NUR 4320 Module 6 End-of-Life Paper: Family Conferences, Comfort Care and Organ Donation in the ICU Example

A Good Death in a Busy Unit: Family Conference, Comfort and Donation for a Patient in Livingston

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-4320: Nursing Care of Clients with Complex Health Conditions

Mentor Name

Month Day, Year

A Good Death in a Busy Unit: Family Conference, Comfort and Donation for a Patient in Livingston

The Patient

Mrs. Bernstein and the ICU are invented. Mrs. Bernstein, 66, a retired public librarian, collapsed at home while gardening. Her husband found her unresponsive. A CT scan showed a large bleed deep in the brain extending into the ventricles. She was intubated by the emergency team and moved to the ICU with no response to pain and absent reflexes on one side. The neurosurgeon judged that surgery would not help. Her husband, two adult sons and a daughter gathered at the bedside. Her driver's license showed that she had registered as an organ donor.

The Family Conference

Lautrette et al. (2007) randomized the relatives of 126 patients who were dying in 22 intensive care units in France either to a proactive conference about the end of life plus a bereavement brochure or to the conference the unit usually held. Clinicians in that arm used the VALUE mnemonic, which asks them to value the family's words, acknowledge feelings, listen, come to understand the patient as a person and draw out questions. At 90 days, relatives in the intervention group reported less post-traumatic stress, and their anxiety and depression scores were lower too. Conferences were longer, and families spoke for a larger share of the time.

For the Bernstein family, the attending physician held a conference on the second day with the nurse, the social worker and the student present. The physician explained the bleed and its prognosis in plain words and then asked the family to describe Mrs. Bernstein. Her daughter said her mother had cared for her own father through a long illness and had said she did not want machines to keep her alive if there was no hope of recovery.

Why Discussion Matters

Wright et al. (2008) studied patients with advanced cancer and their caregivers. Patients who said they had talked with their physicians about the end of life were less likely to be ventilated, resuscitated or admitted to an ICU near death, and they entered hospice earlier. The discussions were not associated with more depression or worry. More aggressive care was associated with worse quality of life for patients near death and with poorer bereavement adjustment for caregivers. Although Mrs. Bernstein could no longer speak for herself, the study supports the value of hearing her wishes through her family.

Donation

Siminoff et al. (2001) interviewed families of eligible potential donors in hospitals in two U.S. regions. Families were more likely to consent when they knew the patient's wishes, when they talked with a coordinator from the organ procurement organization and when more topics about donation were discussed with them. The approach and the conversation mattered, not only the family's prior attitudes.

Hospital policy required the unit to call the organ procurement organization when death was expected. The coordinator met the family after the decision to withdraw life support, separately from the conversation about prognosis. Knowing that she had registered, the family agreed to donation after circulatory death.

Nursing Diagnoses

The student identified risk for complicated grieving in the family, risk for discomfort in the patient during withdrawal and family need for information and support.

Comfort Care

Before withdrawal, the nurse removed monitors that were no longer needed, silenced alarms in the room, set out chairs and invited the family to bring music. Mrs. Bernstein's sons played recordings of the choir she had sung in. Medicines for comfort were given as ordered to prevent signs of breathlessness or distress. The student helped wash her face and brush her hair and gave the family time alone.

The Donation Process

Because she was to donate after circulatory death, withdrawal took place in a room near the operating suite, and the family said goodbye there. The donation team was not present during withdrawal, and the physician who declared death had no role in the transplant. The student stayed with her husband in the family room after she was taken to surgery.

Evaluation

The family said they felt their mother's wishes had been honored. Her kidneys and liver were transplanted. The unit's social worker gave the family a bereavement brochure and called them two weeks later.

Caring for the Caregivers

The student had not been present for a death before. After Mrs. Bernstein was taken to surgery, the nurse suggested they sit for a few minutes in the staff room and talk about what had happened. The unit held a brief pause the following week in which staff remembered the patients who had died. The student learned that nurses who care for dying patients need to name their own grief in order to keep offering care to the next family.

Symptoms at the End

The comfort plan addressed breathlessness, secretions and restlessness. The nurse gave opioid and sedative doses in small steps based on signs of distress, such as a fast breathing rate or grimacing, rather than on a schedule, and documented the reason for each dose. Noisy breathing from secretions was treated by repositioning and medicine, and the student explained to the family that the sound did not mean she was suffering.

The Husband

Mr. Bernstein, married to her for forty-one years, said little during the conference. Afterward the student noticed him standing alone in the hallway and asked whether he wanted to sit with his wife. He did, and he talked about the libraries she had run. The student learned that the quietest family member may need the most attention.

Limits

Lautrette's trial took place in France, Wright's study involved cancer patients, not ICU patients, and Siminoff's study was observational. Practices around donation vary by state and hospital. A student supports the family but does not discuss donation with them.

Conclusion

Mrs. Bernstein's death in a busy ICU was calm and consistent with her wishes. A proactive family conference, honest discussion of her values and a donation conversation held by the right person at the right time made this possible, and the nursing role ran through each step.

References

Lautrette, A., Darmon, M., Megarbane, B., Joly, L. M., Chevret, S., Adrie, C., Barnoud, D., Bleichner, G., Bruel, C., Choukroun, G., Curtis, J. R., Fieux, F., Galliot, R., Garrouste-Orgeas, M., Georges, H., Goldgran-Toledano, D., Jourdain, M., Loubert, G., Reignier, J., . . . Azoulay, E. (2007). A communication strategy and brochure for relatives of patients dying in the ICU. New England Journal of Medicine, 356(5), 469-478. https://doi.org/10.1056/NEJMoa063446

Siminoff, L. A., Gordon, N., Hewlett, J., & Arnold, R. M. (2001). Factors influencing families' consent for donation of solid organs for transplantation. JAMA, 286(1), 71-77. https://doi.org/10.1001/jama.286.1.71

Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., Mitchell, S. L., Jackson, V. A., Block, S. D., Maciejewski, P. K., & Prigerson, H. G. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 300(14), 1665-1673. https://doi.org/10.1001/jama.300.14.1665