I.

Clinical Question People in the final phase of life: what therapeutic nursing interventions are carried out at the emergency room? II. Citation

Search.ebscohost.com Date published: July 1, 2009 III. A. Study Characteristics Patients Included.

The multi-faceted nature of end-of-life care delivery was investigated in over 900 hours of unstructured observations conducted over twelve months in a large, urban Emergency Department (ED). In combination, 27 interviews were carried out with emergency staff, patients with terminal or life limiting illnesses who had attended the ED and their relatives. B. Interventions compared.

The study identifies distinct trajectories of end-of-life care in the Emergency Department based on the care of the patient and their relatives; and the behaviors of emergency staff in response to different deaths. C. Outcomes monitored.

Interviews and field notes were audio-recorded, transcribed verbatim and organized for analysis using NVivo. Data was analyzed thematically. (NVivo 9 is software that helps you to work with unstructured information like documents, surveys, audio, video and pictures - so that you can ultimately make better decisions.) NVivo is a qualitative data analysis (QDA) computer software package.

D.

Does the study focus on a significant problem in clinical practice?

Yes. This study focuses on a significant problem in clinical practice because concerns around the provision of end-of-life care in other areas of the healthcare system have been given little attention especially to the Emergency Department (ED); the front door of the hospital setting. Wherein the nurse has an important role in the patient in the final phase of life since he/she is the closest health professional to the patient and has a greater opportunity to support him in such a difficult phase of life. And it is important for us, nurses to be aware of their own feelings about death. This finding makes a significant contribution to wider understanding of nursing the dying and provides indicators about how the quality of care delivery can be developed to ensure consistency in care pathways and mutual goals at the end-of-life. Overall it provides a framework for the interdisciplinary team to recognize the individual care needs of patients at the end-of-life presenting to the ED. IV. A. A. Methodology/ Design Methodology Used. Design.

A qualitative study was conducted at an urban academic teaching hospital ED that sees approximately 140,000 patients each year. Observation was carried out over a 12 month period involving more than one hundred ED staff. This was complemented by informal supporting interviews within the field and later by more formal in-depth interviews with 15 emergency staff, seven patients diagnosed with a terminal condition that had visited the ED in the last six months and seven relatives. Interviews and field notes were audio-recorded, transcribed verbatim and organized for analysis using NVivo. Data was analyzed thematically. B. Setting.

The study was conducted at Emergency Department of UK Hospital. C. Data sources.

1. Department of Health (2008) End of Life Care Strategy - promoting high quality care for all adults at the end of life. Department of Health, London.

2. Bailey, C.J., Murphy, R., Porock, D. (in press) Annals of Emergency Medicine. 3. Costello, J. (2006) Dying well: nurses' experiences of 'good and bad' deaths in hospital. Journal of Advanced Nursing, 54(5): 594-601. 4. Yates, D.W., McGuiness, S. (1990) Care of the suddenly bereaved. BMJ, 301: 29-31 5. Cartwright A., Hockey L., Anderson J.C. (1973) Life Before Death. Routledge, London. 6. Wilkes, E. ( 1984). Dying now. Lancet, i (6): 950-2. 7. Seale, C. (1991) Death from cancer and death from other causes: the relevance of the hospice approach. Palliative Medicine, 5: 12-19. 8. Smith P. (1992) The Emotional Labour of Nursing. Edward Arnold, London. 9. Seale, C., Kelly, M. (1997) A comparison of hospice and hospital care for people who die: views of the surviving spouse. Palliative Medicine, 11: 93-100 10. Copp, G. (1999) Facing impending death experiences of patients and their nurses. London. Nursing Times Books, London.

D. 1.

Subject Selection. Inclusion Criteria.

Observation was carried out over a 12 month period involving more than one hundred ED staff. This was complemented by informal supporting interviews within the field and later by more formal in-depth interviews with 15 Emergency Staff, seven (7) patients diagnosed with a terminal condition that had visited the ED in the last six months and seven (7) relatives.
2.

Exclusion Criteria.

There are no Exclusion criteria mentioned in the study.

3.

Has the original study been replicated?

No. this study has not been replicated.

4.

What were the risks and benefits of the nursing action/ intervention tested

in the study? There were no risks identified in the study instead, it has been found out that both presence and caring is a therapeutic process. In the study, Patients report an enhanced capacity to cope with their illness. With the presence of the nurse, death for patients is inevitable; presence can make the death a peaceful experience. There is also an improvement in pain and enhanced comfort associated with presence and caring. Both patients and nurses benefit both mentally and physically from the process of presence and caring. V. Results of the Study. Based on the result of the study, from the narratives of the patients, it was clear to see the importance of the patient relationship to the nurse. Whereas the doctors tended to focus on their ability to stabilize or save the patient who still showed signs of life, the nurses were keen to provide an emotional, supportive and caring role to the dying. Despite this, work was seen as the physical activity of the ED; the resuscitation. Care of dying and bereaved, was not highly valued by the majority of nurses compared to other nursing roles in ED such as suturing a large wound or trauma management. Structural constraints of emergency work affected the way in which nurses cared for dying patients and their relatives in practice. Constraints of emergency work meant that care became just the way it is sometimes in the ED. As the patients reflected upon their emergency admission, many found it difficult to interpret the staff nurse from the doctor and EDA. The nurses also acknowledged that in the ED the ability to form relationships with patients and their relatives is different to other areas of healthcare. The lack of time spent with individual patients in the ED became a barrier to the concept of holistic assessment, care planning and delivery because frequently they did not know details of the patient or their condition.

VI. A.

Authors Conclusion/ Recommendations. What contribution to the client health status do the nursing action /

intervention make? Patients judged the quality of care on the level of attention they received in the ED. Nurses did not necessarily have to be doing anything for them, but just had to be present in order for them to feel cared for. The concept of being with patients alludes to the importance of nursing presence at the end of life. With those nursing interventions, the patient may relieve the dying person's pain, keeping comfortable and to help the patient to a peaceful death. It is also important to make the patient feel secure to calm any fears, and give him or her hope. Make the person feel safe and secure by showing that he or she will be taken care and will not be left alone. B. What overall contribution to nursing knowledge does the study make?

The findings make a significant contribution to wider understanding of nursing the dying and provide indicators about how the quality of care delivery can be developed to ensure consistency in care pathways and mutual goals at the end-of-life. Overall it provides a framework for the interdisciplinary team to recognize the individual care needs of patients at the end-of-life presenting to the Emergency Department. VII. A. Applicability Does the study provide a direct enough answer to your clinical question

in terms of type of patients, intervention and outcome? Yes. The study provides a direct enough answer in terms of patient, intervention and outcome. There are sufficient interventions given and provided in the study and the outcome presents a unique case for emergency situations in patients final phase of life.

B.

Is it feasible to carry out the nursing action in the real world?

Yes, it is feasible to carry out the nursing action in the real world since nursing participation is the key component. We have not only cared for our patients, we have also

cared about them. It is important for us to be aware of their own feelings about death. Because it is difficult to see people die who you have cared for. We have to recognize those feelings and do the best care that we have until the last minute of their lives.

VIII.

Reviewers Conclusions/ Commentary

The ED is most commonly associated with the heroic act of saving life rather than with lifes end. Despite this emergency nurses are exposed to death and dying on a regular basis. People are dying for longer with less social support but given the advances in technology and medical knowledge they have higher expectations of survival than ever before. Despite efforts to keep patients in their own homes at the end of life, patients continue to access the Emergency Department during the last stages of life as it is the front door to the hospital where patients and their relatives expect a high level of attention to their care needs. Emergency nurses will continue to care for patients across their illness trajectory and will increasingly have to deal with death and the care of dying patients and their relatives. In the absence of existing evidence, this research has explored nursing care of patients who attend the ED at the end-of-life. The process of care delivery at the end-of-life and specifically the importance of nursing presence to patients near the end-of-life can be more clearly understood in the emergency field. It is envisioned that this contribution to knowledge will help inform the teaching and development of the emergency nurse and consequently improve the quality of patient care at the end of life.

IX. Evaluating the Nursing Care Practices A. Safety

This qualitative study was conducted at an urban academic teaching hospital at Emergency Department where there is provision of ethics committee. B. Competence of the care provider

The study was successfully accomplished and the result is highly recognized that nurse patient interaction is still important in the last phase of life, therefore implying that the care providers were competent in the research process. The health provider who participated on the study was the emergency nurses and the Emergency Department staff. C. Acceptability

This study is acceptable in all clinical settings including Philippine setting. This is one of the best studies that can be contributed to the nursing knowledge. This guideline was augmented by evidence-based recommendations from other key documents related to care of dying patients. D. Effectiveness

In this study, both nursing responsibility and skills related to end-of-life care at the end of life in providing good health care quality are needed to have an effective result. That is why at the very few hours of admission to Emergency Department, nurses knowledge of end-of-life issues in the emergency care setting is fundamental. E. Appropriateness

In this study, there are mentioned that sometimes, it is important to ask the patient and family whether the patient would prefer to stay in the hospital or to go home for the last days. If the patient wants to go home, teach the family how to care for him or her. If the patient stays in the hospital, try, as much as possible to do what he or she and the family want. It is important to provide physical comfort. It is also important to make the patient feel secure to calm any fears, and give him or her hope. Make the person feel safe and secure by showing

that he or she will be taken care of, and will not be left alone. Calm any fears by assuring the patient that he or she will not suffer or die alone. F. Efficiency

To be able to care for the dying patient and family, we nurses must be competent and knowledgeable in doing such procedures or intervention to make a better outcome. And to feel the patient the he/she cared, we should come into action, providing physical, psychological, social, and spiritual care for the patient. G. Accessibility

In this research, the process of care delivery at the end-of-life and specifically the importance of nursing presence to patients near the end-of-life can be more clearly understood in the emergency field. Wherein we nurses are still available in time our patient is in the end of life to help them to a peaceful death.