Background Family members of patients who die in an intensive care unit (ICU) may experience negative outcomes. However, few studies have assessed the effectiveness of bereavement care for families. Objective To evaluate the effectiveness of bereavement follow-up on family members’ anxiety, depression, posttraumatic stress, prolonged grief, and satisfaction with care. Methods A cross-sectional, prospective pilot study of 40 family members of patients who died in 2 tertiary care ICUs. Those in the medical-surgical ICU received bereavement follow-up (bereavement group); those in the cardiac ICU received standard care (nonbereavement group). Both groups completed surveys 13 months after the death. Surveys included the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, Family Satisfaction With Care in the Intensive Care Unit, Prolonged Grief Disorder, and a bereavement survey. Results Of 30 family members in the bereavement group and 10 in the nonbereavement group, most were female and spouses, with a mean (SD) age of 60.1 (13.3) years. Significantly more participants in the nonbereavement group than in the bereavement group had prolonged grief. Posttraumatic stress, anxiety, depression, and satisfaction with care were not significantly different in the 2 groups. However, overall posttraumatic stress scores were higher in the nonbereavement group than the bereavement group, indicating a higher risk of posttraumatic stress disorder. Conclusions Bereavement follow-up after an ICU death reduced family members’ prolonged grief and may also reduce their risk of posttraumatic stress disorder. This type of support did not have a measurable effect on depression or satisfaction with ICU care.

Background Losing a loved one in the intensive care unit can be challenging for families. Providing bereavement support may assist in the grieving process. Objective To describe family members’ experiences with bereavement after the death of a loved one in the intensive care unit. Methods This secondary analysis used an exploratory, descriptive design to study family members’ experiences with bereavement. Family members of patients from 2 intensive care units in a tertiary medical center in the western United States participated. Audiotaped telephone interviews using a semistructured questionnaire were conducted. A qualitative, descriptive technique was used for data analysis. Two independent raters coded transcripts of audiotaped interviews with family members about their bereavement experiences. Results Seventeen family members participated in the study. Most participants were female (n = 12; 71%) and spouses of deceased patients (n = 14; 82%), and their mean (SD) age was 62.4 (10.0) years. Three themes emerged: (1) bereavement was an individual experience; (2) situations occurring during the intensive care unit encounter remained significant for family members beyond a year after the death; and (3) social, cultural, spiritual, and religious events after the death hold importance for families of patients in the intensive care unit. Conclusions Bereavement is a challenging experience for families of deceased intensive care unit patients. The themes identified in this study add insight into the experiences of these family members. The results of this study may guide future interventions to help support bereaved families of intensive care unit patients.

Background Integrating palliative care into intensive care units (ICUs) requires involvement of bedside nurses, who report inadequate education in palliative care. Objective To implement and evaluate a palliative care professional development program for ICU bedside nurses. Methods From May 2013 to January 2015, palliative care advanced practice nurses and nurse educators in 5 academic medical centers completed a 3-day train-the-trainer program followed by 2 years of mentoring to implement the initiative. The program consisted of 8-hour communication workshops for bedside nurses and structured rounds in ICUs, where nurse leaders coached bedside nurses in identifying and addressing palliative care needs. Primary outcomes were nurses’ ratings of their palliative care communication skills in surveys, and nurses’ identification of palliative care needs during coaching rounds. Results Each center held at least 6 workshops, training 428 bedside nurses. Nurses rated their skill level higher after the workshop for 15 tasks (eg, responding to family distress, ensuring families understand information in family meetings, all P < .01 vs preworkshop). Coaching rounds in each ICU took a mean of 3 hours per month. For 82% of 1110 patients discussed in rounds, bedside nurses identified palliative care needs and created plans to address them. Conclusions Communication skills training workshops increased nurses’ ratings of their palliative care communication skills. Coaching rounds supported nurses in identifying and addressing palliative care needs.

Background Integrating palliative care into intensive care requires active involvement of bedside nurses in discussions of patients’ prognosis and goals of care. Objective To improve critical care nurses’ skills and confidence to engage in discussions with patients’ families and physicians about prognosis and goals of care by using a focused educational intervention. Methods An 8-hour-long workshop was developed for critical care nurses. Key roles and skills of nurses in communication about prognosis and goals of care were defined. Participants practiced skills during facilitated role-plays. A reflection session addressed burnout, distress, and self-care. Participants completed surveys before, immediately after, and 3 months after their workshop, rating their confidence and skill in performing key tasks. Use of a participant focus group and open-response items in the surveys further elucidated the impact of the workshop. Results Between March 2011 and April 2013, a total of 82 critical care nurses completed a workshop. Compared with before the workshop, after the workshop, nurses reported greater skill and confidence for 14 survey items ( P < .001), including assessing families’ understanding of prognosis and goals of care, addressing families’ emotional needs, and contributing to family meetings. Increases were sustained 3 months after the workshop. Conclusion Defining roles and providing opportunities for skills practice and reflection can enhance nurses’ confidence to engage in discussions about prognosis and goals of care.

Background The sustained clinical and policy interest in the United States and worldwide in quality and safety activities initiated by the release of To Err Is Human has resulted in some high-profile successes and much disappointment. Despite the energy and good intentions poured into developing new protocols and redesigning technical systems, successes have been few and far between, leading some to argue that more attention should be given to the context of care. Objective To examine the insights provided by qualitative studies of interprofessional care delivery in intensive care. Methods A total of 532 article abstracts were reviewed. Of these, 24 met the inclusion criteria. Results Articles focused on the nurse-physician relationship, patient safety, patients’ families and end-of-life care, and learning and cognition. The findings indicated the complexities and nuances of interprofessional life in intensive care and also that much needs to be learned about team processes. Conclusion The fundamental insight that interprofessional interactions in intensive care do not happen in a historical, social, and technological vacuum must be brought to bear on future research in intensive care if patient safety and quality of care are to be improved.

Critically ill patients often report distressful episodes of severe thirst, but the complex biochemical, neurohormonal mechanisms that regulate this primal sensation still elude clinicians. The most potent stimuli for thirst are subtle increases in plasma osmolality. These minute changes in osmolality stimulate central osmoreceptors to release vasopressin (also known as antidiuretic hormone). Vasopressin in turn acts on the kidneys to promote the reabsorption of water to correct the increased osmolality. If this compensatory mechanism fails to decrease osmolality, then thirst is triggered to motivate drinking. In contrast, thirst induced by marked volume loss, or hypovolemic thirst, is subject to the tight osmoregulation of the renin-angiotensin aldosterone system and accompanying adrenergic agonists. Understanding the essential role that thirst plays in salt and water regulation can provide clinicians with a better appreciation for the complex physiology that underlies this intense sensation.

Concern for the family members of patients who are at high risk of dying in intensive care units is both a necessary and integral part of providing holistic nursing care. When patients are at high risk of dying, their families experience burdens such as decision making and treatment choices that can cause the families psychological and physical symptoms, most commonly stress, anxiety, and depression. These symptoms in turn can affect family members’ general well-being. Since the late 1990s, several quantitative and qualitative studies have been done to assess symptoms in such family members. In this review of the literature, the current state of the science on symptoms experienced by family members of patients in the intensive care unit is reviewed and critiqued. Risk factors associated with an increase in symptoms experienced are discussed. Overall, surveys that use self-report measures were the most common study design. Limitations of the studies include convenience sampling, small sample sizes, and a lack of description of patients’ characteristics, all of which make comparison and use of findings difficult. Recommendations to address gaps in the literature are highlighted, and future research goals are discussed.

• Background Advance directives are important but often underused tools in critical care. Healthcare professionals’ understanding of how culture influences attitudes toward advance directives can improve knowledge and completion of these documents. • Objective To understand the attitudes of critically ill Filipino American patients and their families toward advance directives. • Methods A descriptive, correlational, cross-sectional study with a convenience sample of 22 Filipino American patients and 22 Filipino American family members at a West Coast medical center. All patients were admitted for cardiac surgery or cardiac interventions. Participants were interviewed with the Advance Directive Attitude Survey and A Short Acculturation Scale for Filipino Americans. • Results Family members’ scores were significantly more positive than patients’ scores on the attitude survey (P = .01). Family members were more American acculturated than were patients (P = .001). Family members with more education had more positive attitudes toward advance directives (P = .02). Only 2 patients (and no family members) had completed an advance directive before the study. Only 27.3% of family members had prior knowledge of advance directives. • Conclusion Overall attitudes toward advance directives were positive; however, the completion rate and knowledge of advance directives were low. Participants may have been saying what they thought the researcher wanted to hear in order to avoid disagreement. Such behavior could partly explain the positive attitudes of the Filipino Americans toward advance directives. Further research is warranted to understand how to increase completion rates for advance directives among Filipino Americans.

• Background Pain during chest tube removal can be moderately to severely intense and distressful to patients. Little evidence-based research has guided clinicians in attempts to alleviate such pain. • Objective To test pharmacological and nonpharmacological interventions to alleviate pain during chest tube removal in cardiac surgery patients. • Methods Four interventions were tested in 74 patients in a randomized, double-blind study: (1) 4 mg intravenous morphine and procedural information; (2) 30 mg intravenous ketorolac and procedural information; (3) 4 mg intravenous morphine plus procedural and sensory information; and (4) 30 mg intravenous ketorolac plus procedural and sensory information. Analgesics were administered to correspond to peak effect, and scripted information was provided. Pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and 20 minutes later. Pain quality was measured immediately after chest tube removal. Level of sedation was measured before and 20 minutes after chest tube removal. Repeated-measures analyses of variance were used to test differences among groups over time. • Results Pain intensity, pain distress, and sedation levels did not differ significantly among groups. However, procedural pain intensity (mean 3.26, SD 3.00) and pain distress (mean 2.98, SD 3.18) scores for all were low. Patients remained alert, regardless of which analgesic was administered. • Conclusions If used correctly, either an opioid (morphine) or a nonsteroidal anti-inflammatory (ketorolac) can substantially reduce pain during chest tube removal without causing adverse sedative effects. Thus, clinicians may choose among several safe and effective analgesic interventions during chest tube removal.

• Background Little research has been done on pain assessment in critical care, especially in patients who cannot communicate verbally. • Objectives To describe (1) pain indicators used by nurses and physicians for pain assessment, (2) pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and (3) pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are intubated. • Methods Medical files from 2 specialized healthcare centers in Quebec City, Quebec, were reviewed. A data collection instrument based on Melzack’s theory was developed from existing tools. Pain-related indicators were clustered into nonobservable/subjective (patients’ self-reports of pain) and observable/objective (physiological and behavioral) categories. • Results A total of 183 pain episodes in 52 patients who received mechanical ventilation were analyzed. Observable indicators were recorded 97% of the time. Patients’ self-reports of pain were recorded only 29% of the time, a practice contradictory to recommendations for pain assessment. Pharmacological interventions were used more often (89% of the time) than nonpharmacological interventions (<25%) for managing pain. Almost 40% of the time, pain was not reassessed after an intervention. For reassessments, observable indicators were recorded 66% of the time; patients self-reports were recorded only 8% of the time. • Conclusions Pain documentation in medical files is incomplete or inadequate. The lack of a pain assessment tool may contribute to this situation. Research is still needed in the development of tools to enhance pain assessment in critically ill intubated patients.

Assessment and management of patients’ pain across practice settings have recently received the increased attention of providers, patients, patients’ families, and regulatory agencies. Scientific advances in understanding pain mechanisms, multidimensional methods of pain assessment, and analgesic pharmacology have aided in the improvement of pain management practices. However, pain assessment and management for critical care patients, especially those with communication barriers, continue to present challenges to clinicians and researchers. The state of nursing science of pain in critically ill patients, including development and testing of pain assessment methods and clinical trials of pharmacological interventions, is described. Special emphasis is placed on results from the Thunder Project II, a major multisite investigation of procedural pain.