Palliative care practice and moral distress during COVID-19 pandemic (PEOpLE-C19 study): a national, cross-sectional study in intensive care units in the Czech Republic

Tereza Prokopová, Jan Hudec, Kamil Vrbica, Jan Stašek, Andrea Pokorná, Petr Štourač, Kateřina Rusinová, Paulína Kerpnerová, Radka Štěpánová, Adam Svobodník, Jan Maláska, RIPE-ICU study group, Jan Maláska, Kateřina Rusinová, David Černý, Jozef Klučka, Andrea Pokorná, Miroslav Světlák, František Duška, Milan Kratochvíl, Alena Slezáčková, Milan Kratochvíl, Petr Štourač, Tomáš Gabrhelík, Josef Kuře, Daniel Suk, Tomáš Doležal, Tereza Prokopová, Jana Čerňanová, Kamil Vrbica, Klára Fabiánková, Eva Straževská, Jan Hudec, Tereza Prokopová, Jan Hudec, Kamil Vrbica, Jan Stašek, Andrea Pokorná, Petr Štourač, Kateřina Rusinová, Paulína Kerpnerová, Radka Štěpánová, Adam Svobodník, Jan Maláska, RIPE-ICU study group, Jan Maláska, Kateřina Rusinová, David Černý, Jozef Klučka, Andrea Pokorná, Miroslav Světlák, František Duška, Milan Kratochvíl, Alena Slezáčková, Milan Kratochvíl, Petr Štourač, Tomáš Gabrhelík, Josef Kuře, Daniel Suk, Tomáš Doležal, Tereza Prokopová, Jana Čerňanová, Kamil Vrbica, Klára Fabiánková, Eva Straževská, Jan Hudec

Abstract

Background: Providing palliative care at the end of life (EOL) in intensive care units (ICUs) seems to be modified during the COVID-19 pandemic with potential burden of moral distress to health care providers (HCPs). We seek to assess the practice of EOL care during the COVID-19 pandemic in ICUs in the Czech Republic focusing on the level of moral distress and its possible modifiable factors.

Methods: Between 16 June 2021 and 16 September 2021, a national, cross-sectional study in intensive care units (ICUs) in Czech Republic was performed. All physicians and nurses working in ICUs during the COVID-19 pandemic were included in the study. For questionnaire development ACADEMY and CHERRIES guide and checklist were used. A multivariate logistic regression model was used to analyse possible modifiable factors of moral distress.

Results: In total, 313 HCPs (14.5% out of all HCPs who opened the questionnaire) fully completed the survey. Results showed that 51.8% (n = 162) of respondents were exposed to moral distress during the COVID-19 pandemic. 63.1% (n = 113) of nurses and 71.6% of (n = 96) physicians had experience with the perception of inappropriate care. If inappropriate care was perceived, a higher chance for the occurrence of moral distress for HCPs (OR, 1.854; CI, 1.057-3.252; p = 0.0312) was found. When patients died with dignity, the chance for moral distress was lower (OR, 0.235; CI, 0.128-0.430; p < 0.001). The three most often reported differences in palliative care practice during pandemic were health system congestion, personnel factors, and characteristics of COVID-19 infection.

Conclusions: HCPs working at ICUs experienced significant moral distress during the COVID-19 pandemic in the Czech Republic. The major sources were perceiving inappropriate care and dying of patients without dignity. Improvement of the decision-making process and communication at the end of life could lead to a better ethical and safety climate.

Trial registration: NCT04910243 .

Keywords: COVID-19; Ethical climate; Inappropriate care; Moral distress; Palliative care; Pandemic; Survey.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Expression and respect of HCPs opinion regarding perceiving disproportionate organ support
Fig. 2
Fig. 2
Factors associated with moral distress – multivariate analysis
Fig. 3
Fig. 3
Bar charts depicting proportion of reported moral distress related to the predictors for moral distress

References

    1. Radbruch L, de Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. Redefining palliative care—a new consensus-based definition. J Pain Symp Manag. 2020;60:754–764. doi: 10.1016/j.jpainsymman.2020.04.027.
    1. Radbruch L, SA P. White paper on standards and norms for hospice and palliative care in Europe: part 1. Eur J Palliat Care. 2010;17:22–33.
    1. Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiol. 2018 doi: 10.1186/s12871-018-0574-9.
    1. Zangrillo A, Beretta L, Scandroglio AM, Monti G, Fominskiy E, Colombo S, et al. Characteristics, treatment, outcomes and cause of death of invasively ventilated patients with COVID-19 ARDS in Milan. Italy Crit Care Resusc NLM. 2020;22:200–211.
    1. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy. JAMA J Am Med Assoc Am Med Assoc. 2020;323:1574–1581. doi: 10.1001/jama.2020.5394.
    1. Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review. JAMA J Am Med Assoc Am Med Assoc. 2020;324:782–793. doi: 10.1001/jama.2020.12839.
    1. Immovilli P, Morelli N, Antonucci E, Radaelli G, Barbera M, Guidetti D. COVID-19 mortality and ICU admission: the Italian experience. Crit Care. 2020 doi: 10.1186/s13054-020-02957-9.
    1. Vincent J-L, Wendon J, Martin GS, Juffermans NP, Creteur J, Cecconi M. COVID-19: what we’ve done well and what we could or should have done better—the 4 Ps. Crit Care. 2021 doi: 10.1186/s13054-021-03467-y.
    1. Riccioni L, Ingravallo F, Grasselli G, Mazzon D, Cingolani E, Forti G, Zagrebelsky V, Zoja R, Petrini F. The Italian document: decisions for intensive care when there is an imbalance between care needs and resources during the COVID-19 pandemic. Annal Intensiv Care. 2021 doi: 10.1186/s13613-021-00888-4.
    1. Supady A, Curtis JR, Abrams D, Lorusso R, Bein T, Boldt J, et al. Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks. Lancet Respir Med. 2021;9:430–434. doi: 10.1016/S2213-2600(20)30580-4.
    1. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med. 2020;382:2049–2055. doi: 10.1056/NEJMsb2005114.
    1. Ferrell BR, Twaddle ML, Melnick A, Meier DE. National consensus project clinical practice guidelines for quality palliative care guidelines. J Palliat Med. 2018;21:1684–1689. doi: 10.1089/jpm.2018.0431.
    1. deLima TJ, Leiter RE, Abrahm JL, Shameklis JC, Kiser SB, Gelfand SL, et al. Development of a palliative care toolkit for the COVID-19 Pandemic. J Pain Symp Manag. 2020;60:e22–e25. doi: 10.1016/j.jpainsymman.2020.05.021.
    1. Fernando GVMC, Hughes S. Team approaches in palliative care: a review of the literature. Int J Palliat Nurs. 2019;25:444–451. doi: 10.12968/ijpn.2019.25.9.444.
    1. Aissaoui N, Amilien V, Antier N, Auvet A, Azoulay E, Barbar SD, et al. End of life in the critically ill patient: evaluation of experience of end of life by caregivers (EOLE study) Annal Intensiv Care. 2011 doi: 10.1186/s13613-021-00944-z.
    1. Wakam GK, Montgomery JR, Biesterveld BE, Brown CS. Not dying alone — modern compassionate care in the COVID-19 pandemic. N Engl J Med. 2020;382:e88. doi: 10.1056/NEJMp2007781.
    1. Valley TS, Schutz A, Nagle MT, Miles LJ, Lipman K, Ketcham SW, et al. Changes to visitation policies and communication practices in Michigan ICUs during the COVID-19 pandemic. Am J Respir Crit Care Med Am Thorac Soc. 2020;202:883–885. doi: 10.1164/rccm.202005-1706LE.
    1. Dennis B, Vanstone M, Swinton M, Brandt Vegas D, Dionne JC, Cheung A, et al. Sacrifice and solidarity: a qualitative study of family experiences of death and bereavement in critical care settings during the pandemic. BMJ Open. 2022;12:e058768. doi: 10.1136/bmjopen-2021-058768.
    1. Teles Sarmento J, Lírio Pedrosa C, Carvalho AS. What is common and what is different: recommendations from European scientific societies for triage in the first outbreak of COVID-19. J Med Ethics. 2021;48:472. doi: 10.1136/medethics-2020-106969.
    1. Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, et al. Ethical recommendations for a difficult decision-making in intensive care units due to the exceptional situation of crisis by the COVID-19 pandemia: a rapid review & consensus of experts. Med Intensiva. 2020;44:439–445. doi: 10.1016/j.medin.2020.04.006.
    1. Renata Č-P. Stanovisko výboru ČSARIM 13/2020: Rozhodování u pacientů v intenzivní péči v situaci nedostatku vzácných zdrojů. Anesteziologie a intenzivní medicína. 2020;31:249–255.
    1. Sheather J, Fidler H. Covid-19 has amplified moral distress in medicine. BMJ. 2021 doi: 10.1136/bmj.n28.
    1. Jones J, Hunter D. Qualitative research: consensus methods for medical and health services research. BMJ. 1995;311:376. doi: 10.1136/bmj.311.7001.376.
    1. Burns KEA, Duffett M, Kho ME, Meade MO, Adhikari NKJ, Sinuff T, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008;179:245–252. doi: 10.1503/cmaj.080372.
    1. Eysenbach G. Improving the quality of web surveys: the checklist for reporting results of internet E-surveys (CHERRIES) J Med Int Res. 2004;6(3):e34. doi: 10.2196/jmir.6.3.e34.
    1. Sharma A, Minh Duc NT, Luu Lam Thang T, Nam NH, Ng SJ, Abbas KS, et al. A Consensus-based checklist for reporting of survey studies (CROSS) J Gen Intern Med. 2021;36:3179–3187. doi: 10.1007/s11606-021-06737-1.
    1. Flannery L, Ramjan LM, Peters K. End-of-life decisions in the intensive care unit (ICU) - exploring the experiences of ICU nurses and doctors - a critical literature review. Aust Crit Care. 2016;29:97–103. doi: 10.1016/j.aucc.2015.07.004.
    1. Garten L, Danke A, Reindl T, Prass A, Bührer C. End-of-Life care related distress in the PICU and NICU: a cross-sectional survey in a German Tertiary Center. Front Pediatr. 2021 doi: 10.3389/fped.2021.709649.
    1. Shen X, Zou X, Zhong X, Yan J, Li L. Psychological stress of ICU nurses in the time of COVID-19. Crit Care. 2020 doi: 10.1186/s13054-020-02926-2.
    1. Benoit DD, Jensen HI, Malmgren J, Metaxa V, Reyners AK, Darmon M, et al. Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA. Intensiv Care Med. 2018;44:1039–1049. doi: 10.1007/s00134-018-5231-8.
    1. McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: the state of the science. Nurs Ethics. 2018;25:552–570. doi: 10.1177/0969733016664975.
    1. O’Mahony S, McHenry J, Blank AE, Snow D, Eti Karakas S, Santoro G, et al. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med. 2010;24:154–165. doi: 10.1177/0269216309346540.
    1. Ma J, Chi S, Buettner B, Pollard K, Muir M, Kolekar C, et al. Early palliative care consultation in the medical ICU: a cluster randomized crossover trial. Crit Care Med. 2019;47:1707–1715. doi: 10.1097/CCM.0000000000004016.
    1. Downar J, Delaney JW, Hawryluck L, Kenny L. Guidelines for the withdrawal of life-sustaining measures. Intensiv Care Med. 2016;42:1003–1017. doi: 10.1007/s00134-016-4330-7.
    1. Myburgh J, Abillama F, Chiumello D, Dobb G, Jacobe S, Kleinpell R, et al. End-of-life care in the intensive care unit: report from the task force of world federation of societies of intensive and critical care medicine. J Crit Care. 2016;34:125–130. doi: 10.1016/j.jcrc.2016.04.017.
    1. Azoulay E, Resche-Rigon M, Megarbane B, Reuter D, Labbé V, Cariou A, et al. Association of COVID-19 acute respiratory distress syndrome with symptoms of posttraumatic stress disorder in family members after ICU discharge. JAMA. 2022;327:1042. doi: 10.1001/jama.2022.2017.
    1. Kentish-Barnes N, Cohen-Solal Z, Morin L, Souppart V, Pochard F, Azoulay E. Lived experiences of family members of patients with severe COVID-19 who died in intensive care units in France. JAMA Netw Open. 2021;4(6):e2113355. doi: 10.1001/jamanetworkopen.2021.13355.
    1. Brighton LJ, Bristowe K. Communication in palliative care: talking about the end of life, before the end of life. Postgrad Med. 2016;92:466–470. doi: 10.1136/postgradmedj-2015-133368.
    1. Bergenholtz H, Timm HU, Missel M. Talking about end of life in general palliative care – what’s going on? A qualitative study on end-of-life conversations in an acute care hospital in Denmark. BMC Palliat Care. 2019 doi: 10.1186/s12904-019-0448-z.
    1. Wittenberg E, Ferrell B, Goldsmith J, Buller H. Provider difficulties with spiritual and forgiveness communication at the end of life. Am J Hosp Palliat Med. 2016;33:843–848. doi: 10.1177/1049909115591811.
    1. Wittenberg E, Ragan SL, Ferrell B. Exploring nurse communication about spirituality. Am J Hosp Palliat Med. 2017;34:566–571. doi: 10.1177/1049909116641630.
    1. Guidet B, Jung C, Flaatten H, Fjølner J, Artigas A, Pinto BB, et al. Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19. Intensiv Care Med. 2022;48:435–447. doi: 10.1007/s00134-022-06642-z.
    1. Jung C, Flaatten H, Fjølner J, Bruno RR, Wernly B, Artigas A, et al. The impact of frailty on survival in elderly intensive care patients with COVID-19: the COVIP study. Crit Care BioMed Central Ltd. 2021;25:1–9. doi: 10.1186/s13054-021-03551-3.
    1. Flaatten H, Guidet B, de Lange DW, Beil M, Leaver SK, Fjølner J, et al. The importance of revealing data on limitation of life sustaining therapy in critical ill elderly Covid-19 patients. J Crit Care. 2022;67:147–148. doi: 10.1016/j.jcrc.2021.10.024.

Source: PubMed

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