"At Least I Can Push this Morphine": PICU Nurses' Approaches to Suffering Among Dying Children

Elizabeth G Broden; Ijeoma Julie Eche-Ugwu; Danielle D DeCourcey; Joanne Wolfe; Pamela S Hinds; Jennifer Snaman

doi:10.1016/j.jpainsymman.2024.04.018

"At Least I Can Push this Morphine": PICU Nurses' Approaches to Suffering Among Dying Children

J Pain Symptom Manage. 2024 Apr 26:S0885-3924(24)00738-3. doi: 10.1016/j.jpainsymman.2024.04.018. Online ahead of print.

Authors

Elizabeth G Broden¹, Ijeoma Julie Eche-Ugwu², Danielle D DeCourcey³, Joanne Wolfe⁴, Pamela S Hinds⁵, Jennifer Snaman⁶

Affiliations

¹ Department of Psychosocial Oncology and Palliative Care (E.G.B., J.S.), Dana-Farber Cancer Institute, Boston Massachussetts; National Clinician Scholars Program (E.G.B.), Yale Schools of Medicine and Public Health, New Haven, Connecticut. Electronic address: Elizabeth.broden@yale.edu.
² Phyllis F. Cantor Center for Research in Nursing and Patient Care Services(I.J.E.U.), Dana-Farber Cancer Institute, Boston, Massachussetts.
³ Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts; Division of Medical Critical Care (D.D.D.), Boston Children's Hospital, Boston, Massachussetts.
⁴ Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts; Department of Pediatrics (J.W.), Massachusetts General Hospital and Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachussetts.
⁵ Department of Nursing Science (P.H.), Professional Practice and Quality, Children's National Hospital, Washington, DC; Department of Pediatrics (P.H.), The George Washington University, Washington, DC.
⁶ Department of Psychosocial Oncology and Palliative Care (E.G.B., J.S.), Dana-Farber Cancer Institute, Boston Massachussetts; Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts.

PMID: 38679304
DOI: 10.1016/j.jpainsymman.2024.04.018

Abstract

Context: Parents of children who die in the pediatric intensive care unit (PICU) carry memories of their child's suffering throughout a lifelong grieving experience. Given their prolonged time at the bedside, PICU nurses are poised to attend to dying children's suffering.

Objectives: We aimed to explore how PICU nurses identify, assess, and attend to EOL suffering.

Methods: Interpretive descriptive qualitative study with thematic analysis of virtual focus groups from a geographically diverse sample of PICU nurses.

Results: Nurses participated in five focus groups (N = 19). Most identified as White (89%) females (95%) with a range of 1-24 years of PICU experience and involvement in >10 EOL care cases (89%). Nurses described approaches to suffering within five themes: 1) Identifying and easing perceptible elements; 2) Recognizing and responding to subtleties moment-to-moment; 3) Acclimating to family interdependence; 4) Synchronizing nurse in-the-room insight with systemic complexity; and 5) Accounting for ambiguity. Nurses detailed elements of suffering they could "fix" with straightforward, external interventions (e.g., pain medication). More complex tasks like optimizing care within familial and interprofessional team relationships while navigating psychosocial responses from children and families challenged nurses. Nurses attempted to minimize EOL suffering amidst ambiguity and complexity using internal processes including managing the environment and titrating moment-to-moment care.

Conclusions: While physical suffering may be remedied with direct nursing care, holistically attending to EOL suffering in the PICU requires both bolstering external processes and strengthening PICU nurses' internal resources. Improving psychosocial training and optimizing interprofessional care systems could better support dying children and their families.

Keywords: nursing; pediatric; pediatric intensive care; qualitative research.