Latest Australian research

Lecuyer K, Weatherburn C, Greenwood M.

Background: The gap between organ availability and the number of people waiting for a transplant remains a major healthcare issue. Most transplanted organs and tissue are received from donors who have died in intensive care units (ICUs). To increase the number of donors, national guidelines and professional bodies in Australia support routine consideration of organ and tissue donation at the end of life. Referral to donation specialists is the first important step to explore a patient's donation wishes and consider the potential for donation, but practice is variable, and not all patients receiving end-of-life care in the ICU are referred.

Objectives: The aim of this study was to investigate health professionals' experiences of making a referral for organ and tissue donation in the intensive care setting and to identify barriers and facilitators that influence practice.

Methods: A qualitative research approach with semistructured interviews and interpretive description analysis methods was used in this study. Doctors and nurses from a single tertiary referral hospital in Australia who had worked in the intensive care setting were invited to participate. Content from interviews was analysed through a process of coding and inductive thematic analysis. Nine health professionals were interviewed.

Findings: A local protocol was in place to support multidisciplinary referral for organ and tissue donation; however, there were organisational barriers and referral misconceptions that discouraged clinicians to make a referral. Nurses felt disempowered to refer and had limited knowledge of what was required. Doctors supported nurses making referrals, acknowledging that the responsibility should be shared to minimise the chance that a referral will be missed. Donation specialist nurses provided valuable support for health professionals navigating the organ and tissue donation process.

Conclusions: Research outcomes suggest the need for greater interprofessional collaboration to support a more inclusive referral culture in the ICU to optimise opportunities for organ and tissue donation.

Lovell T, Mitchell M, Powell M, Strube P, Tonge A, O'Neill K, et al.

Background: The provision of end-of-life care (EOLC) is an ongoing component of practice in intensive care units (ICUs). Interdisciplinary, multicomponent interventions may enhance the quality of EOLC for patients and the experience of family members and ICU clinicians during this period.

Objectives: This study aimed to assess the impact of a multicomponent intervention on EOLC practices in the ICU and family members' and clinicians' perceptions of EOLC.

Methods: A before-and-after interventional study design was used. Interventions comprising of EOLC guidelines, environmental and memory-making resources, EOLC education day for nurses, web-based resources, and changes to EOLC documentation processes were implemented in a 30-bed adult tertiary ICU from September 2020 onwards. Data collection included electronic health record audits of care provided post initiation of EOLC and family and clinician surveys. Open-ended survey questions were analysed using content analysis. Data from before and after the intervention were compared using the Chi-squared test for categorical variables, unpaired two-sample t-tests for normally distributed continuous measurements, and Mann-Whitney U tests for non-normally distributed data.

Findings: A reduction in documented observations and medications and an increased removal of invasive devices unrelated to EOLC were observed post the intervention. The mean overall satisfaction of family members improved from 4.5 to 5 (out of 5); however, this was not statistically significant. Statistically significant improvements in clinicians' perception of overall quality of EOLC (mean difference = 0.28, 95% confidence interval: 0.18, 0.37; t₂₈₂ = 5.8, P < 0.01) were found. Although statistically significant improvements were evident in all subscales measured, clinicians' work stress related to EOLC and support for staff, patients, and their families were identified as needing further improvement.

Conclusions: The development and implementation of a multicomponent interdisciplinary intervention successfully improved EOLC quality, as measured by chart audit and family and clinician perceptions. Continuing interdisciplinary collaboration is needed to drive further change to continue to support high-quality EOLC for patients, families, and clinicians in the ICU.

Gooley M, Delardes B, Hopkins S, Oswald J, Cameron C, Nehme E.

Background: Paramedics are increasingly involved in palliative care and often support community-based palliative care service delivery to facilitate integrated practice. However, the impact of specific palliative care guidelines on clinical practice remains unknown.

Aim: To determine the impact of an ambulance service palliative care guideline on rates of supportive medication administration and non-transport.

Design: A retrospective cohort study of electronic patient care records from January 2014 to June 2023. Baseline characteristics were compared pre- and post-guideline introduction. Interrupted time series analysis was performed to examine guideline efficacy.

Seting/ participants: Patients of all ages receiving palliative care who were attended by paramedics in Victoria, Australia.

Results: A total of 31,579 patients were included. The median age was 75 years (IQR = 64-84 years), and 56.4% were men. Overall, 25.8% of patients were not transported to hospital. Following guideline introduction, there were no significant trend changes in administration of supportive medications. However, the non-transport rate increased significantly per month (0.2%, p = 0.007), amounting to a 9.9% (p = 0.020) total increase by the end of the study period compared to a scenario in which the guideline had not been introduced. Subgroup analysis of patients diagnosed with 'pain' or attended after-hours also showed significant increases in non-transport (monthly increase: pain 0.3%, p = 0.003; after-hours 0.3%, p < 0.001; total increase: pain 29.7%, p < 0.001, after-hours 22.6%, p = 0.001).

Conclusions: Introduction of a palliative care guideline was associated with a decrease in ambulance transport to emergency departments, allowing more patients continuity of care in the community.

Lee CW, Wong AB, Lazarakis S, Lim WK, Darvall J.

Background: Identifying surgical patients at the end of life (EOL) is the first step in integrating palliative and perioperative practices. Palliative prognostic tools (PPTs) are established frameworks from palliative care that assess patients at risk of early death. We conducted a systematic review investigating PPTs in adult surgical populations, their role in surgical decision-making, and their association with perioperative outcomes.

Methods: A prospectively registered systematic review was performed (PROSPERO registration: CRD42023411303). Ovid MEDLINE, Ovid EMBASE, and Cochrane CENTRAL (Wiley) databases were searched for studies investigating PPTs in surgical patients. The primary outcome was the decision to proceed to surgery; secondary outcomes included mortality, quality of life, palliative care consultation, and EOL documentation completion. Abstract screening, full-text review, and study quality appraisal were performed by two authors independently. Results were synthesised narratively owing to study heterogeneity.

Results: Seven studies assessing four different PPTs were included in the review. Studies identified that 12-61% of surgical patients were at the EOL. Patients identified as being at the EOL by a PPT using an illness phase, trajectory approach, or both had an increased in-hospital and 12-month mortality. The impact on decisions to proceed to surgery was uncertain because of conflicting results. Palliative care referral and EOL document completion occurred in <15% of surgical patients at the EOL. No studies described patient-reported outcomes.

Conclusions: Palliative prognostic tools have significant potential for incorporation into preoperative assessment. Future research should focus on preoperative end of life assessments and patient-reported outcomes such as quality of life, decision satisfaction, and disability-free survival.

O'Neill K, Brooks L, Manias E, Bloomer MJ.

Background: Australia is culturally and linguistically diverse. Yet little is known about perceived barriers to the provision of end-of-life care tailored to diverse cultural needs and preferences.

Aims: The aim of this study was to measure critical care nurses' cultural intelligence, comfort, and capabilities in providing end-of-life care and explore the perceived barriers to providing end-of-life care for culturally diverse patients and their families.

Method: An explanatory mixed-method approach was undertaken utilising surveys and interviews. A national survey was distributed in February 2024, collecting data about critical care nurses' capability, comfort, and cultural intelligence when providing end-of-life care. Individual interviews were conducted with nurses between March and April 2024. Quantitative data were analysed using descriptive and inferential statistics, and open-ended survey and interview responses were analysed using inductive content analysis.

Findings: From the sample of 89 survey responses, the median number of years nurses worked in the intensive care unit was 15 (interquartile range = 7.0-21.5). Respondents came from 14 different countries, 20.2% (n = 18) spoke a second language, and 50.6% (n = 45) were affiliated with a religion. One-third had completed end-of-life care training (34.8%, n = 31), whilst 31.5% (n = 28) had completed training in cultural diversity. Respondents who completed end-of-life care training had significantly higher comfort and capability scores regarding end-of-life care provision (Mdn = 91.0) than those with no training (Mdn = 80.5, U = 1301.0, p < 0.001). Interview participants acknowledged some discomfort with diversity, and the importance of prioritising comfort and dignity, and understanding and interpreting cultural preferences. Communication challenges associated with professional interpreter access were also identified.

Conclusion: Critical care nurses' comfort and capabilities with end-of-life care and perceptions of the barriers are critical to understand because end-of-life care is about more than clinical care. Supporting nurses to build their understanding and comfort with providing care that aligns with cultural and religious needs and preferences, and optimising access to professional interpreters, is imperative.