Review article
Interprofessional interventions and factors that improve end-of-life care in intensive care units: An integratory review
Intervenciones interprofesionales y factores que mejoran los cuidados al final de la vida en unidades de cuidados intensivos: revisión integradora
S.M. Hernández-Zambranoa,
, A.J. Carrillo-Algarraa, O.E. Manotas-Solanob, S.E. Ibáñez-Gamboab, L.M. Mejia-Mendezb, O.H. Martínez-Montoyab, M. Fernández-Alcántarac, C. Hueso-Montorod
Corresponding author
a Grupo Perspectivas del Cuidado, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
b Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
c Departamento de Psicología de la Salud, Universidad de Alicante, Alicante, Spain
d Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Jaén, Instituto de Investigación Biosanitaria de Granada (Ibs.GRANADA), Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC), Jaén, Spain
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"apellidos" => "Hueso-Montoro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Grupo Perspectivas del Cuidado, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Psicología de la Salud, Universidad de Alicante, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Jaén, Instituto de Investigación Biosanitaria de Granada (Ibs.GRANADA), Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC), Jaén, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intervenciones interprofesionales y factores que mejoran los cuidados al final de la vida en unidades de cuidados intensivos: revisión integradora" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2522 "Ancho" => 2507 "Tamanyo" => 301883 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Search flowchart.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Introduction</span><p id="par0015" class="elsevierStylePara elsevierViewall">The Intensive Care Unit (ICU) is a complex area whose goal is to preserve life; however, it generates stress and suffering for the patient and family due to organ dysfunction that can even lead to imminent death.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The changes in health dynamics caused by the SARS-COVID-2 pandemic and its consequences (including isolation and lack of communication between patient, family, and environment) brought about a greater need to integrate palliative care in the ICU area.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Several studies have shown that relatives of ICU patients have to cope with emotions such as distress with regard to their loved one's health, anxiety, stress, isolation, loneliness, and feelings of helplessness.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore, especially in end-of-life situations in the ICU, the company and support of primary caregivers can provide the patient with greater peace of mind and acceptance of their health condition, and help them work through their fears and coping strategies in the face of death, enabling a process of saying goodbye.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">These types of interventions, directly related to palliative care, require an interdisciplinary team that understands the critical state of the patient, the specific care they should receive, and demonstrates sensitivity to the suffering, vulnerability, and fragility of critically ill patients<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> ensuring holistic care. In this sense, intensive care and palliative care should coexist, the benchmark being the values, principles and decision-making of the patient and their family, performing interventions that include assertive communication, psycho-emotional support, qualified attention, pain, and symptom management, and if necessary, end-of-life accompaniment.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Health systems are gradually becoming more aware of the need for information and expertise from different disciplines to develop valid solutions and provide comprehensive care for patients and their families. For this, Interprofessional Collaborative Practice (ICP) is essential to optimise the quality of care because it integrates clinical, contextual, social, and psychological aspects aimed at redirecting the care of patients with an unfavourable clinical course to find relief from suffering, improvement of symptoms, and greater well-being.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Educational programmes for professionals caring for critically ill patients at the end of life must be developed that include palliative care measures from admission to the unit, to control pain, symptoms and alleviate the patient’s suffering and that of their family.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Likewise, to guarantee effective care in this final stage of life in which palliative care is important as the disease progresses towards the death of the patient in the ICU.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,11</span></a> Therefore, the aim of this study was to identify the interprofessional interventions and factors that affect improvement of end-of-life care in the ICU.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Methods</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">Integrative review, a design that allowed scientific evidence to be gathered that met previously established criteria, in order to reduce bias, generate reliable results, and obtain the best scientific evidence. This type of review is consistent with the objective of this work, because it allows for a broad approach to the field of study, which enabled the selection of both primary and secondary research.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Selection criteria</span><p id="par0040" class="elsevierStylePara elsevierViewall">We selected analytical and descriptive observational studies with correlation of variables, experimental, quasi-experimental, and systematic reviews, published from 2010 to 2021, whose subjects were adults admitted to the ICU. We analysed the interventions and associations of variables by the interprofessional team of the ICU, which evaluated outcomes associated with end-of-life care.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Information retrieval procedure and documentary sources</span><p id="par0045" class="elsevierStylePara elsevierViewall">We conducted a search of the databases and meta-search engines COCHRANE, CINAHL, CUIDEN, LILACS, SCIELO, Dialnet, PsychInfo, PubMed, PROQUES, PSYCHOLOGY, JOURNALS, and SCIENCEDIRECT in Spanish, English, and Portuguese, with search equations that included the Boolean operators AND, OR, and NOT. Key terms used were standardised terms (MESH/DECS) and free terms: critical care, intensive care unit, family, end-of-life care, life support, palliative care, advance care planning, right to die, shared decision making, comfort, quality of life, pain control.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Search results and selection of papers</span><p id="par0050" class="elsevierStylePara elsevierViewall">To select the studies, titles were read, and then abstracts and full texts of those that contributed to the objective of the review were located from the platform of the Fundación Universitaria de Ciencias de la salud (FUCS) (University Foundation of Health Sciences) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Information analysis process</span><p id="par0055" class="elsevierStylePara elsevierViewall">The CONSORT checklists for clinical trials, experimental and quasi-experimental studies, AMSTAR for systematic reviews, and STROBE for observational studies were used to evaluate the studies. To select the articles, three investigators read them independently, and in case of discrepancy, a fourth investigator reviewed them. Data were extracted from each study, using a form that included language, country, objective, design, participants, measurements, intervention, synthesis of results, effect of interventions, association of factors correlated with end of life, conclusions, and recommendations. Due to the heterogeneity and diversity of designs and studies, we undertook a thematic analysis of the results. We applied the parameters of the Joanna Briggs Institute to assign the level of evidence.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Of 31 selected articles,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–43</span></a> 16.7% were experimental designs, 3.3% quasi-experimental, and 80% analytical and descriptive observational with correlation of variables. Regarding language, the largest number of publications were in English 74%, followed by Portuguese 16%. The largest number was published in the United States 38%, and Brazil 19%. The years 2018 and 2019 reported the highest number of publications 45%. The pooled sample was 24,779 participants, 23,016 patients, 1122 family members, and 641 professionals. The included studies have a good level of scientific evidence and degree of recommendation, 32.2% had level of evidence 1, recommendation (c), 25.8% level of evidence 2, recommendation (c), 12.9% level of evidence 3, recommendation (a), and 9.6% level of evidence 3, recommendation (b), with equal percentage of evidence 3, recommendation (d), assigned as proposed by the Joanna Briggs Institute<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding the thematic analysis, the results were put into two categories to meet the objectives of the review.</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Interprofessional interventions with impact on the improvement of end-of-life care</span><p id="par0070" class="elsevierStylePara elsevierViewall">In the literature described, most of the interventions were performed multidisciplinarily, mainly by nursing, medical, and social work staff, and focused on the management of physical symptoms such as thirst<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a> and emotional symptoms (stress, depression, grief, and pain management)<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,17</span></a> and training<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> of health staff and family members to improve the quality of death and reduce the length of stay in ICU.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">18,20</span></a> However, we found that early palliative care consultation was associated with a decrease in Do Not Resuscitate/ Do Not Intubate code status, with a positive impact on critical patient care and adequate consultations, which can guide the different triggers of clinical severity in the various settings of each patient,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> and reduce utilisation of the ICU.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">20</span></a> Including the family member in decision-making also shortened the length of stay of patients, as demonstrated in the intervention by Liu et al.,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">17</span></a> where physician-family shared decision-making improved family members' satisfaction and symptoms of depression, and reduced stays in the ICU.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Verbal communication with communication facilitators,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> and written communication through information pamphlets were identified as reducing symptoms of post-traumatic stress in family members.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Curtis et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> state that facilitators are indispensable at the end-of-life stage because they can improve communication on the goals of care and palliative care in the ICU between the interdisciplinary team and the family. Similarly, Robin et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> conducted an intervention using a pamphlet on the role of family members during end-of-life decisions, resulting in a significant reduction in the risk of developing symptoms related to anxiety, depression, and bereavement (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Factors influencing improvement of end-of-life care in the ICU</span><p id="par0080" class="elsevierStylePara elsevierViewall">It became evident that some factors that improve end-of-life care in ICU patients involve the patient's family and all the healthcare staff of the service. As is well known in the ICU, end-of-life care is a major concern in terminally ill patients, and the entire interdisciplinary health team is important as a fundamental pillar of this process. It was found that lack of training and adequate information were the most frequent obstacles, there is a lack of education on palliative care among health professionals, and end-of-life care should be an integral part of critical care management.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">According to Barros Gulini et al., the highest incidence of mortality in critically ill patients relates to the clinical condition of the patient, age, frailty, functionality, and disease history; this means an objective assessment on admission is essential, because there are patients who arrive at the ICU and require palliative management from the outset, in this way, therapeutic limits can be established and false hopes can be avoided for the family and attending healthcare staff.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">22</span></a> When deciding on a therapeutic ceiling in patients hospitalised in the ICU, family members find it difficult to make decisions for their loved ones on end-of-life; they say that it is better for the patients themselves to decide on early non-resuscitation. It is said that having these conversations about whether or not to resuscitate, before or during the initial stay in the ICU, gives patients the ability to make their own decisions, promotes patient autonomy, results in greater likelihood of receiving care in accordance with their wishes, and saves the family the additional stress of deciding on the matter.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">On decision-making, Bertolini et al. indicated a participation of relatives of 44.4%, and 16.9% had no participation or contact whatsoever in the decisions made by the patient; this was a factor associated with the low participation of the relative or caregiver in the end-of-life process of patients in the ICU. However, Kim et al., in identifying the factors associated with the decision- making of elderly patients and their relatives on the initiation of treatment in the unit, found that from a sample of 125 patients only 45 accepted admission to the ICU considering their clinical condition, of these patients, 1 had signed a previous advance directive, the study reported greater survival in patients who decided to enter the ICU.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">24,25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">According to Ouyang et al.,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a> most nurses suggest that invasive procedures may be the mechanism that prolongs the dying process and is associated with less peace and the worst possible death, before adjusting to procedures such as dialysis, mechanical ventilation, cardiac resuscitation, among others. Some report that they may feel more comfortable administering opioids for pain or providing sedation than with a DNR order in place, suggesting that early DNR orders are associated with less suffering and loss of dignity.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">26,27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">However, Cavalcanti et al. report that nurses considered palliative care in ICU to be of great importance for clinical practice in terminally ill patients. However, other studies showed little training in palliative care, which influences how the nurse puts the principles into practice, those scoring lowest were the consideration and recognition of death as a natural process of life, the value of each medical attitude assumed, the participation of nurses in decisions, and better communication among the team facilitates adherence to the principles of palliative care and it is suggested that this issue should be widely discussed among the teams, empower nurses to assume a mediating role between team and family, and reinforce ideal and individualised care for each case.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">28</span></a> Kross et al. discuss the importance of identifying family members' characteristics and risk factors for depression and anxiety, it is evident that family members of older patients had lower scores, as did family members present at the time of death and withdrawal of the ventilator, simply in providing accompaniment<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">29</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The aim of this review was to identify interprofessional interventions and factors that influence improvement of end-of-life care in the ICU. Thirty publications were found with a favourable level of evidence and recommendation, 32.2% had level of evidence 1, recommendation (c), 25.8% level of evidence 2, recommendation (c).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Four interventions that have an impact on the end of life are considered, the first of which is in the management of physical and emotional symptoms. Evidence shows that admission to the ICU generates processes of anxiety, stress, fear, or depression, due to lack of intimacy and trust. Therefore, actions aimed at reducing stress levels favour the safety of patients and their families.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">44</span></a> This is achieved through training, which should be ongoing for the multidisciplinary team in the ICU, to improve end-of-life care, given that the staff would have the tools to deal with any situation, regularly monitor for any shortcomings and promptly correct them.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">45</span></a> Likewise, Ke et al.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">45</span></a> state that good interdisciplinary communication and collaboration leads to better perception of the quality of palliative care, providing improvement in physical symptoms and psychosocial and spiritual needs.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">46</span></a> Thus, ICP provides benefits from the point of view of clinical decision-making and therapeutic goal-setting. Similarly, Hermann et al.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">47</span></a> mention that training in palliative care should start at the university level, and therefore it is essential to include it in curricula, so that students are equipped with tools to enable interprofessional communication, teamwork, and shared decision-making.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Similarly, another intervention covers the importance of implementing assertive communication. This practice was highlighted in the context of the SARS-COVID-2 pandemic, where remote communication through conference calls and videoconferences was associated with significant family experiences (acceptance process, grief management, reducing psychological trauma), in addition to allowing objective and clear conversations with families at certain stages of this disease, where shared decision-making can change the course of interventions aimed at end-of-life care.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">48–50</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">However, the factors that affect improvement of end-of-life care in the ICU tackle the lack of knowledge about everything related to underlying conditions or complication of the disease shown by relatives, and the development of a palliative care programme, which requires an exhaustive initial assessment for access, where a classification will be made according to the severity markers used in the ICU, which range from patient age, frailty, neurological impairment to multi-organ failure; the sum of two of these being key to entry into the programme.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">21,51</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Great difficulty is demonstrated with regard to limitation of the therapeutic ceiling, and it is evident that in most cases it is the patient who decides to limit a type of treatment or invasive procedure that would postpone their clinical state of pain and suffering; this must be considered between doctor, family, and patient, to make a final decision.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a> Likewise, the limitation or withdrawal of treatment within the ICU involves challenges and some reluctance within particular cultural or religious contexts.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">52</span></a> In a scenario of decision-making complexity, the study by Tanaka et al. proposes a stepwise approach in cases of family conflict and the incorporation of communication skills in medical and nursing education.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">53</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Ruland and Moore's end-of-life theory is a reference that can guide palliative care practice, since it describes the best way to provide care, using technology, to give a better quality of life and achieve a peaceful death, without pain, with dignity, respect, peace, serenity, understanding, and with the proximity of family and friends.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> Some authors link the theory of end-of-life care in the ICU, through actions such as clear and sincere communication with both the patient and their caregiver, and creating a calm environment, without suffering, with accompaniment, allowing the grieving process of family members and promoting specialised care for a dignified death.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">54–57</span></a> Secunda et al. state that patient- and family-centred care includes, in addition to communication, interventions to improve the presence, support, and participation of the family in that care.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">58</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In general, this work synthesises evidence aimed at favouring interprofessional collaborative practice (ICP) in the ICU to improve end-of-life care. Interventions also help achieve established therapeutic objectives, with the aim of implementing effective policies, plans, and care programmes for the care of the critically ill patient and their family, with professional criteria and individualised for each patient. Similarly, the factors influencing the limitations of access to palliative care can be improved by implementing training and continuing education for healthcare personnel.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Reported as limitations of this work, although an attempt was made to analyse the largest number of articles, there were limitations in accessing the full texts of some articles and grey literature was not included. Secondly, the diversity of study types and designs increases the risk of bias in the results. Most of the studies were conducted in the United States, which should be considered to assess the transferability of the findings to other geographical contexts.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">According to the objective of this review, the interventions identified are oriented towards the management of physical and emotional symptoms through training and emotional support strategies. These interventions are aimed at healthcare staff and family members to improve the quality of dying and to reduce ICU stay.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Likewise, the factors influencing improvement of end-of-life care are related to participation in shared decision-making with family members and assertive communication between them and the medical staff, covering education on end-of-life care and the collaboration of the interdisciplinary team in these processes. It is noteworthy that patients who receive early palliative care consultation have lower in-hospital mortality, and more substitutes for hospital care are chosen when palliative care medicine is involved earlier.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Based on the observed findings, it is suggested that end-of-life care interventions be applied in Colombia, since few studies were found in Latin America. It would also be interesting to conduct qualitative studies to understand the perceptions of family members, patients, and healthcare personnel in this life cycle. In addition, it is proposed that future research should focus on shared decision-making between healthcare team, patient, and family to better understand how palliative care can be integrated in the ICU. It is also suggested that studies be developed to design and evaluate interprofessional interventions to improve end-of-life care in the ICU.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0160" class="elsevierStylePara elsevierViewall">This study is part of the project: "<span class="elsevierStyleItalic">Mejoramiento de los cuidados al final de la vida del paciente crítico ingresado en la UCI y de sus family members</span>" (Improving end-of-life care for critically ill patients admitted to the ICU and their families), funded by the Internal Call for the Promotion fo Research 2018 of the University Foundation of Health Sciences (Fundación Universitaria de Ciencias de la Salud).</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres2169672" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methodology" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1839826" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2169671" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Metodología" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1839827" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0020" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Selection criteria" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Information retrieval procedure and documentary sources" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Search results and selection of papers" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Information analysis process" ] ] ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Interprofessional interventions with impact on the improvement of end-of-life care" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Factors influencing improvement of end-of-life care in the ICU" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack753010" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-06-18" "fechaAceptado" => "2023-08-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1839826" "palabras" => array:7 [ 0 => "Critical care" 1 => "Intensive care units" 2 => "Terminal care" 3 => "Vital supportive care" 4 => "Palliative care" 5 => "Planning advance of care" 6 => "Right to die" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1839827" "palabras" => array:8 [ 0 => "Cuidados críticos" 1 => "Unidades de cuidados intensivos" 2 => "Cuidados terminales" 3 => "Cuidados de soporte vital" 4 => "Cuidados paliativos" 5 => "Planificación anticipada de cuidados" 6 => "Derecho a morir" 7 => "Toma de decisiones compartidas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The changes in health dynamics, caused by the SARS-COVD-2 pandemic and its consequences, generated a greater need to integrate palliative care in the ICU to promote a dignified death.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Identify interprofessional interventions and factors that improve the care of patients at the end of life.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methodology</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Integrative review, including experimental, quasi-experimental, observational, analytical, and descriptive studies with correlation of variables, published from 2010 to 2021, identified in COCHRANE, CINAHL, CUIDEN, LILACS, SCIELO, Dialnet, PsychInfo, PubMed, PROQUES, PSYCHOLOGY, JOURNALS, SCIENCEDIRECT, with MeSH/DECS terms: “Critical Care”, “IntensiveCare” “Life support care”, “Palliative care”, “Life Quality”, “Right to die”. 36,271 were identified, after excluding duplicate title, abstract, year of publication, design, theme, methodological quality, objectives, and content, 31 studies were found.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">It included 31 articles, 16.7% experimental, 3.3% quasi-experimental, 80% observational, analytical, and descriptive with correlation of variables, 38% published in the United States, 38%, and 19% in Brazil. The pooled sample was 24,779 participants. 32.2% of the studies had level of evidence 1 recommendation (c), and 25.8% level of evidence 2 recommendation (c). This paper synthesises evidence to promote Interprofessional Collaborative Practice in the ICU, improve end-of-life care, and interventions to achieve established therapeutic goals, implement effective care policies, plans, and programmes for critically ill patients and their families; factors that affect palliative care and improve with training and continuing education for health personnel.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">There are interventions to manage physical and emotional symptoms, training strategies and emotional support aimed at health personnel and family members to improve the quality of death and reduce stays in the ICU. The interdisciplinary team requires training on palliative and end-of-life care to improve care.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methodology" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Los cambios de la dinámica en salud, ocasionados por la pandemia por SARS-COVD-2 y sus consecuencias, generaron mayor necesidad de integrar los cuidados paliativos en UCI para favorecer una muerte digna.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Identificar intervenciones interprofesionales y factores que mejoren el cuidado de pacientes en fin de vida.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Metodología</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Revisión integrativa, incluyó estudios experimentales, cuasi experimentales, observacionales analíticos y descriptivos con correlación de variables, publicados del 2010 al 2021, identificados en COCHRANE, CINAHL, CUIDEN, LILACS, SCIELO, Dialnet, PsychInfo, PubMed, PROQUES, PSYCHOLOGY, JOURNALS, SCIENCEDIRECT, con términos MeSH/DECS «Critical Care»,«Intensive Care», «Life support care», «Palliative care», «Life Quality», «Right to die». Se identificaron 36.271, tras excluir por duplicado, título, resumen, año de publicación, diseño, temática, calidad metodológica, objetivos y contenido resultaron 31 estudios.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Incluyó 31 artículos, 16.7% experimentales, 3.3% cuasi-experimentales, 80% observacionales, analíticos y descriptivos con correlación de variables, 38% publicados en Estados Unidos y 19% en Brasil. La muestra agrupada fue de 24.779 participantes. 32.2% de estudios tuvo nivel de evidencia 1 recomendación (c), y 25.8% nivel de evidencia 2 recomendación (c). Este trabajo sintetiza evidencias para favorecer la Práctica Colaborativa Interprofesional en UCI, mejorar la atención en fin de vida, e intervenciones para alcanzar objetivos terapéuticos establecidos, implementar políticas, planes y programas de cuidado efectivos para pacientes crítico y sus familias; factores que inciden en el cuidado paliativo y mejoran con capacitaciones y educación continua al personal de salud.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusión</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Existen intervenciones para manejar síntomas físicos y emocionales, estrategias de capacitación y apoyo emocional dirigidas al personal de salud y familiares para mejorar calidad de muerte y disminuir estancias en UCI. El equipo interdisciplinario, requiere formación sobre cuidados paliativos y fin de vida para mejorar el cuidado.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Metodología" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2522 "Ancho" => 2507 "Tamanyo" => 301883 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Search flowchart.</p>" ] ] 1 => array:9 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Compiled by the authors." "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ICU, Intensive Care Unit; POLST, Physician Orders for Life-Sustaining Treatment; PTSD, post-traumatic stress disorder; RCT, Randomised Clinical Trial; USA, United States.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Source: Own elaboration.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference (1st author, year, and country \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Objective \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Methodological design \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level of evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Participants \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Robin et al. (2021), France<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the impact of a communication structure with an information pamphlet on the role and responsibility of relatives in end-of-life decisions, according to the French ‘Leonetti law’ of April 2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 family members \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leemhuis et al. (2019), USA<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the effectiveness of an intervention to palliate patient thirst and aspects that may influence its adoption in practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">123 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 family members \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ma et al. (2019), USA<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the impact of early palliative care consultation on the outcomes of high-risk ICU patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cluster RCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">199 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liu. et al. (2022), China<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">17</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To investigate whether a family-clinician shared decision making (FCSDM) intervention benefits ICU patients, families, and clinicians \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">548 patients with their families \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Curtis et al. (2011), USA<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the effectiveness of a quality-improvement intervention to improve ICU end-of-life care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cluster RCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2318 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Curtis et al. (2016), USA<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To determine whether an ICU communication facilitator reduces family distress and intensity of end-of-life care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">168 patients, 268 families \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ramos et al. (2018), Brazil<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">20</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the effect of a palliative care programme on DNR orders and ICU utilisation during terminal hospitalisations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quasi- experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1071 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Agrawal et al. (2019), India<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate knowledge and awareness of end-of-life care among doctors working in ICU on end- of- life-care (EOLC) in critical patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">255 healthcare professionals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gulini et al. (2018), Brazil<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">22</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To identify predictors of death in an ICU and relate eligible patients to preferential palliative care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective case control study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">170 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ouyang et al. (2020) USA<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To determine the association between the timing of DNR order placement in the ICU and nurses ‘perceptions of patients’ distress and quality of death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observational cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">200 deceased patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bertolini et al. (2010), Italy<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">24</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the association between the inclination to limit treatment and overall survival at ICU level \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective, multicentre, observational \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3793 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kim et al. (2016), USA<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To identify the factors that influence the decision of elderly patients and their families about whether to initiate intensive care in case of an acute event \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lee et al. (2020), USA<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the association between Physician Orders for Life-Sustaining Treatment (POLST) and ICI admission among patients hospitalised near the end of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1818 deceased adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mazutti et al. (2016), Brazil<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To estimate the incidence of limitations to Advanced Life Support in critically ill patients admitted to an intensive care unit with integrated palliative care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3487 patients admitted to ICU \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cavalcanti et al. (2018), Brazil<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">28</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess intensivist nurses' perception of adherence to the principles of palliative care in their care practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional descriptive correlational \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104 nurses from 12 ICU in 5 hospitals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kross et al. (2011), USA<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">29</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To identify patient characteristics and caregiving factors as risk factors for developing PTSD and depression in family members of patients dying in ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">268 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wang et al. (2019), USA<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To use latent class analysis to separate ICU patients into different classes of palliative care needs and determine if such classes differ in their palliative care resource requirements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">689 ICU patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tang et al. (2021), Taiwan<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">31</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the impact of early palliative care consultation on the outcomes of high-risk ICU patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective, longitudinal, and observational \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">278 family members \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alliprandini et al. (2019), Brazil<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">32</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To analyse the implementation of palliative care components, in “procedures not performed” or "futile/unnecessary treatment" \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observational cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">253 patients admitted to 5 ICU \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Romano et al. (2017), USA<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">33</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the effect of a comprehensive early palliative care programme on ICU use among patients with advanced cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">200 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Creutzfeldt et al. (2017), USA<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">34</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To examine the association of a daily palliative care needs checklist on outcomes for family members of patients discharged from neuro-ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parallel-group prospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">193 family members \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orford et al. (2019), Australia<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">35</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses referred to ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">222 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kwok et al. (2011), USA<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">36</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To understand how often older Americans undergo surgery in the last year of life and how interventions vary by age and healthcare markets \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,802,029 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fleischmann-Struzek et al. (2019), Germany<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">37</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To examine trends in hospital deaths and use of intensive care services during terminal hospitalisations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observational, prospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.6 million in 2007 and 18.7 million in 2015 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Del Barrio et al. (2007), Spain<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">38</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To understand ICU nurses' perceived aids and barriers to end-of-life care and to analyse their relationship to ICU nurses' perceptions of end-of-life care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Descriptive correlational \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">151 nurses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rosa Ramos et al. (2018), Brazil<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the effect of the implementation of a palliative care programme on do-not-resuscitate orders and ICU utilisation during terminal hospitalisations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective analytical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1071 hospitalised patient deaths \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Girbau et al. (2017), Spain<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">40</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the quality of care received by deceased patients in Spanish ICUs using the Robert Wood Foundation (RWF) Intensive Care Task Force quality indicators. To highlight areas for improving quality at the end of life in ICUs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observational, retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">282 deceased patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moreira et al. (2020), Uruguay<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">41</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To determine the prevalence of triggers for early consultation with PC, their relationship with survival in the unit, and to evaluate the use of invasive measures in this group of patients, to develop strategies to improve the quality of care in the ICU and the transition from care to the ward \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2850 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graham et al. (2018), Canada<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">42</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To describe an end-of-life/palliative care educational intervention, including symptom management, communication skills, decision-making and a face-to-face group integration activity, from the perspective of the interprofessional team \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cross-sectional, correlational, descriptive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 physicians \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tan et al. (2019), USA<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">43</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To describe the end-of-life care preferences of individuals, and to examine the influence of age and sex on these preferences \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retrospective cohort study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3380 patients \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3573846.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Characterisation of the reference sample.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0011" class="elsevierStyleSimplePara elsevierViewall">CSCAD, the Collaboration and Satisfaction About Care Decisions tool; ICU, Intensive Care Unit; PTSD, post-traumatic stress disorder.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference, 1st author, year, country \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intervention \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Principal outcomes \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Robin et al., (2021), France<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Information pamphlet given to family members of ICU patients describing their role in end-of-life decisions to decrease their risk of developing symptoms related to post-traumatic stress disorder (PTSD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">On day 90, the number of family members with PTSD symptoms was significantly lower in Group 1 than in Group 2. Mean scores on the Impact of Event Scale, anxiety, and depression decreased in Group 1 compared to Group 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ma et al., (2019) United States<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients received a visit from a certified interprofessional palliative care team 48 h after admission to the ICU that included review of the hospital record, meeting with the patient and healthcare team, identifying physical and emotional needs of patient and family, discussion with the primary team about how best to meet needs, and communication among all parties regarding goals, values and treatment decisions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than in the control group. The intervention group had significantly more transfers to palliative care; fewer ventilator days, tracheostomies, emergency department visits, readmissions after discharge, and medical ICU and pharmacy operating costs. In-hospital and 30-day mortality were lower in the intervention group \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liu et al., (2022) China<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">17</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meetings with family members were held which: 1) explained the patient's current condition, treatments, prognosis, etc.; (2) commented on the above debriefing and checked whether the families fully understood the information; (3) elicited families’ perspectives on the patient's medical care; (4) explored the patient's willingness by asking the families or the patient if they can communicate; (5) provided various options of medical care, explained pros and cons of each option; (6) clinicians and families expressed their own views; (7) listened to the families attentively and expressed empathy at least once; (8) focused on patient-centeredness, respected their wishes, and reached the care decision supported by both clinicians and families \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The intervention group reported significant differences in family satisfaction, quality of life, family depression level, and patients. The mean CSCAD score of physicians was more positive. There were no significant differences between the groups in daily ICU medical cost, but the intervention group reported fewer days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Curtis et al., (2011), United States<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The intervention promoted clinical behaviour change through five components: 1) education about palliative care in ICU 2) identification and training in ICU 3) academic visits by ICU nurse and physician 4) decisions in ICU: including family satisfaction, 5) implementation of system for requesting palliative care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The family showed no change with the intervention. There was a significant increase in ICU days before death after the intervention. In patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Curtis et al., (2016) United States<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Improve communication about goals of care and palliative care in ICU between the interdisciplinary team and families of critically ill patients. It included: 1) interviews to understand family concerns; 2) facilitator meetings with physicians and nurses to resolve questions; 3) providing family emotional support; 4) facilitator participation in family members conferences; and 5) 24-h follow-up after discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The intervention was associated with decreased family depressive symptoms at 6 months, no significant difference at 3 months in psychological symptoms or anxiety or PTSD at 6 months. The intervention did not reduce mortality, but did reduce ICU costs for all patients. Among those who died, the intervention reduced ICU length of stay and hospital stay \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rosa Ramos et al., (2018) Brazil<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the effects of implementing a palliative care programme on the proportion of in-hospital deaths in patients with a do not resuscitate order (DNR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deaths were preceded by DNR orders in 25.8% of cases and ICU non-admission in 76%. DNR orders increased from 20.4%–33%, with the trend increasing from .5% to 2.9% with the implementation of the palliative care programme \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3573845.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Interprofessional interventions that impact on improvement of end-of-life care.</p>" ] ] 3 => array:9 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Compiled by the authors." "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0012" class="elsevierStyleSimplePara elsevierViewall">DNR, resuscitate order; EOLC, end-of-life-care; GCAD, Goals of Care and Advance Directives; ICU, Intensive Care Unit; MVA, mechanical ventilation assistance; PC, palliative care; POLST, Physician Orders for Life-Sustaining Treatment; PTSD, post-traumatic stress disorder; SAPS III, Simplified Acute Physiology Score III.</p><p id="spar0013" class="elsevierStyleSimplePara elsevierViewall">Source: Own elaboration.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference (1st author, year, country) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Study objective \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Principal outcomes \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cavalcanti et al., (2018), Brazil<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">28</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess intensivist nurses' perception of adherence to the principles of palliative care (PC) in their practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The most relevant principles of care were to relieve pain and other associated symptoms, ensure quality of life and dying, prioritise the patient's best interests, respect patient autonomy, and that of their legal representatives. The lowest scores were on considering death as part of life and evaluating the cost-benefit of each medical approach \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wang et al., (2019), United States<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To use latent class analysis to separate ICU patients into different classes of palliative care needs and determine if such classes differ in their palliative care resource requirements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In a sample of 689 patients, a four-class model produced the most meaningful groupings: 1) Pain and Symptom Management, 2) Goals of Care and Advance Directives (GCAD), 3) All Needs, and 4) Supportive Care. In comparison to GCAD patients, all other classes were more likely to require “high use” of palliative care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tang et al., (2021), Taiwan<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">31</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the impact of early palliative care consultation on the outcomes of high-risk ICU patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The surrogates’ lower likelihood of severe anxiety or depressive symptoms 3−6 months post loss was associated with death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and higher family satisfaction with end-of-life care in ICU \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alliprandini et al., (2019), Brazil<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">32</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To analyse the application of components of palliative care, either “unperformed procedures” or elements of “futile/unnecessary treatment” \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Of 253 patients, 52 died; 38.5% met criteria for ELM-PC which was started after day 3 in 60%, three patients received adequate palliative care. “Analgesia” and “daily family interviews” were the most applied. “Terminal extubation/weaning” was not performed in any of the patients. In patients who underwent "correct" interventions: 66.6% died on the first day of ELM-PC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Romano et al., (2017), United States<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">33</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the effect of a comprehensive early palliative care programme on ICU use and other outcomes among patients with advanced cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients in the control group had statistically significantly higher likelihood of ICU admission at the end of life, higher likelihood of death in the hospital or ICU, and lower likelihood of hospice enrolment. Use of chemotherapy or radiation did not significantly differ between groups, nor did length of ICU stay, code status, ICU procedures other than cardiopulmonary resuscitation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bertolini et al., (2010), Italy<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">24</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the association between the average inclination to limit treatment and overall survival at ICU level \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment limitation preceded 62% of deaths. In 25% of cases, nurses were involved in the decision. Half the limitations were do-not-resuscitate orders, with the remaining half almost equally split between withholding and withdrawing treatment. Units less inclined to limit treatments showed higher overall standardised mortality ratio \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kross et al., (2011), United States<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">29</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To identify patient characteristics and caregiving factors as risk factors for developing PTSD and depression in family members of patients dying in ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">226 patients participated. Patients who were older had family members with lower symptom scores for PTSD. Family members who were present at time of death and family members of patients with early family conference reported higher scores for PTSD. When withdrawal of a ventilator was ordered, family members reported lower symptoms of depression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Creutzfeldt et al., (2017), United States<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">34</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To examine the association of a daily palliative care needs checklist on outcomes for family members of patients discharged from neuro-ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The mean modified Rankin scale score of neuro-ICU patients was 3.1. Ratings of quality of care were high (82.2 on a scale of 0–100) with 32% family members meeting screening criteria for depressive syndrome. Satisfaction and post-traumatic stress ratings did not differ significantly between families of patients from the neuro-UCI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orford et al., (2019). Australia<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">35</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses (LLI) referred to ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The study reported significant decrease in critical care as the choice of resuscitation goal. Admission to ICU did not decrease but there was a significant decrease in medical emergency team call prevalence. The cancer and organ failure groups had a significant decrease in 90-day mortality and the frailty group had a significant decrease in 90-day readmissions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kwok et al., (2011) United States<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">36</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To understand how often older Americans undergo surgery in the last year of life and how interventions vary by age and healthcare markets \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,802,029 beneficiaries of fee-for-service Medicare aged 65 years or more died in 2008, 31.9% underwent an inpatient surgical procedure during the year before death, compared to 13.9% of survivors during 2008. In the last 3 months of life, 25.1%, in the last month 18.3%, and in the last week 8% underwent a surgical procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kim et al., (2016), United States<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To identify the factors that influence the decision of elderly patients and their families about whether to initiate intensive care in case of an acute event \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Of 125 patients, 45 agreed to receiving intensive care. Characteristics at the time of intensive care unit referral were similar between the intensive care and non-intensive care groups. One patient had advance directives before referral. Lower economic status and cognitive impairment were associated with a lower likelihood of agreeing to ICU. Participants involved in decision-making were associated with a higher likelihood of ICU use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tan et al., (2019), United States<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">43</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To describe the end-of-life care preferences of individuals, and to examine the influence of age and sex on these preferences \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Across healthy and chronically ill patients, 94% of individuals with advanced illnesses preferred not to attempt CPR or other life-sustaining measures, 40% chose to be cared for, and to die at home. Age and sex significantly predict preferences in those with advanced illnesses. Those aged 75 years preferred the home as place of care and death. Being female was associated with lower odds for home as preferred place of care and place of death \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lee et al., (2020), United States<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate the association between Physician Orders for Life-Sustaining Treatment (POLST) and ICI admission among patients hospitalised near the end of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The primary outcome was the association between POLST order and ICU admission during the last hospitalisation of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fleischmann et al., (2019), Germany<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">37</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To examine trends in hospital deaths and use of intensive care services during terminal hospitalisations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Standardised hospital admission rates increased by .8% and hospital admissions involving ICU care increased by 3.0% annually. Among all deaths in the German population, the proportion of hospital deaths with ICU care increased by 2.3% annually. In patients aged 65, the use of ICU during terminal hospitalisations increased 3 times faster than hospital deaths \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Agrawal et al., (2019), India<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To evaluate knowledge and awareness of end-of-life care among doctors working in ICU on end-of- life-care (EOLC) in critical patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Most had not counselled more than five families regarding EOLC over 1 month and 81.7% had heard of EOLC, the major source of information being their work in the specialty. Only 29.2% applied EOLC principles. Main barriers were lack of information and training. Only 20.3% were aware of Indian guidelines about EOLC. Most disagree regarding the use of ICU and resuscitation of terminally ill patients and were in favour of home care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gulini et al., (2018), Brazil<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">22</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To identify predictors of death in an ICU and relate eligible patients to preferential palliative care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One hundred and seventy patients were evaluated. A greater possibility of death was observed among older and more frail patients with less functionality, chronic cardiac and/or renal insufficiencies, or acute non-traumatic neurological insult, with multiorgan failure for more than 5 days, and hospitalised for longer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ouyang et al. (2020) USA<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To determine the association between the timing of DNR order placement in the ICU and nurses’ perceptions of patients’ distress and quality of death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Of the patients, 29.5% had a DNR placed within 48 h of ICU admission (early DNR), 55% placed after 48 h (late DNR), and 15.5% had no DNR order placed. The latter had significantly fewer non-beneficial procedures, and lower odds of being rated by nurses as not being at peace and experiencing worst possible death; reduction in severe suffering and loss of dignity were reported \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mazutti et al., (2016), Brazil<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. To learn the aids and obstacles perceived by ICU nurses in the care of patients at the end of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The mean age of the nurses was 35 years and experience in ICU 9.2. The item perceived as the most helpful in providing good end-of-life care was “all physicians agreeing with the approach to care”. The minimum aid was “having an ethics committee member of the daily review”. The highest obstacle was “the patient having pain that is difficult to control” and the lowest to “nurses knowing the patient’s poor prognosis before the family”. There is a statistically significant correlation in age, years of experience in ICU and postgraduate training with the variables of interest, aids, and obstacles \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. To analyse whether there is a relationship between the aids and obstacles perceived by ICU nurses in the care of patients at the end of life and the sociodemographic variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rosa Ramos et al., (2018). Brazil<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the effects of implementing a palliative care programme on do-not-resuscitate orders (DNR) and ICU use during terminal hospitalisations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A total of 48,372 admissions and 1071 in-hospital deaths were analysed. Deaths were preceded by DNR orders in 25.8% of cases and ICU admissions occurred in 76% of cases. Do-not-resuscitate orders increased from 20.4% to 33% with implementation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Girbau et al., (2017). Spain<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">40</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To assess the quality of care received by deceased patients in Spanish ICUs using the Robert Wood Foundation (RWF) Intensive Care Task Force quality indicators. To highlight areas for improving quality at the end of life in ICUs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A total of 282 patients from 15 Spanish ICUs were included. A median of 13% compliance with the indicators was observed. Of the medical records, 96% documented patient decision-making capacity and 98% communication with the family, 50% contained a care plan or goal of care. Two ICUs had open visiting arrangements for family members. Dyspnoea assessment was better documented 48%, than pain assessment 28%. Thirteen ICUs had no protocols for withdrawal of supportive measures. Emotional and spiritual support indicators reported less than 10% compliance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moreira et al., (2021), Uruguay<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">41</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To determine the prevalence of triggers for early consultation with PC, their relationship with survival in the unit, and to evaluate the use of invasive measures in this group of patients, to develop strategies to improve the quality of care in the ICU and the transition from care to the ward \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2850 patients were analysed, 26% had at least one trigger for consultation with PC. The most prevalent: ICU stay 50% above the mean. These patients were older: 61 vs. 54 years and more severe, SAPS III of 60 vs. 47 points. They required more mechanical ventilation assistance (MVA) 87% vs. 55%, vasopressors 48% vs. 24% and haemodialysis 8% vs 4%. They had longer stay 18 vs. 4 days, and time on MVA 14 vs. 3 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graham et al., (2018), Canada<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">42</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To describe an end-of-life/palliative care educational intervention, including symptom management, communication skills, decision-making and a face-to-face group integration activity, from the perspective of the interprofessional team in terms of acceptability and feasibility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The intervention was perceived to be appropriate and adequate to provide clinicians with knowledge and skills in symptom management and communication through self-reflection and self-assessment, the provision of assessment tools and the promotion of interprofessional teamwork. The online format was more feasible, but the face-to-face group activity was key to integrating knowledge and promoting interprofessional discussions \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3573844.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Factors influencing improvement of end-of-life care in the ICU.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:58 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cuidados de enfermería a pacientes al final de la vida en una unidad de cuidado intensivo. [Trabajo de Grado de Especialización]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Bertha" 1 => "H. 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