A Study On The Construction Of Palliative Care Model For Patients With ICU In The End Of Life

Background:With the development of emergency medical technologies such as cardiopulmonary resuscitation(CPR), intra-aortic balloon pump(IABP), life-sustaining methods are increased. Even if many patients enter the end- of-life(EOL) stage, they can still continue their "life" in the ICU. These life support technologies not only consume a lot of medical resources, but also slow down the unnecessary suffering of patients, resulting in poor quality of life. In recent years, palliative care which focuses on humanity and hospice care is gradually attached more importance. Besides traditional treatment to save lives in ICU, the end-of-life quality of patients is also attracting more attention. Effective palliative care can improve the quality of life of ICU patients, and also can reduce waste of costly medical resources, which can ease the current doctor-patient tense situation. In China, the development of palliative care is relatively slow, medical care workers mostly focuses on advanced cancer patients, and the palliative care services for ICU patients is not clearly defined, which lead to medical care workers still give positive rescue and life supports for a large number of end-of life patients, seriously affecting the patients’ palliative care services quality and application. Establishing a suitable palliative care model for ICU patients in China has important practical significance and far-reaching impact.Objective:This study aims to investigate and analyze the life quality and palliative care status of Chinese ICU patients at their end-of-life stages, to find the existing problems of palliative care service, to discuss elements of ICU palliative care system, to propose theoretical basis and construction principle of ICU palliative care training mode, to explore the factors that influence the end-of-life clinical decision for ICU patients, and then construct a palliative care model for ICU patients at their end-of life stages so as to provide a more scientific and effective theoretical basis for the development of palliative care in ICU patients, and to promote the future ICU palliative care service quality.Methods:1. Literatures about the development history of end-of-life palliative care were reviewed, the problems, and ethical problems and factors of end-of-life care for ICU patients in China were summarized. Content analysis method was used to summarize the theoretical basis of end of life palliative care for ICU patients, so as to provide a theoretical basis for the construction of end of life palliative care model for ICU patients.2. Method such as Taiwan Mc Gill life quality scale, questionnaires and medical record review were used to investigate the quality of life and palliative care services status for end-of-life ICU patients; individual in-depth interviews and questionnaires were used to investigate factors affecting clinical decision making for ICU patients. Based on reviewing the related literatures, the authors analyze the core elements of the palliative care mode system. Also, the Chinese-version ICU families QODD scale was diveloped so as to provide criteria for evaluating the quality of end-of-life palliative care for ICU patients and to provide foundation for palliative care model for end-of-life ICU patients.3. Based on the theoretical research and empirical research, theoretical model framework for buliding palliative care model for end-of-life ICU patient was proposed, and the end-of-life palliative care model for ICU patients was initially established.Result:1. Contents and characteristics of end-of-life palliative care quality for ICU patients: the contents of end-of-life palliative care for ICU patients are composed by the following parts: to relieve and improve the end-of-life symptoms, to enhance the end-of-life quality, to help patients and their families to make the best end-of-life medical decisions, and to provide mental and social support for patients and their families. The end-of-life care quality evaluation index included symptom management, physical comfort care, psychological care, emotional support, spiritual care, ethics, legal and cultural and social factors(such as disease condition inform, end-of-life medical decisions), persistent care plan, team worker support and education, and mutual cooperation of team members. The elements for the end-of-life palliative care mode for ICU patients included quality of death and dying(QODD).2. Theoretical basis for the end-of-life palliative care model for ICU patients and the inherent logic relationship: the humanistic nursing theory was taken as the core theory of the end-of-life palliative care model for ICU patients, the general system theory provides system support, the basic human hierarchy needs theory is the basis for the end-of-life palliative care model for ICU patients, the human care theory provides direction guideance, and the comfort care theory provides objective guidance for end-of-life palliative care model for ICU patients.3. Taiwan McGill Life Quality Survey showed the following results: the overall end-of-life quality was lower for ICU patients; the suffering symptoms of end-of-life ICU patients mainly included pain, breathing difficulty, limited mobility, weakness, fear, etc; the mental scores of end-of-life ICU patients were lowest, which indicated that we should pay attention to end-of-life pateints’ spiritual needs; the ICU care of physical symptoms was not satisfactory, and symptom management needs to be strengthened.4. Current status and influencing factors of end-of-life palliative care services for ICU patients: cases review indicated a seldom usage of sedation drug for ICU end-of-life patients, less family meeting, higher frequencies of the active treatments, less palliative care or no palliative care. Qualitative interviews showed that the factors affecting the families of ICU patients and medical staff to make end-of-life decisions included current doctor-patient relationship, patients’ life quality, prognosis, lifetime wishes, whether having a hospice place, economic conditions, policy support, etc. Qusetioniare showed that the factors affecting the families of ICU patients and medical staff to make end-of-life decisions mainly included the attitude toward to the end-of-life truth, whether to conduct aggressive treatment at end-of-life stage, awareness of palliative care, and whether to have seen others apply CPR.5. This study developed the Chinese-version ICU families QODD scale, which received good evaluation fot its face validity, content validity and construction validity evaluation, and was suitable to assess the palliative care quality for end-of-life ICU patients. Also. This study has constructed a theoretical framework of the end-of-life palliative care model for ICU patients which focuses on the interaction of health care workers and their families and emphasizes the quality of dying patients.Conclusion:This study establishes a palliative care quality elements system for ICU patient, which is consisted of 3 elements and 12 sub-element, and provides reference for the development of end of life palliative care model for ICU patients. Also, the study constructes the theoretical framework which is composed by care service providers(doctors, nurses, family members), care service recipients and policy environment support. This study investigates the end of life palliative care quality status and affecting factors for health care workers and their families to make end-of-life decisions, which is important to implement targeted care programs. The end of life palliative care model helps improve the quality of life of dying ICU patients. In our future study, we need to further verify and revise the end-of-life palliative care mode, to further improve the evaluation index of palliative care model and to improve the palliative care services for Chinese ICU patients.