The Royal Marsden NHS Foundation Trust, London, UK.
The Christie NHS Foundation Trust, Manchester, UK.
J Clin Nurs. 2018 Nov;27(21-22):3900-3912. doi: 10.1111/jocn.14618. Epub 2018 Aug 2.
Rapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment.
To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness.
An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis.
Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions.
Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency.
There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions.
探讨重症监护外展团队的决策过程如何影响终末期疾病、基于病房的危重病患者过渡点的管理。
在两家医院进行了一项民族志研究，通过重症监护外展的视角观察过渡点和降低治疗强度的决策。通过深入访谈阐明了在观察中观察到的实践的理由。详细的实地记录被记录下来，并以描述性的方式呈现。使用主题分析对民族志数据进行分析、分类和组织成主题。
数据收集历时 74 周，包括 32 个观察期和 20 名工作人员，总计超过 150 小时。进行了 10 次正式工作人员访谈和 20 次非正式工作人员访谈。出现了三个主要主题：早期决策和重症监护外展的作用；沟通临终过渡；临终关怀和重症监护外展的投入。研究结果表明，在重症监护外展团队、父母或病房医疗团队之间，存在着为个别患者实现平稳过渡的协商。这个协商过程受到许多因素的影响，这些因素要么阻碍，要么促进及时过渡。
重症监护外展团队在共同决策中具有重要作用。与父母医疗团队的冲突以及作为单独从业者相关的情感成本。团队工作的文化背景对他们的互动和代理机构有重大影响。
需要朝着早期和公开讨论治疗目标和医疗治疗限制的方向转变，特别是在面临严重疾病时。通过培训和能力，外展护士非常适合促进这些讨论。
