A recent Audit Commission report (1999) revealed that the average mortality rate for patients nursed in critical care units is 17%.
VOL: 96, ISSUE: 45, PAGE NO: 38
Kate Wilkins, RN, is clinical nurse manager at Leicester General Hospital
Liz Dalby, RN, BA, is professional development nurse, critical care, at Leicester General Hospital
A recent Audit Commission report (1999) revealed that the average mortality rate for patients nursed in critical care units is 17%. Roberts (1983) asserts that while a patient enters a unit in a state of physiological crisis, the family enters critical care in a state of psychological crisis that could end in bereavement. However, time pressures and lack of opportunity to build relationships can result in a lack of support for relatives in these acute environments.
Following publication of the Intensive Care Society’s bereavement guidelines (1998) it was decided to implement a bereavement service in the critical care unit at Leicester General Hospital. The department is staffed by 65 nurses and comprises seven intensive care beds and four high dependency beds taking a broad range of medical, surgical and renal patients. The bereavement service was the first major project to be initiated by the critical care unit’s Shared Governance Council (SGC) shortly after its formation in July 1998. This is a group of 16 nurses aiming to ‘retain influence about decisions that affect practice, work environment and professional development’ (O’Grady, 1992).
In order to foster a bottom-up approach to change, the SGC consists mainly of D- and E-grade staff nurses with a limited number of senior nurses. It is divided into four sub-groups: research; clinical practice; professional development; and quality.
Implementing the service
The first step involved asking the critical care nurses for their opinions. The SGC circulated a questionnaire that covered three key areas:
- Education and training needs;
- Information given to other staff, patients and relatives at the time of a patient’s death;
- Other support requirements.
The results highlighted the way forward for the project. The educational/training needs identified among staff included: teaching sessions on breaking bad news; the psychological aspects of bereavement; cultural and religious rites associated with dying; support mechanisms for relatives; the administrative/legal requirements after death; and the role of the coroner. Staff also requested a register of colleagues trained in bereavement and a peer support group.
During the circulation of the questionnaire, the research subgroup phoned other units to ascertain what they had in place. The clinical practice subgroup, meanwhile, investigated the needs of different religious groups at the time of death.
Attitudes to death
A defining characteristic of a culture is its attitude to death. However, while it is important to know the beliefs that underpin the cultural attitude, it is also important to remember that people are individuals and have their own interpretation of these beliefs. Following meetings with a number of religious groups and their leaders, laminated cards were produced for use at the bedside containing information on death and bereavement for a variety of religions. The cards were only intended as a guide and not a replacement for face-to-face discussions with the bereaved.
A newsletter was sent to all members of staff outlining the results of the questionnaire and the findings of the research sub-group. A second questionnaire looked at whether relatives should be sent a sympathy card, bereavement letter and/or telephone call. Respondents believed both a sympathy card and bereavement letter should be sent following the death of a patient.
The selection of the card was an important process, as we wanted the card to be non-religious and tasteful, yet concise and supportive. A variety of cards were displayed for staff to comment on. The choice was narrowed down to two cards and the final decision left with the SGC. We decided to provide a personal message and signature on the card. Cards are sent one week following the death, the completed card being placed in an index box ready for postage along with relevant information surrounding the death.
Discussions took place about sending a letter and the appropriate time to send it. It was decided that eight weeks was a suitable period and that it would be pre-printed. The letter offers the family an opportunity to come back and speak to the nursing staff about the care their loved one received. It is pointed out in the letter that we do not offer a formal counselling service but can put them in touch with various agencies.
The replies to these letters are forwarded to the SGC, which organises an appointment for the bereaved with the appropriate nurses. The venue for the meeting is a choice of quiet rooms within the hospital. Reminders for sending cards and letters are put in the unit’s diary.
Guidelines for bereavement care were compiled with the aim of raising awareness among medical and nursing staff of the importance of providing care for bereaved relatives in critical care. The guidelines also include details of the shared governance sub-groups and their responsibilities.
A flowchart was also produced (Fig 1), providing an easy-to-read checklist for the nurse at the bedside. All nurses working on the unit were asked to fill in an index card at the time of death including vital information such as next of kin.
The SGC also liaised with the patient and family services department and their nurses’ checklist was altered to include a reference to the bereavement flowchart. It was also agreed that it may be more appropriate to give out the booklet about what to do after death (DSS, 2000) around the time of death, rather than relatives having to wait until their return visit to hospital to receive it.
We decided to launch the bereavement service on 1 July, 1999. Guidelines were placed in strategic places such as toilet doors, noticeboards, communication folders and the coffee room. Our first card was sent on 5 July, 1999 and the first letter on 30 August, 1999.
Experiences to date
One year on, out of 106 deaths (15% mortality, see Box 1), we have had 10 visits, resulting in a 10% uptake of the service. We have taken six telephone calls asking for more details of the service and have received three letters thanking us for the offer of help. One relative said: ‘This service has provided us with the opportunity to discuss issues surrounding my father’s untimely death.’
Issues highlighted by an informal audit included the need to access the patient’s medical notes before a visit by the bereaved relative and the importance of providing an experienced critical care nurse to support the named/primary nurse during these sessions. A formal audit of the service is currently underway, consisting of a retrospective study of 20% of the patient deaths, and involves in-depth interviews with the nurses involved at the time of death as well as examination of written records.
It is felt that this service complements our philosophy of delivering holistic care and can be viewed as a natural continuation of the support given to families during critical illness. However, there were barriers to the service, such as lack of confidence among staff and concerns about taking the nurse away from the bedside. Some nurses also feared that the service would become a counselling service and the relatives would become ‘dependent’. It was therefore felt that to ensure the service was a success it would be important to provide the nurses with support. A manager made commitments to meet the training needs of staff and recognised the importance of giving protected time to provide the service. Peer support took the form of meetings of D- and E-grade staff nurses. Clinical supervision was offered to all staff and support by the senior nurses was given on all bereavement visits.
Many of the nurses have come to recognise the need for the service and welcomed the bottom-up approach to its implementation. Training opportunities have been made available, such as the ENB 931 (Care of the Dying) and courses in counselling skills. We feel the bereavement service has improved the quality of our care and is in the process of being implemented across the whole hospital by the clinical governance steering group.