Ghent University Academic Bibliography

Advanced

End-of-life care in the acute hospital

Ruth Piers UGent (2011)
abstract
During the last decades, the awareness has grown that prolonging life at any cost may not always be the best solution, and that palliation and improvement of the quality of life may prevail over often burdensome treatments. Less aggressive care is associated with better quality of life of the patient at the end of life and less burden on the family after their loved one died. Although the acute hospital is the place where most people die in Western countries, research into the quality of end-of-life care in this setting is rather neglected compared to end-of-life care research in other settings. Therefore, this dissertation aims to explore the current challenges of end-of-life care in the acute hospital. It describes end-of-life care from three different viewpoints: the healthcare provider’s view, patients’ views on end-of-life care, and the institutional level. First, the healthcare provider’s view on the appropriateness of care is explored. Moral distress develops in situations where healthcare providers cannot fulfil their moral obligations to patients or fail to pursue what they believe to be the correct course of action due to forces often out of their control. Providing too aggressive care is the main cause of moral distress in both ICU physicians and nurses as well as in geriatric nursing care. Low levels of multidisciplinary discussions about ethical dilemmas and little involvement of nurses in end-of-life decision-making are associated with higher prevalence of perceived inappropriate care. Advance care planning - the ongoing communication process by which patients, in conjunction with their physicians and loved ones, establish goals and preferences for future care - is widely encouraged as a way to improve the quality of dying. Interviews with older persons having limited prognosis show that the majority of participants are willing to engage in advance care planning. However, there seems to be a risk of pseudo-participation in case persons have to make choices about issues beyond their power of imagination or beyond their ability to face the imminence of dying. This finding advocates for advance care planning as a process aiming to give meaning to choices by focusing on patients’ personal experiences and fears rather than focusing on the completion of written advance directives. Finally, the difficulties of end-of-life care at the institutional level are explored. The quality of do-not-resuscitate decisions in a Belgian acute hospital is studied. The transition from life prolongation to a more palliative approach is less anticipated in some specialties. In particular, surgical patients are more often referred to the intensive care unit at the end of life compared to medical patients despite a similar Charlson comorbidity score. Similarly, patients without malignant diseases are more frequently referred to the ICU before dying compared to patients with an active malignancy. This seems to be partly caused by a difference in physicians’ attitude towards goals of care (disease-oriented versus a more patient-oriented approach). Taken together, this dissertation shows that there is room for improvement in the integration of palliative care goals in the acute hospital. Looking at the results of this dissertation, interventions should focus on raising awareness of the importance of palliative care goals and good quality advance care planning. A step further in improving the quality of end-of-life care, is the development of good ethical work environments in which self-reflection, mutual trust and open communication among team members are encouraged. Last but not least, efforts should be made to improve physicians’ communication skills to explore patient’s true wishes at the end-of-life.
Please use this url to cite or link to this publication:
author
promoter
UGent and UGent
organization
year
type
dissertation
publication status
published
subject
keyword
Inappropriate Care, Advance Care Planning, Moral distress, ICU, End-of-life care, Hospital
pages
145 pages
publisher
Ghent University. Faculty of Medicine and Health Sciences
place of publication
Ghent, Belgium
defense location
Gent : UZ (auditorium C)
defense date
2011-11-08 16:00
ISBN
9789490695958
language
English
UGent publication?
yes
classification
D1
additional info
dissertation consists of copyrighted material
copyright statement
I have transferred the copyright for this publication to the publisher
id
1995463
handle
http://hdl.handle.net/1854/LU-1995463
date created
2012-01-18 18:15:13
date last changed
2017-01-16 10:38:40
@phdthesis{1995463,
  abstract     = {During the last decades, the awareness has grown that prolonging life at any cost may not always be the best solution, and that palliation and improvement of the quality of life may prevail over often burdensome treatments. Less aggressive care is associated with better quality of life of the patient at the end of life and less burden on the family after their loved one died.
Although the acute hospital is the place where most people die in Western countries, research into the quality of end-of-life care in this setting is rather neglected compared to end-of-life care research in other settings. Therefore, this dissertation aims to explore the current challenges of end-of-life care in the acute hospital. It describes end-of-life care from three different viewpoints: the healthcare provider{\textquoteright}s view, patients{\textquoteright} views on end-of-life care, and the institutional level.   
First, the healthcare provider{\textquoteright}s view on the appropriateness of care is explored. Moral distress develops in situations where healthcare providers cannot fulfil their moral obligations to patients or fail to pursue what they believe to be the correct course of action due to forces often out of their control. Providing too aggressive care is the main cause of moral distress in both ICU physicians and nurses as well as in geriatric nursing care. Low levels of multidisciplinary discussions about ethical dilemmas and little involvement of nurses in end-of-life decision-making are associated with higher prevalence of perceived inappropriate care.
Advance care planning - the ongoing communication process by which patients, in conjunction with their physicians and loved ones, establish goals and preferences for future care - is widely encouraged as a way to improve the quality of dying. Interviews with older persons having limited prognosis show that the majority of participants are willing to engage in advance care planning. However, there seems to be a risk of pseudo-participation in case persons have to make choices about issues beyond their power of imagination or beyond their ability to face the imminence of dying. This finding advocates for advance care planning as a process aiming to give meaning to choices by focusing on patients{\textquoteright} personal experiences and fears rather than focusing on the completion of written advance directives. 
Finally, the difficulties of end-of-life care at the institutional level are explored. The quality of do-not-resuscitate decisions in a Belgian acute hospital is studied. The transition from life prolongation to a more palliative approach is less anticipated in some specialties. In particular, surgical patients are more often referred to the intensive care unit at the end of life compared to medical patients despite a similar Charlson comorbidity score. Similarly, patients without malignant diseases are more frequently referred to the ICU before dying compared to patients with an active malignancy. This seems to be partly caused by a difference in physicians{\textquoteright} attitude towards goals of care (disease-oriented versus a more patient-oriented approach). 
Taken together, this dissertation shows that there is room for improvement in the integration of palliative care goals in the acute hospital. Looking at the results of this dissertation, interventions should focus on raising awareness of the importance of palliative care goals and good quality advance care planning. A step further in improving the quality of end-of-life care, is the development of good ethical work environments in which self-reflection, mutual trust and open communication among team members are encouraged. Last but not least, efforts should be made to improve physicians{\textquoteright} communication skills to explore patient{\textquoteright}s true wishes at the end-of-life.},
  author       = {Piers, Ruth},
  isbn         = {9789490695958},
  keyword      = {Inappropriate Care,Advance Care Planning,Moral distress,ICU,End-of-life care,Hospital},
  language     = {eng},
  pages        = {145},
  publisher    = {Ghent University. Faculty of Medicine and Health Sciences},
  school       = {Ghent University},
  title        = {End-of-life care in the acute hospital},
  year         = {2011},
}

Chicago
Piers, Ruth. 2011. “End-of-life Care in the Acute Hospital”. Ghent, Belgium: Ghent University. Faculty of Medicine and Health Sciences.
APA
Piers, R. (2011). End-of-life care in the acute hospital. Ghent University. Faculty of Medicine and Health Sciences, Ghent, Belgium.
Vancouver
1.
Piers R. End-of-life care in the acute hospital. [Ghent, Belgium]: Ghent University. Faculty of Medicine and Health Sciences; 2011.
MLA
Piers, Ruth. “End-of-life Care in the Acute Hospital.” 2011 : n. pag. Print.