Transcript Adaptive strategies that work with families

Judith A. Adams, RN, MSN, FNP, PhD Candidate
Ruth A. Anderson, RN, PhD
Anthony N. Galanos, MD
Jennifer H. Gentry, RN, MSN, FNP
N. Marcus Thygeson, MD
and Donald E. Bailey, Jr. RN, PhD
Duke University School of Nursing
Funded by:
• Duke University School of Nursing
• Duke University NIH Roadmap Scholarship/ Clinical and Translational Science
Award (CTSA) TL1RR024126
• Hospice and Palliative Nurses Association
• National Institute of Nursing Research: National Research Service Award
1F31NR013327-01A1
Introduction
 90% of ICU deaths involve a decision to withhold or
withdraw life support
 Patients Lack capacity
 Family members make substituted decisions
Adaptive Leadership Framework
in ICU
Patient/Caregiver Challenges
Technical Challenges
Adaptive Challenges
Technical work
Adaptive
Work
Adaptive
Leadership
Provider
Patient/Caregiver
Provider
Adaptive Leadership Framework developed by Heifetz & Linsky
Adapted from Thygeson, 2010
Aim
 Describe Adaptive Leadership
behaviors of health care providers as
they communicated with family
members who were experiencing the
transition of their loved one from
curative to palliative care in the ICU
Methods
 Single In-Depth Prospective Case Study
 Setting/Sample
 MICU
 Patient Identified by team as likely to not survive ICU
stay

Multiple co-morbidities
Aspiration
MI
W/D Life Support
 Family: Wife, 2 sons, 1 daughter-in-law
 Staff: 1 RN, 2 MD Fellows, 1 Palliative Care physician
Data Collection
Audio recordings of three family
meetings
In depth interview with family
members after third family
meeting
Analysis
Qualitative Content Analysis
 Structural Coding based on
taxonomy of Adaptive Leadership
behaviors
 Pattern Coding used to refine
taxonomy
Results
 Adaptive Leadership Behaviors
 Provide Information
 Provide Decision Support
 Support Hope
 Address Work Avoidance
Adaptive Leadership Behaviors:
Information
Fellow 1
“We support the body until it can start working
and heal…But when your body isn’t able to do
that, my ability to keep your blood pressure up
with medications and keep your lungs going
with a ventilator doesn’t help.”
Adaptive Leadership Behaviors:
Decision Support
Palliative Care MD
He’s not able to hold fluid in his system…
and…his protein stores, something that we
call albumin, [are] a predictor of how well
people do. You need an albumin of at least 2.
His is 1, so…we’re looking at a life threatening
situation, both in the short haul and then in
the long haul what could be expected even if
he survived this particular episode.”
Adaptive Leadership Behaviors:
Decision-Support
Palliative Care MD
“This gets down to the values of the patient. So
would he want to be able to speak or would he
want his shortness of breath controlled. ‘Cause all
the medicines…for pain…or for shortness of
breath, they are sedating, and that’s an issue.”
Adaptive Leadership Behaviors:
Decision Support
Nurse
“He is at risk for having another heart
attack…there’s always the risk for another
event. And we do a lot of things to try to
prevent that…but it still is a risk.
Adaptive Leadership Behaviors:
Decision-Support
Daughter-in-law
“If they just told us what kind of decisions we had to
make and then couldn’t tell us what it would look like
after we made those decisions…then I think it would
be a lot scarier…they just painted a picture of what
could happen, and…it helps with the scariness of it.”
Adaptive Leadership Behaviors:
Support Realistic Hope
Palliative Care MD:
Fellow 1:
“I think the easiest and shortest
goal is that he could hear
you…One good thing about the
situation is that he is not
struggling…I would encourage
you to talk and assume he hears
it.”
“We can certainly decrease the
sedation, and if he starts looking
uncomfortable it goes back on very, very
quickly. So I don’t want you to think
that if we do that he’s going to be
suffering for a long time while we’re
trying to get him comfortable again.”
Adaptive Leadership Behaviors:
Support Realistic Hope
Fellow 1
“We think
these antibiotics…will treat
anything that’s gone down into his
lungs…
[This episode of aspiration] puts a stress on a
body that was already sick…I’m hoping that
he’ll get better. But it could go the other way
as well, and then we would be having a very
different talk.”
Adaptive Leadership Behaviors:
Support Realistic Hope
Son 1
“So it sounds like, (begins to cry)…there’s no
way he’s ever going to get out of ICU.”
Fellow 1
“The truth is, no. I wish that I could…tell you
something different. I wish that I could come here
with an encouraging nod or say, ‘he’s gotten some
better.’”
Adaptive Leadership Behaviors:
Address Work Avoidance
Palliative Care MD
“I can look at your faces and know that there’s a
ton of compassion and love for this gentleman…
And our job is to find out what his wishes are and
try to abide by that. We have a job to make sure
he’s not suffering because of what we’re doing to
him.”
Discussion
 Adaptive Challenges:
 Patient not responding to technical
interventions
 Change in belief in patient’s ability to
thrive
 Identify goals and values
 Make trade-offs
 Reframe hope
 Cope with loss and grief
Discussion
Adaptive Leadership Behaviors:
 Provide Information
 Provide Decision Support
 Support Realistic Hope
 Address Work Avoidance
Next Steps
 Qualitative Descriptive Study in an ICU:
 Aim: To identify and explore nursing strategies
from the perspective of the family members,
including how these strategies affect their ability
to make decisions on behalf of their loved ones
and how these strategies change over the
trajectory of the decision-making process