Abstract
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Purpose
Over 10% of intensive care unit (ICU) patients die; however, research aimed at assessing and improving the quality of their deaths remains scarce. This study investigated the impact of communication among healthcare professionals and person-centered care provided by ICU nurses on the quality of dying and death (QODD) experienced by ICU patients.
-
Methods
We measured general characteristics of ICU nurses, interprofessional communication, and person-centered care, and identified their impact on the quality of death for patients who died in the ICU. Participants consisted of 103 ICU nurses employed at two tertiary hospitals in South Korea. Data were collected between January and May 2023. Descriptive statistics, the t-test, analysis of variance, the Mann-Whitney U test, Pearson correlation coefficients, and multiple linear regression analyses were conducted using SPSS version 23.0.
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Results
The mean QODD score was 44.73±21.26. QODD was positively correlated with openness (nurse-physician), understanding (nurse-physician), satisfaction (nurse-physician), and person-centered care. Factors significantly influencing QODD included nurse-physician communication, specifically understanding (β=.35, p=.010), and person-centered care (β=.19, p=.033), explaining 20.2% of the total variance (F=7.44, p<.001).
-
Conclusion
Improved communication among healthcare professionals and enhanced person-centered care are essential for improving the QODD for ICU patients. To achieve this, educational initiatives focusing on end-of-life care and communication training programs for healthcare professionals should be implemented.
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Key Words: Communication; Death; Intensive care units; Nurses; Patient-centered care
INTRODUCTION
In South Korea, approximately 744.6 per 100,000 people are admitted to intensive care units (ICUs) annually, and 102.9 per 100,000 die in ICUs [
1]. Despite advancements in technology and treatments, ICUs remain environments in which many patients face death. As ICUs predominantly focus on life-extending interventions, they frequently fall short of adequately supporting end-of-life preparations for patients and their families [
2]. Studies have highlighted the high prevalence of symptoms such as pain, dyspnea, agitation, anxiety, depression, confusion, and fatigue among ICU patients, contributing significantly to poor-quality dying and death [
3]. Quality of death is a multidimensional concept reflecting an individual’s dying experience, including effective pain and symptom management, preservation of autonomy and control, and the ability to die with dignity and respect [
4]. When death becomes imminent and unavoidable, treatment should prioritize alleviating suffering while safeguarding human dignity and autonomy [
4]. Consequently, assessing and examining the quality of death is essential to ensuring meaningful final moments for each patient and for improving healthcare approaches.
Improving the quality of death in ICUs begins with its accurate measurement using a valid and comprehensive assessment tool and by identifying the nursing factors influencing it. However, evaluating the quality of death from the deceased individual's perspective is inherently impossible, and family evaluations can be affected by grief and stress [
5]. Instead, nurses, who closely observe the dying process, may provide more objective assessments [
6]. Given nurses’ close proximity to patients, examining how their care influences the quality of death could offer valuable insights for improvement.
Research on quality of death has primarily examined the influence of various factors from the perspectives of family members or healthcare professionals [
5,
7-
10]. Prior studies on factors influencing the quality of death among terminal ICU patients have mostly concentrated on patient- and treatment-related characteristics. Significant influencing factors include the presence of malignant tumors, the use of life-support devices [
7], invasive procedures such as life-sustaining equipment and cardiopulmonary resuscitation (CPR) [
8], and analgesic administration [
9]. Recently, research examining the impacts of person-centered care and interprofessional communication on the quality of death of terminal patients has increased [
8,
10]. Nevertheless, studies specifically addressing the influence of nurse-related variables on quality of dying and death (QODD) in ICU patient populations remain scarce. In research assessing interprofessional communication’s impact on end-of-life care in ICUs, collaborative and consistent communication among healthcare professionals was found to enhance patients’ end-of-life experiences [
11]. Furthermore, a study conducted among ICU nurses in South Korea reported that nurses’ person-centered care significantly influenced patients’ quality of death [
10].
Effective communication between patients and healthcare professionals is crucial for ensuring a good quality of death [
12]. In ICUs, where verbal communication with patients is often limited and patients are isolated from their families, nurses assume a critical role in decision-making by conveying patients’ wishes to other healthcare professionals and encouraging patient and family involvement [
13]. Interprofessional communication can help uphold the autonomy and dignity of terminally ill patients and support decisions regarding life-prolonging treatments [
12]. Effective communication includes open dialogue, timely information exchange, and shared understanding of care goals among nurses and between nurses and physicians, thus ensuring patient safety and high-quality care [
14]. However, excessive workloads, hierarchical organizational structures, and an emphasis on curative treatments often hinder communication and limit nurses’ ability to advocate effectively for patients [
15]. Therefore, further exploration of the impact of interprofessional communication on patients’ quality of death in ICUs is necessary.
Person-centered care emphasizes respecting patients’ individuality, responding empathically, and ensuring comfort as defined by the patients themselves, based on their values and needs [
16]. In ICUs, person-centered care involves understanding patients’ conditions, offering emotional support, preserving dignity, and encouraging active participation in care [
17]. Such an approach by ICU nurses promotes physical and emotional stability, improving overall patient satisfaction [
18]. However, the ICU environment, characterized by life-support devices and urgent clinical situations, frequently restricts nurse-patient interactions and reduces patients to treatment objects rather than unique individuals [
19]. A task-oriented nursing environment may hinder the delivery of person-centered care, compromising patients’ dignity and respect at the end of life and negatively influencing the quality of death. In light of this, empirical evidence is required to understand how person-centered care delivered by ICU nurses affects quality of death. Therefore, this study aims to assess interprofessional communication, person-centered care, and the quality of death, and to identify factors influencing the quality of death in ICU settings.
METHODS
1. Study Design
This descriptive research study examined the impact of interprofessional communication and person-centered care provided by ICU nurses on the quality of death among ICU patients. This study was reported following the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines (
https://www.strobe-statement.org/).
This study employed a convenience sampling method, targeting nurses who provided care for adult patients (aged ≥18 years) admitted to ICUs of two general hospitals with over 900 beds located in Daegu. Nurses were included if they had cared for patients who stayed in the ICU longer than 6 hours, as shorter durations would not permit meaningful implementation of person-centered care or effective interprofessional communication, both of which are important for assessing the quality of death. Death in children is perceived differently in social and emotional terms, often involving greater feelings of loss and frustration. Consequently, perceptions of death quality and decision-making surrounding end-of-life care may differ significantly. For these reasons, patients younger than 18 years were excluded from this study. Additionally, to ensure familiarity with the organizational structure and promote team cohesion, only nurses with over 6 months of ICU experience were included [
20].
The required sample size was calculated using G*Power 3.1.9.7, assuming an effect size of 0.25 based on prior studies [
10], an α error of 0.05, power of 0.85, and 14 predictors (including 9 subscales for interprofessional communication, person-centered care, patient characteristics such as ICU stay duration, age, and CPR administration within 24 hours before death, and nurses’ clinical experience). The calculated sample size necessary for regression analysis was 94 [
21]. Accounting for an approximate dropout rate of 10%, 105 questionnaires were distributed, and 103 valid responses were included in the final analysis after excluding two duplicates.
1) Quality of death
Patients’ quality of death was assessed using the Korean version of the QODD instrument, version 3.2, developed by Patrick et al. [
5] and adapted specifically for ICU nurses. The Korean version, translated and validated by Cho et al. [
6], was used with permission from the original authors and translators. The QODD questionnaire is a validated instrument that evaluates end-of-life experiences from the perspectives of family members and healthcare providers, encompassing domains such as symptom control, preparation, connectedness, and transcendence [
22]. The 25-item tool consists of four subdomains: patient experiences during ICU stay (15 items), medical treatment at death (5 items), experiences at the moment of death (3 items), and overall evaluation of care (2 items). Each item comprises two questions: one assessing whether a specific experience occurred and another assessing the quality of the experience, rated from 0 (“terrible”) to 10 (“almost perfect”). Total scores, calculated according to the SPSS scoring method for QODD version 3.2 [
23], range from 0 to 100, with higher scores indicating better quality of death. Cronbach’s α reliability was .89 in the original development study [
22], above .80 in the Korean version [
6], and .91 in the current study. Although the original instrument permits one nurse to assess multiple patients, this study measured only one patient per nurse to precisely evaluate the impact of caregiving on death quality.
2) Interprofessional communication
Communication among healthcare providers was evaluated using the Korean version of the ICU Nurse-Physician Questionnaire, originally developed by Shortell et al. [
14] and adapted by Cho et al. [
24]. Permission to use this tool was obtained from the original authors and translators. The tool includes 30 items divided into nine subscales: openness (nurse-physician, nurse-nurse), accuracy (nurse-physician, nurse-nurse), understanding (nurse-physician), shift communication (nurse-nurse), timeliness (nurse-nurse and physician), and satisfaction (nurse-physician, nurse-nurse). Interpretation of the tool relies on subscale scores rather than a total score. Each item is rated on a 5-point Likert scale from 1 (“strongly disagree”) to 5 (“strongly agree”), with higher scores indicating more positive perceptions of communication. Seven negatively worded items (2, 4, 7, 18, 20, 22, and 24) were reverse-scored. Cronbach’s α ranged from .64 to .88 in the original version [
14], from .59 to .89 in Cho et al. [
24], and from .58 to .91 in the present study.
3) Person-centered care
Person-centered care was assessed using the Person-centered Critical Care Nursing (PCCN) tool developed by Kang et al. [
16], reflecting the local conditions and cultural context of ICU nurses. Permission for use was obtained from the original authors. This tool comprises 15 items grouped into four subscales: compassion (4 items), individuality (4 items), respect (4 items), and comfort (3 items). Items are rated on a 5-point Likert scale ranging from 1 (“not at all”) to 5 (“very much”), with higher scores indicating greater provision of person-centered care by ICU nurses. Cronbach’s α reliability was .84 in the original development study [
16] and .82 in this study.
Survey data were collected from January 2 to May 15, 2023, from nurses working in seven ICU units—medical ICU (MICU), surgical ICU, emergency ICU, neurosurgical ICU, trauma ICU (TICU), coronary care unit/stroke unit, and cardiac ICU—at two general hospitals in Daegu. Approval was obtained from the nursing departments of each hospital. The researcher visited each ICU to explain the study purpose and methods, and personally distributed questionnaires.
The questionnaires were placed in sealed envelopes in the head nurse’s office. It was emphasized that each nurse should complete the QODD for only one deceased patient. The head nurse oversaw questionnaire distribution to prevent duplication. Nurses completed questionnaires within 48 hours following a patient’s death. The attending nurse at the time of death was prioritized; however, if unavailable (e.g., due to vacation or limited patient familiarity), another nurse who had cared for the deceased patient completed the questionnaire. Participants provided written informed consent, completed the questionnaire, and sealed it individually. The researcher visited the ICUs biweekly to collect questionnaires and monitor participation rates. Participants received a small gift coupon upon completing the questionnaire.
5. Ethical Considerations
The Institutional Review Board (IRB) of Kyungpook University Hospital (KNUH 2022-11-018-001, KNUCH 2022-11-029-001) approved this study. Participants were recruited after being informed about the study purpose and procedures, and voluntarily provided written consent. Participants were informed of their right to withdraw at any time without penalty and were assured that no associated costs or risks would occur. Data and personal information were coded, stored securely, and will be disposed of safely after three years.
6. Data Analysis
Data were analyzed using IBM SPSS Win 23.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics (frequencies, percentages, means, standard deviations) summarized the general characteristics of participants and terminally ill patients. Levels of interprofessional communication, person-centered care, and quality of death were expressed using means and standard deviations. Differences based on participants’ general characteristics were examined using the independent-sample t-test, Analysis of Variance (ANOVA), and the Mann-Whitney U test. Similarly, differences in quality of death based on patients’ general and disease-related characteristics were analyzed using the t-test and ANOVA. Pearson’s correlation coefficients were used to assess relationships among quality of death, interprofessional communication, and person-centered care. The effects of communication and person-centered care on terminally ill ICU patients’ quality of death were evaluated using multiple linear regression.
RESULTS
1. Quality of Death According to the General Characteristics of ICU Nurses, and Deceased Patients’ Characteristics
The study participants were predominantly female nurses (84.5%), with a mean age of 28.12±4.52 years. Most nurses had no religious affiliation (78.7%) and had completed a bachelor's degree (97.1%). The average clinical experience of nurses was 58.66±50.80 months. Nearly all nurses (97.1%) reported not having received any post-graduation education on end-of-life care. No statistically significant differences were observed in QODD scores based on the nurses’ general characteristics.
Among the 103 deceased patients, 58.3% were male, with a mean age of 63.85±19.45 years. The mean duration of hospitalization was 11.63±15.35 days, and the average ICU stay was 8.16±11.18 days. The most common ICU type was the TICU (21.3%), followed by the MICU (19.4%). Of these patients, 24.3% received CPR, and 82.5% utilized life-support devices within 24 hours before death. QODD scores did not significantly differ based on patients’ general or disease-related characteristics (
Table 1).
The mean QODD score for the 103 patients was 44.73±21.26 out of 100. Valid sample sizes for individual items ranged from 49 to 103. Among the QODD domains, the item scoring highest was “having desired people present at the time of death” (6.89±2.75). Conversely, the items with the lowest scores were “being able to feed oneself” (1.90±2.81) and “having a spiritual service or ceremony before death” (2.82±3.23). In terms of medical care experiences at the end of life, “receiving mechanical ventilation” and “receiving dialysis” were rated relatively higher (5.05±2.77 and 5.28±2.69, respectively), whereas discussions with doctors about end-of-life care occurred less frequently (3.57±2.61) (
Table 2).
Interprofessional communication scores exhibited variability, with nurse-nurse communication rated higher in openness (3.85±0.69) and accuracy (3.35±0.61) compared to nurse-physician communication (2.86±0.79 and 2.85±0.60, respectively). Satisfaction with communication was also rated higher in nurse-nurse interactions (3.88±0.67) than in nurse-physician interactions (2.77±0.84).
The mean person-centered care score was 3.47±0.44 out of 5. Among the subscales, the highest ratings were for comfort (3.77±0.62) and respect (3.74±0.60), followed by compassion (3.37±0.57) and individuality (3.03±0.63) (
Table 3).
Among communication-related variables, significant positive correlations were identified between QODD and openness in nurse-physician communication (
r=.20,
p=.040) and understanding in nurse-physician communication (
r=.39,
p<.001). Additionally, satisfaction with nurse-physician communication showed a moderate positive correlation with QODD (
r=.36,
p<.001). The total PCCN score was positively correlated with QODD (
r=.27,
p=.005), indicating that higher levels of compassion, individuality, respect, and comfort in patient care correlated with improved QODD outcomes (
Table 4).
The factors influencing QODD in terminally ill ICU patients were analyzed using multiple linear regression. Predictor variables included those significantly correlated with QODD in the univariate analyses: openness, understanding, and satisfaction in nurse-physician communication, and PCCN. Tolerance values ranged from 0.43 to 0.93, and variance inflation factors ranged from 1.06 to 2.31, indicating that multicollinearity was not a concern. The Durbin-Watson statistic (2.08) confirmed residual independence. The regression model was statistically significant (F=7.44,
p<.001), explaining 20.2% of the variance (adjusted R²=.202). Among the subscales of interprofessional communication, understanding in nurse-physician communication was the most influential factor (β=.35,
p=.010), followed by person-centered care (β=.19,
p=.033), with significant impacts on quality of death in ICU patients (
Table 5).
DISCUSSION
This study aimed to assess interprofessional communication, person-centered care, and the quality of death in ICUs, as well as to identify key factors influencing quality of death, thereby informing future interventions in end-of-life care. The findings indicated that mutual understanding among healthcare professionals—particularly between nurses and physicians—and person-centered care significantly affected patients’ quality of death. The discussion below expands on these results.
In this study, all dimensions of interprofessional communication—including openness, accuracy, mutual understanding, and satisfaction—scored below 4 (“agree”) for nurse-to-nurse communication, and below 3 (“neutral”) for nurse-to-physician communication. These findings align with previous research assessing nurses’ perceptions of interprofessional communication in Korean general hospitals [
24]. Such scores suggest the need for improvement in both nurse-to-nurse and nurse-to-physician communication. However, the particularly low nurse-to-physician communication scores underscore an urgent need for targeted interventions. Lower scores in nurse-physician communication compared to nurse-nurse interactions may result from factors such as heavy workloads, physicians’ primary focus on disease treatment, and hierarchical structures within clinical environments [
13]. Improving interprofessional communication—especially between nurses and physicians—is crucial for promoting collaboration, facilitating shared decision-making, and ultimately improving the quality of death for ICU patients.
The level of person-centered care reported in this study was similar to that found in a previous Korean study [
25], which evaluated person-centered care among ICU nurses and identified related predictors. Among subscales, the “individuality” domain scored lowest, likely due to ICU restrictions limiting patients’ personal preferences and activities, including family visitation [
19]. To overcome these challenges, practical interventions such as the “Get to Know Me Board,” which displays personal details like nicknames and hobbies, can reinforce patient identity beyond clinical status [
26]. Supporting patient individuality, adapting care within ICU constraints, and allowing more flexible visitation policies could enhance patients’ quality of death in ICU settings.
In this study, the quality of death score in the ICU was approximately 45 points, considerably lower than the scores of approximately 60–70 points reported in studies from the United States and the Netherlands [
27]. One key reason for the comparatively lower quality of death in Korean ICUs appears to be inadequate education and training regarding end-of-life care [
6,
9,
10]. Indeed, 97% of the nurses in this study had never received end-of-life care training since graduating from nursing school. In South Korea, fewer than one-quarter of undergraduate nursing programs offer courses on end-of-life care [
28], indicating that insufficient nursing education likely contributes to the lower quality of death experienced by ICU patients. Previous studies have shown that end-of-life care education significantly improves nurses’ knowledge and performance regarding palliative care [
29], while systematic approaches to managing terminal care help reduce stress, anxiety, and depression among patients and their families, thus improving quality of death [
30]. Providing ICU nurses with explicit guidelines and targeted education on communication and mourning practices is therefore essential. Additionally, the decision-making process surrounding end-of-life care in Korea may be another contributing factor. Unlike Western cultures that prioritize individual autonomy, Korean culture typically avoids direct discussions about prognosis and death, and the views of family members and medical staff usually outweigh patient preferences in treatment decisions [
31]. The score for patient-doctor discussions about end-of-life wishes in this study was below 40%, substantially lower than scores from international studies employing the same instrument [
27]. As of December 2024, over 2.5 million advance directives have been registered since the enactment of the Life-Sustaining Treatment Decision Act in 2008 [
32]. However, public and professional awareness about this Act remains limited, and insufficient training and experience continue to hinder its effective implementation [
33]. Expanding educational efforts and promoting awareness of the Act among the public and medical institutions are essential steps for improving decision-making and care quality for terminally ill patients.
In this study, the score for religious and spiritual care among the QODD sub-items was below 3 points, notably lower than in a U.S. study, where the median score was 8, with an interquartile range of 5 to 10 [
27]. In Korea, hospitalized patients frequently express moderate to high spiritual needs, encompassing love, holistic care, forgiveness, and the search for meaning and purpose [
34]. However, variations in hospital policies regarding religious groups and differences in nurses’ perceptions of spiritual care, shaped by religious backgrounds and experiences with end-of-life care, hinder consistent spiritual support [
15]. Addressing these barriers requires a national evaluation of hospitals’ spiritual support systems and the integration of spiritual nursing education into undergraduate curricula.
The regression analysis identified interprofessional communication—specifically mutual understanding between nurses and physicians—as the most significant factor influencing ICU patients’ quality of death, followed by person-centered care. Higher levels of mutual understanding between nurses and physicians correlated with better quality of death. Mutual understanding here refers to a shared comprehension of care goals and plans, effective communication during shift changes, and a collaborative approach among healthcare professionals [
16]. Collaboration characterized by mutual understanding and respect improves nursing performance and organizational commitment [
35]. Such understanding facilitates the effective exchange of patient-related information, promotes proactive attitudes toward end-of-life care, and supports life-sustaining treatment decisions aligned with patients’ values and preferences, thus enhancing death preparedness. Promoting mutual respect between nurses and physicians is therefore essential. Regular communication opportunities should be established, and targeted programs aimed at improving interprofessional communication should be implemented.
Additionally, the finding that ICU nurses who provide higher levels of person-centered care contribute to improved quality of death aligns with results from a previous study examining factors influencing ICU patients’ quality of death through an online survey among ICU nurses in South Korea [
10]. ICU patients have distinct characteristics, such as experiencing severe symptoms, communication challenges, isolation from their families, and receiving care primarily focused on life-sustaining treatments [
2]. Under these challenging conditions, person-centered care significantly contributes to improving quality of death. Specifically, person-centered care alleviates patients’ emotional distress through compassionate interactions, preserves patients’ identities by employing strategies that respect individual differences (e.g., the “Get to Know Me Board”), and enhances autonomy and trust by aligning care with patient values and preferences. Additionally, effective symptom management and the creation of a comfortable care environment foster patient comfort and facilitate a more peaceful dying process within the ICU. Therefore, enhancing person-centered care in ICU settings requires targeted educational programs and training to increase nurses’ sensitivity to individual patient needs, alongside the development of institutional policies that support personalized care practices even in high-acuity environments.
This study is academically significant within the field of nursing as it highlights the influence of nurses on ICU patients’ quality of death. From a practical standpoint, these findings suggest that when nurses treat patients not merely as individuals with diseases but holistically as human beings—and when nurses and physicians actively strive to share understanding and knowledge across disciplines—the quality of death can be enhanced.
Despite these strengths, this study has several limitations. First, it was conducted in only two hospitals, thus limiting generalizability. Second, patient quality of death was assessed exclusively by nurses, potentially introducing subjective bias. Third, two items in the QODD assessment had valid response rates below 50%, with a median of 71 valid responses overall. Due to the design of the QODD tool, responses are recorded only when patients have specific experiences or nurses possess sufficient information to evaluate those experiences, resulting in a lower number of valid responses [
5]. However, the number of valid responses in this study is consistent with previous studies [
7,
9]. Lastly, the study’s exclusive focus on nursing practices such as communication and person-centered care restricts interpretation regarding other relevant factors, such as patient consciousness, decisions about life-sustaining treatments, and CPR refusal.
CONCLUSION
This study aimed to examine the relationships among interprofessional communication, person-centered care, and the quality of death among ICU patients, emphasizing the role of ICU nurses. Furthermore, it sought to identify nurse-related factors influencing ICU patients’ quality of death. The results demonstrated that higher mutual understanding between nurses and physicians, as well as greater implementation of person-centered care, were significantly associated with improved quality of death for ICU patients. Therefore, this study underscores the importance of developing targeted strategies to enhance interprofessional communication and support person-centered care practices, ultimately improving ICU patients’ quality of death.
Based on these findings, several recommendations are proposed. First, as this study was limited to ICU nurses in specific regions, future research should expand geographic scope and participant sampling. Second, considering the identified lack of end-of-life education for nurses in Korea, future studies should focus on developing and evaluating the effectiveness of comprehensive end-of-life educational programs for clinical nurses. Third, given the impact of interprofessional communication and person-centered care on patients’ quality of death, research should be conducted to develop educational programs facilitating effective communication and evaluate the efficacy of flexible visitation policies, nursing practices tailored to individual patient needs, and interventions involving family participation in treatment. Fourth, due to the limited research on quality of death in ICU settings, further quantitative and qualitative studies addressing diverse variables are required to establish a systematic foundation for improving the quality of death.
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CONFLICTS OF INTEREST
The authors declared no conflict of interest.
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AUTHORSHIP
Study conception and/or design acquisition - HJK and SHK; analysis - HJK; interpretation of the data - HJK; and drafting or critical revision of the manuscript for important intellectual content - HJK and SHK.
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FUNDING
None.
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ACKNOWLEDGEMENT
This article is a revision of Hye-Jin Kim’s master’s thesis from Kyungpook National University.
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DATA AVAILABILITY STATEMENT
The data can be obtained from the corresponding authors.
Table 1.Quality of Death Based on Deceased Patients’ Characteristics and the General Characteristics of ICU Nurses (N=103)
|
Characteristics |
Categories |
n (%) or M±SD |
QODD |
|
M±SD |
t/Z or F (p) |
|
ICU nurses |
Sex |
Men |
16 (15.5) |
47.94±22.45 |
0.82 (.414) |
|
Women |
87 (84.5) |
42.99±22.11 |
|
Age (year) |
≤25 |
30 (29.1) |
45.38±22.37 |
2.86 (.062) |
|
26–29 |
47 (45.7) |
47.53±22.78 |
|
≥30 |
26 (25.2) |
35.08±18.80 |
|
28.12±4.52 |
|
|
Religion |
Yes |
22 (21.4) |
47.58±18.89 |
0.91 (.365) |
|
No |
81 (78.6) |
42.73±22.92 |
|
Clinical career (month) |
6–12 |
13 (12.6) |
44.25±28.45 |
0.97 (.413†) |
|
13–36 |
25 (24.3) |
45.67±16.70 |
|
37–60 |
32 (31.1) |
47.01±26.62 |
|
≥61 |
33 (32.0) |
38.98±18.01 |
|
58.66±50.80 |
|
|
Education |
Bachelor |
100 (97.1) |
44.84±21.37 |
–0.11 (.919‡) |
|
≥Master |
3 (2.9) |
41.31±20.43 |
|
Training in end-of-life care |
Yes |
3 (2.9) |
53.83±41.06 |
–0.55 (.595‡) |
|
No |
100 (97.1) |
44.46±20.71 |
|
Deceased patients assigned to ICU nurses |
Sex |
Men |
60 (58.3) |
43.78±21.60 |
–0.53 (.595) |
|
Women |
43 (41.7) |
46.06±20.95 |
|
Age (year) |
18–40 |
16 (15.5) |
49.69±21.00 |
0.98 (.404) |
|
41–60 |
13 (12.7) |
51.24±26.81 |
|
61–75 |
41 (39.8) |
41.98±22.00 |
|
≥76 |
33 (32.0) |
43.20±17.81 |
|
63.85±19.45 |
|
|
Length of hospital stay (day) |
≤3 |
38 (36.9) |
47.50±21.62 |
0.97 (.381) |
|
4–10 |
33 (32) |
45.62±23.57 |
|
≥11 |
32 (31.1) |
40.54±18.07 |
|
11.63±15.35 |
|
|
Length of ICU stay (day) |
≤4 |
55 (53.4) |
46.19±21.32 |
0.74 (.459) |
|
>4 |
48 (46.6) |
43.06±21.29 |
|
8.16±11.18 |
|
|
Type of ICU |
CCU/SU |
17 (16.5) |
50.22±20.39 |
2.18 (.051) |
|
CICU |
4 (3.9) |
49.43±21.36 |
|
EICU |
18 (17.5) |
40.83±19.56 |
|
MICU |
20 (19.4) |
37.33±19.75 |
|
NSICU |
5 (4.9) |
29.67±6.54 |
|
SICU |
17 (16.5) |
42.15±24.94 |
|
TICU |
22 (21.3) |
54.98±20.11 |
|
Primary diagnosis |
CVD |
36 (34.9) |
48.20±20.49 |
1.49 (.229) |
|
Cancer |
12 (11.7) |
36.08±15.27 |
|
Others |
55 (53.4) |
44.35±22.56 |
|
CPR within 24 hours of death |
Yes |
25 (24.3) |
39.56±18.01 |
–1.40 (.163) |
|
No |
78 (75.7) |
46.39±22.04 |
|
LSE within 24 hours of death |
Yes |
85 (82.5) |
44.10±21.58 |
0.65 (.512) |
|
No |
18 (17.5) |
47.74±19.92 |
|
Number of LSE§ (n=85) |
<2 |
52 (61.2) |
45.02±21.39 |
0.19 (.845) |
|
≥2 |
33 (38.8) |
44.13±21.28 |
Table 2.Levels of Quality of Death (N=103)
|
QODD |
M±SD |
No. of valid |
Range |
|
Total score |
44.73±21.26 |
103 |
0–100 |
|
Patient experiences at the end of life |
|
Having pain under control |
4.96±2.58 |
68 |
0–10 |
|
Having control over what is going on around oneself |
3.17±2.59 |
53 |
0–10 |
|
Being able to feed oneself |
1.90±2.81 |
63 |
0–10 |
|
Being able to breath comfortably |
4.20±3.20 |
88 |
0–10 |
|
Feeling at peace with dying |
3.80±3.22 |
54 |
0–10 |
|
Feeling unafraid of dying |
4.06±3.04 |
50 |
0–10 |
|
Being able to laugh and smile |
2.93±3.23 |
58 |
0–10 |
|
Keeping one’s dignity and self-respect |
3.97±3.17 |
62 |
0–10 |
|
Spending time with family and friends |
4.85±3.57 |
87 |
0–10 |
|
Spending time alone |
4.18±2.98 |
71 |
0–10 |
|
Being touched or hugged by loved ones |
4.77±3.57 |
86 |
0–10 |
|
Saying goodbye to loved ones |
3.72±3.76 |
71 |
0–10 |
|
Clearing up bad feelings |
3.08±3.36 |
49 |
0–10 |
|
Having one or more visits from a religious or spiritual advisor |
2.97±3.40 |
63 |
0–10 |
|
Having a spiritual service or ceremony before death |
2.82±3.23 |
68 |
0–10 |
|
Medical care at the end of life |
|
Experience of receiving mechanical ventilation |
5.05±2.77 |
83 |
0–10 |
|
Experience of receiving dialysis |
5.28±2.69 |
64 |
0–10 |
|
Having discussed end-of-life care wishes with your doctor |
3.57±2.61 |
60 |
0–10 |
|
Experience at moment of death |
|
Having desired people present at the time of death |
6.89±2.75 |
87 |
0–10 |
|
State at moment of death (i.e., asleep, awake, unconscious) |
4.88±2.50 |
80 |
0–10 |
Table 3.Level of CHP and PCCN (N=103)
|
Variables |
M±SD |
Range |
|
CHP |
Openness (N-P) |
2.86±0.79 |
1–5 |
|
Openness (N-N) |
3.85±0.69 |
1–5 |
|
Accuracy (N-P) |
2.85±0.60 |
1–5 |
|
Accuracy (N-N) |
3.35±0.61 |
1–5 |
|
Shift Communication (N-N) |
3.83±0.61 |
1–5 |
|
Understanding (N-P) |
2.87±0.69 |
1–5 |
|
Timeliness (N-N & N-P) |
3.85±0.56 |
1–5 |
|
Satisfaction (N-P) |
2.77±0.84 |
1–5 |
|
Satisfaction (N-N) |
3.88±0.67 |
1–5 |
|
PCCN |
Compassion |
3.37±0.57 |
1–5 |
|
Individuality |
3.03±0.63 |
1–5 |
|
Respect |
3.74±0.60 |
1–5 |
|
Comfort |
3.77±0.62 |
1–5 |
|
Total |
3.47±0.44 |
1–5 |
Table 4.Correlations among Variables
|
Variables |
r (p) |
|
1.1 |
1.2 |
1.3 |
1.4 |
1.5 |
1.6 |
1.7 |
1.8 |
1.9 |
2 |
3 |
|
1 |
CHP |
|
|
|
|
|
|
|
|
|
|
|
|
1.1 |
Openness (N-P) |
1 |
|
|
|
|
|
|
|
|
|
|
|
1.2 |
Openness (N-N) |
.44 (<.001) |
1 |
|
|
|
|
|
|
|
|
|
|
1.3 |
Accuracy (N-P) |
.21 (.032) |
.03 (.738) |
1 |
|
|
|
|
|
|
|
|
|
1.4 |
Accuracy (N-N) |
.08 (.381) |
.18 (.069) |
.50 (<.001) |
1 |
|
|
|
|
|
|
|
|
1.5 |
Shift Communication (N-N) |
.41 (<.001) |
.63 (<.001) |
.21 (.030) |
.27 (.005) |
1 |
|
|
|
|
|
|
|
1.6 |
Understanding (N-P) |
.68 (<.001) |
.33 (.001) |
.33 (.001) |
.14 (.152) |
.41 (<.001) |
1 |
|
|
|
|
|
|
1.7 |
Timeliness (N-N & N-P) |
.43 (<.001) |
.48 (<.001) |
.24 (.014) |
.12 (.218) |
.52 (<.001) |
.48 (<.001) |
1 |
|
|
|
|
|
1.8 |
Satisfaction (N-P) |
.65 (<.001) |
.33 (.001) |
.36 (<.001) |
.17 (.071) |
.37 (<.001) |
.68 (<.001) |
.46 (<.001) |
1 |
|
|
|
|
1.9 |
Satisfaction (N-N) |
.30 (.002) |
.72 (<.001) |
.01 (.952) |
.26 (.007) |
.72 (<.001) |
.27 (.006) |
.49 (<.001) |
.34 (<.001) |
1 |
|
|
|
2 |
PCCN |
.22 (.023) |
.30 (.002) |
.25 (.010) |
.32 (.001) |
.20 (.035) |
.23 (.017) |
.34 (<.001) |
.20 (.040) |
.28 (.004) |
1 |
|
|
3 |
QODD |
.20 (.040) |
.18 (.067) |
.16 (.088) |
.10 (.303) |
.06 (.511) |
.39 (<.001) |
.18 (.064) |
.36 (<.001) |
.18 (.068) |
.27 (.005) |
1 |
Table 5.Factors Affecting Quality of Death (N=103)
|
Variables |
B |
SE |
ß |
t |
p
|
|
Constant |
–17.04 |
15.35 |
|
–1.11 |
.270 |
|
CHP |
|
|
|
|
|
|
Openness (N-P) |
–6.29 |
3.46 |
–.23 |
–1.81 |
.072 |
|
Understanding (N-P) |
10.73 |
4.11 |
.35 |
2.61 |
.010 |
|
Satisfaction (N-P) |
5.96 |
3.26 |
.23 |
1.82 |
.071 |
|
PCCN |
9.35 |
4.32 |
.19 |
2.16 |
.033 |
|
F (p) |
7.44 (<.001) |
|
R2
|
.233 |
|
Adj.R2
|
.202 |
|
Durbin-Watson |
2.08 |
REFERENCES
- 1. Park J, Jeon K, Chung CR, Yang JH, Cho YH, Cho J, et al. A nationwide analysis of intensive care unit admissions, 2009-2014: the Korean ICU National Data (KIND) study. J Crit Care. 2018;44:24-30. https://doi.org/10.1016/j.jcrc.2017.09.017
- 2. Seol EM, Koh CK. Experiences of critical care nurses caring for dying patients. J Korean Crit Care Nurs. 2018;11(2):1-10.
- 3. Cran A. The prevalence of symptoms in intensive care unit patients: a systematic review and meta-analysis. BMJ Support Palliat Care. 2020;10:A8.
- 4. Stewart AL, Teno J, Patrick DL, Lynn J. The concept of quality of life of dying persons in the context of health care. J Pain Symptom Manage. 1999;17(2):93-108. https://doi.org/10.1016/s0885-3924(98)00131-6
- 5. Patrick DL, Engelberg RA, Curtis JR. Evaluating the quality of dying and death. J Pain Symptom Manage. 2001;22(3):717-26. https://doi.org/10.1016/s0885-3924(01)00333-5
- 6. Cho JY, Lee J, Lee SM, Park JH, Kim J, Kim Y, et al. Transcultural adaptation and validation of quality of dying and death questionnaire in medical intensive care units in South Korea. Acute Crit Care. 2018;33(2):95-101. https://doi.org/10.4266/acc.2017.00612
- 7. Lee YJ, Ahn S, Cho JY, Park TY, Yun SY, Kim J, et al. Change in perception of the quality of death in the intensive care unit by healthcare workers associated with the implementation of the "well-dying law". Intensive Care Med. 2022;48(3):281-9. https://doi.org/10.1007/s00134-021-06597-7
- 8. Naya K, Sakuramoto H, Aikawa G, Ouchi A, Yoshihara S, Ota Y, et al. Family members' feedback on the "quality of death" of adult patients who died in intensive care units and the factors affecting the death quality: a systematic review and meta-analysis. Cureus. 2024;16(4):e58344. https://doi.org/10.7759/cureus.58344
- 9. Cho JY, Park JH, Kim J, Lee J, Park JS, Cho YJ, et al. Factors associated with quality of death in Korean ICUs as perceived by medical staff: a multicenter cross-sectional survey. Crit Care Med. 2019;47(9):1208-15. https://doi.org/10.1097/CCM.0000000000003853
- 10. Lee H, Choi SH. Factors associated with quality of dying and death in Korean intensive care units: perceptions of nurses. Healthcare (Basel). 2021;9(1):40. https://doi.org/10.3390/healthcare9010040
- 11. Boyle DK, Miller PA, Forbes-Thompson SA. Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes. Crit Care Nurs Q. 2005;28(4):302-16. https://doi.org/10.1097/00002727-200510000-00002
- 12. Moon JY, Kim JO. Ethics in the intensive care unit. Tuberc Respir Dis. 2015;78(3):175-9. https://doi.org/10.4046/trd.2015.78.3.175
- 13. Frank RK. Shared decision making and its role in end of life care. Br J Nurs. 2009;18(10):612-8. https://doi.org/10.12968/bjon.2009.18.10.42466
- 14. Shortell SM, Rousseau DM, Gillies RR, Devers KJ, Simons TL. Organizational assessment in intensive care units (ICUs): construct development, reliability, and validity of the ICU nurse-physician questionnaire. Med Care. 1991;29(8):709-26. https://doi.org/10.1097/00005650-199108000-00004
- 15. Ahn K, Kong BH, Song YJ. A study on the life-sustaining treatment decision-making and end-of-life care experiences of intensive care nurses after the enforcement of the life-sustaining treatment decision-making act. J Korean Bioeth Assoc. 2020;21(2):31-53. https://doi.org/10.37305/jkba.2020.12.21.2.31
- 16. Kang J, Cho YS, Jeong YJ, Kim SG, Yun S, Shim M. Development and validation of a measurement to assess person-centered critical care nursing. J Korean Acad Nurs. 2018;48(3):323-34. https://doi.org/10.4040/jkan.2018.48.3.323
- 17. Hong HJ, Kang J. A qualitative content analysis of the person-centered care experienced by critical care patients. J Korean Crit Care Nurs. 2018;11(2):21-33.
- 18. Jeon KB, Park MH. A concept analysis of person-centered care in intensive care units. Pers Bioeth. 2021;11(1):129-76.
- 19. Jakimowicz S, Perry L. A concept analysis of patient-centred nursing in the intensive care unit. J Adv Nurs. 2015;71(7):1499-517. https://doi.org/10.1111/jan.12644
- 20. Yang YS, Kang YH. ICU new nurses' job stress, job satisfaction, organizational commitment and turnover intention. Nurs Sci. 2013;25(2):47-58.
- 21. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149-60. https://doi.org/10.3758/BRM.41.4.1149
- 22. Downey L, Curtis JR, Lafferty WE, Herting JR, Engelberg RA. The Quality of Dying and Death Questionnaire (QODD): empirical domains and theoretical perspectives. J Pain Symptom Manage. 2010;39(1):9-22. https://doi.org/10.1016/j.jpainsymman.2009.05.012
- 23. UW School of Medicine. Healthcare professional after-death self-administered questionnaire [Internet]. Washington, D.C: UW School of Medicine; 2023 [cited 2023 August 16]. Available from: https://depts.washington.edu/eolcare/products/instruments/
- 24. Cho YA, Kim MK, Cho MS, Nam EY. Nurses' communications with health professionals. J Korean Clin Nurs Res. 2013;19(1):20-32. https://doi.org/10.22650/JKCNR.2013.19.1.20
- 25. Youn H, Lee M, Jang SJ. Person-centred care among intensive care unit nurses: a cross-sectional study. Intensive Crit Care Nurs. 2022;73:103293. https://doi.org/10.1016/j.iccn.2022.103293
- 26. Ahmad SR, Rhudy L, Fogelson LA, LeMahieu AM, Barwise AK, Gajic O, et al. Humanizing the intensive care unit: perspectives of patients and families on the get to know me board. J Patient Exp. 2023;10:23743735231201228. https://doi.org/10.1177/23743735231201228
- 27. Gerritsen RT, Koopmans M, Hofhuis JG, Curtis JR, Jensen HI, Zijlstra JG, et al. Comparing quality of dying and death perceived by family members and nurses for patients dying in US and Dutch ICUs. Chest. 2017;151(2):298-307. https://doi.org/10.1016/j.chest.2016.09.003
- 28. Kim MW, Park JM, Han AK. Analysis of curriculum of 4-year nursing schools. J Korean Acad Soc Nurs Educ. 2011;17(3):414-23. https://doi.org/10.5977/jkasne.2011.17.3.414
- 29. Woo YW, Kim KH, Kim KS. Death anxiety and terminal care stress among nurses and the relationship to terminal care performance. Korean J Hosp Palliat Care. 2013;16(1):33-41. https://doi.org/10.14475/kjhpc.2013.16.1.033
- 30. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345. https://doi.org/10.1136/bmj.c1345
- 31. Kim SH, Kim SH. The attitude of primary caregivers of critically ill elderly patients on do-not-resuscitate status. J Korean Geriatr Soc. 2008;12(4):215-21.
- 32. National Agency for Management of Life-Sustaining Treatment. Advance directives: monthly statistics [Internet]. Seoul: Korea National Institute for Bioethics Policy; 2024 [cited 2024 January 20]. Available from: https://www.lst.go.kr/comm/monthlyStatistics.do
- 33. Jeon H, Choi J, Lee I. Experiences with a life-sustaining treatment decision system: focus group interview. Bio Ethics Policy. 2023;7(1):25-47. https://doi.org/10.23183/konibp.2023.7.1.002
- 34. Song HS, Kim KH. A study for the spiritual well-being and the spiritual needs of inpatients. Chung-Ang J Nurs. 2002;6(2):27-35.
- 35. Kwon EO, Lee MH, Jeong SH, Kim HS. Effects of nurse-physician collaboration on nursing performance and organizational commitment in intensive care unit nurses. J Korean Acad Nurs Adm. 2019;25(3):186-97. https://doi.org/10.11111/jkana.2019.25.3.186
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