this area so that they canprovide more effective symptom management andcoordination of care and (b) the need to assistnurses in dealing with patient and family’s grief pro-cesses as well as their own stress. This researchlays the ground for developing and testing interven-tions for this high-risk population of families andnurses.

Level of Evidence: VI.

ReferencesBaggs J.G., Norton S.A., Schmitt M.H. & Sellers C.R.

(2004). The dying patient in the ICU: Role of the inter-disciplinary team. Critical Care Clinics, 20(3), 525–540.

Guyatt G. & Rennie D. (2002). Users’ guides to the medicalliterature. Washington, DC: American Medical Associa-tion Press.

Harris R.P., Hefland M., Woolf S.H., Lohr K.N., MulrowC.D., Teutsch S.M., et al. (2001). Current methods ofthe U.S. Preventive Services Task Force: A review of theprocess. American Journal of Preventive Medicine, 20(3Suppl), 21–35.

Melnyk B.M. & Fineout-Overholt E. (2005). Evidence-based practice in nursing and healthcare. A guide to bestpractice. Philadelphia: Lippincott, Williams & Wilkins.

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