A qualitative exploration of the factors influencing the decision to transfuse elective platelets in cancer care.

OBJECTIVES: To explore factors contributing to decisions to transfuse platelets in cancer care outside guidelines using case study methods. METHODS: Two case studies were examined, using instrumental case study methodology, to qualitatively explore factors that influence the decision to transfuse platelets. Interviews (n=10) were conducted around cases in haematology and critical care. In-depth review of documentary evidence was undertaken and propositions were developed to provide rigour during the investigation. Thematic analysis and triangulation of documents was undertaken to find specific factors, and propositions analysed, as per instrumental case study methods. RESULTS: Both cases emphasised how patient complexity, and individual response to platelet administration, was an influencing factor. Other themes included uncertainty of clinical situations coupled with uncertainty about platelet availability. Other factors worthy of further investigation include the concept of professional safety and the trustworthiness of platelet thresholds against platelet monitoring for bleeding episodes. CONCLUSION: The findings indicated several factors influence decisions to transfuse, including clinical context, and individual ability to trust guidelines and assume any perceived risks.

Bereavement in critical care: A narrative review and practice exploration of current provision of support services and future challenges.

This special article outlines the background to bereavement in critical care and scopes the current provision and evidence for bereavement support following death in critical care. Co-authored by a family member and former critical care patient, we aim to draw out the current challenges and think about how and where support can be implemented along the bereavement pathway. We draw on the literature to examine different trajectories of dying in critical care and explore how these might impact bereavement, highlighting important points and risk factors for complicated grief. We present graphic representation of the critical junctures for bereavement in critical care. Adjustment disorders around grief are explored and the consequences for families, including the existing evidence base. Finally, we propose new areas for research in this field.

Hope against hope in cancer at the end of life.

Hope has many facets to it in the context of cancer. This article outlines an instrumental case study for a patient with aggressive lymphoma who rapidly deteriorated to the point of dying. How her and her family's hope was managed is outlined here from various perspectives. Interviews were carried out with the patient's family, medical consultant-in-charge (attending physician) and nurses caring for her at the end of life. The findings outline the transition from hope for cure to hope for a good death and the role that the patient and family's Christian hope played in this. Religiosity and spirituality of hope in terms of Christian hope is explored from the theological perspective. Practical aspects of care in the face of changing hope are discussed. Conclusions are drawn about reframing hope in a changing clinical situation with reference to theories of hope. The importance of acknowledging hope, coping, spirituality and religiosity, especially at end of life, is emphasised.

After critical care: a study to explore patients' experiences of a follow-up service.

AIMS AND OBJECTIVES: To establish patients' experiences after discharge from critical care and to evaluate implementation of a follow-up service. BACKGROUND: Government recommendations advise critical care follow-up to prevent readmission and address problems after discharge. Admission to critical care results in significant psychological and physiological sequelae. DESIGN: A prospective, longitudinal and exploratory study of surgical cancer patients requiring >48 hours in critical care. Qualitative interviews were conducted and short questionnaires were used. METHODS: Patient Expert Advisory Groups were invited to participate in research design. Patients were visited in the ward at days 1 and 5 after discharge, invited to nurse-led follow-up clinic and interviewed at three and six months. Short questionnaires were administered at six and 12 months. FINDINGS: Twenty-seven patients participated in the study. All patients experienced benefit from the service. Emergent themes included: rehabilitation from critical care: physiological issues and needs, memories: real and unreal, uncertainty and fear and empathy. A core theme of reassurance was underlying through the research. Issues while in critical care included: the need for nursing presence, nightmares, delusions, confusion, fear of ward transfer, inability to remember, disorientation and being prepared for the experience. After discharge, issues shifted to longer term needs. Psychological support, in the form of the follow-up clinic, proved useful. The ability to move on with life after discharge varied and uncertainty about the future and their cancer had an impact upon this. Recovery was made easier through the follow-up clinic. Patients required reassurances that their experiences were valid and also wanted reassurances about their cancer. CONCLUSION: Critical care causes various difficulties for patients that may impinge on recovery. Incorporating patients into the design process helps identify needs more closely. Follow-up proved beneficial and highlighted the role nurses have in improving patient experiences after discharge from critical care. Nurses should be vigilant for both immediate and longer-term needs. RELEVANCE TO CLINICAL PRACTICE: This research into nurse-led follow-up clinics after critical care highlights an important, and often neglected, part of the critical illness continuum. Attending such clinics may help reassure patients after discharge from critical care.