August 24, 2001

Impact of ICU death examined

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Vanderbilt’s Dr. Wes Ely is participating in the study.

Impact of ICU death examined

Patient families and medical professionals often have very different perceptions of the quality of death in the Intensive Care Unit, according to a preliminary study by physicians at Vanderbilt University Medical Center.

In the hectic and stressful environment of intensive care units, doctors are looking for ways to provide the best atmosphere for patients and families when a death occurs. In order to achieve this, a study investigating the quality of the dying process was initiated.

“Much of my day is spent talking to the families of people dying in the ICU,” said Dr. Wes Ely, assistant professor of Medicine. “A significant percentage of patients treated in the ICU will die despite our best efforts to save their lives. Once this is apparent to us, the best we can offer is a peaceful dying process.

“We want to ensure that those people who are dying in these units have a quality death,” he said. “We want to find out if there is anything we can modify to promote excellent health care in the end of life.”

Many people think that the ICU would be an awful place to die, but this is not necessarily so, the study investigators said. The rooms are private with nurses providing round-the-clock care for no more than two patients. Doctors are readily available to speak to family members and updated patient information is easier to come by.

Ely along with chief resident of internal medicine at Saint Thomas Dr. Cari Loss, in partnership with Kate Payne, an ethicist at Saint Thomas and Dr. John Johnson, chairman of medicine at Saint Thomas, studied 87 adults in the ICUs of both hospitals. The mean age was 65 years old with an average stay of seven days with illnesses ranging from pneumonia, heart attacks, cancer and GI bleeding.

The doctors used the Quality of Dying and Death (QODD), a questionnaire designed by Dr. Randy Curtis, a collaborating physician at the University of Washington Seattle, to ask patient families and hospital caregivers about the last week of the patient’s life. What they found was surprising.

“I admit, I went in assuming that the family members would be horrified seeing their loved one die in the ICU,” said Loss. “But that was not the case at all. They perceived the ICU stay as an all-out effort to save their loved one. It was a symbol of an attempt to save them, although the outcome was tragic.”

Study investigators found that family members and attending physicians had very similar views, while nursing staff and medical students had a less favorable overall perception of the dying process.

Loss said the disparity in perceptions tells her that more needs to be done in discovering what the needs are of the nursing staff in the ICU and making sure those needs are being met.

“There is a lot going on with the end-of-life process,” Loss said. “We have such great advancements in technology today. Medical care is not just about prolonging life; we must also focus on providing comfort. Those two entities coexist.

“We must bridge the gap between the medical professionals’ views of a good death and those of the families,” Loss added.

Although the study is in the early stages, Ely hopes to incorporate what is learned to all levels of hospital care.

“The instrument has good performance characteristics and our results suggest that it may be a useful outcome measure for interventions designed to improve the quality of death for patients dying during or shortly after a stay in the ICU,” Ely said. “Medical care is provided by a team, which includes the doctors, nurses, families and patients. As a team, we need to know how to provide care for a dying patient.

“Adding to work that Kate Payne had done over the past five years at Saint Thomas, this study will help us uncover specific issues in the dying process that have previously been overlooked.

“We can optimize this process and if we document how we measured these experiences, then it will allow others to have a tool to do the same thing.

“Most health care facilities monitor medications and other quality management pieces, but not a person’s quality of death. It’s a very important piece that must not be overlooked.”