Prerequisites for palliative care provision in intensive care

Abstract

Palliative care provision is aimed at improving patients’ quality of life when cure no longer possible through healthcare systems, including intensive care. It has been ob-served that ongoing challenges exist concerning integration of palliative care into inten-sive care contexts. This necessitates an understanding of the contextual facilitators and barriers. The overall aim of this thesis therefore was to explore the prerequisites of palli-ative care provision in intensive care contexts. A multimethod approach was employed, including a systematic review, intensive care professionals and managers interviews, as well as a psychometric evaluation of an instrument with potential to be used for as-sessing intensive care professionals’ attitudes in a future evaluation of a knowledge translation strategy. Study I is a mixed-method systematic review identifying factors influencing the integration of palliative approaches in intensive care units. The review included a total of 24 qualitative and quantitative studies and the findings indicated that the prerequisite factors were (a) an organizational structure that facilitates policies and environmental dimensions, and (b) interpersonal factors/barriers, related to the patient and the patient’s family, including decision making, multidisciplinary team communi-cation, and prognostication. Study II is an interpretive description design study in-volving interviews with 36 intensive care professionals, and was designed to explore their perspectives on the provision of palliative care within intensive care settings. The findings illuminated intensive care professionals’ perceptions of palliative care within intensive care contexts, their decision-making related to goals for care strategies, and the challenges pertaining to family involvement in care goals. Study III is an interpretive description study exploring the association of organizational structures when integrating palliative care within an intensive care units. The study included interviews with 15 managers and 36 intensive care professionals. The findings show a ‘do not resuscitate’ policy as a gateway to palliative care, facilitating family members to enable to participa-tion and support, while barriers to palliative care in the intensive care units exists in the way intensive care is organized. In study IV, a cross-sectional design was applied to measure the differential item functioning of the Frommelt Attitudes Toward Care of the Dying (FATCOD) scale. A convenience sampling method was used, recruiting partici-pants from both Sweden and Saudi Arabia professionally working in intensive care contexts. Ordinal logistic regression was undertaken to investigate potential differences in the perceptions of the items between different professional groups and in different geographical locations. The results establish that 12 out of 30 items in the FATCOD had significant differential item functioning among the groups. The conclusion derived from this thesis enhances our understanding of the facilitators and barriers of palliative care initiatives, as it illuminates the importance of acknowledging attitudes of death and dying within the professional groups in ways that go beyond the “do not resuscitate (DNR)” decision making as a gatekeeping process and considers the potential of inte-grating a palliative approach in intensive care.