Weaning from mechanical ventilation – from the patient, next-of-kin and healthcare professionals’ perspective

Abstract: Critically ill patients with failing respiratory and vital body functions might need invasive mechanical ventilation (IMV). When the patient’s condition improves, the need for respiratory support decreases and weaning from IMV begins. Even though weaning is a central part of intensive care, a stringent and well-accepted definition of this concept is lacking, implying that meanings, descriptions, strategies, and routines vary. The weaning process involves the expertise of diverse healthcare professionals (HCP), whose roles differ between different contexts. Today, person-centred care (PCC) is common and widely spread in healthcare. Still, it is unclear how PCC is recognised, used,and implemented in intensive care and during weaning. The overall aim of the thesis was to explore and describe the process when weaning patients from invasive mechanical ventilation in the ICU from thepatient, next-of-kin, and health care professionals’ perspective. To achieve the thesis's overall and specific aims, four studies (study I-IV) using a qualitative, explorative and descriptive design were conducted. In study I, the patients’ perspectives on weaning were explored, i.e., their lived experience of being on IMV during weaning. Data were collected through 20 interviews and analysed by using a hermeneutic phenomenological approach. Study II explored the meaning of being a next-of-kin when the patient was weaning. The study included eight next-of-kin who were asked to write diary notes based on their experience while the patient was weaning, followed by interviews after the patient’s time in the intensive care unit (ICU). Data were analysed using a hermeneutic phenomenological approach. Study III and IV described and explored the HCP’ perspectives on weaning and the factors that influenced their decision-making. Twenty ICU nurses (study III) and 16 physicians (study IV) were interviewed to describe and explore the factors that influenced decision-making when weaning patients from IMV. Data were inductively analysed using qualitative content analysis.It was found that weaning was not a separate phenomenon for the patient and next-of-kin. It was challenging to distinguish and was intertwined with experiences of intensive care. Patients and next-of-kin had both favourable and depressing experiences, but the favourable ones were more clearly described than in previous research. Moreover, it was essential for the patients to be treated with humanity. This helped them endure the physical and cognitive strains of IMV and intensive care, gain confidence in their body’sability, be given hope, and experience a safe environment. This was strengthened by several circumstances where the relationship with others was central. For next-of-kin, it was essential to be close to the patient as this gave them strength to get through the ICU-time and with their support, patients’less favourable experiences were alleviated. Furthermore, their resources, capabilities, and suffering varied between persons and over time.Weaning was a delimited process with a clear goal for HCP, which was strongly influenced and linked to other care processes. ICU nurses and physicians conducted the weaning and decision-making aligned with the patient’s medical condition, strengths, and wishes. Weaning rarely followed any protocol and planning was not done consistently. Understanding the importance of a caring relationship for decision-making and how this could affect patients and the experiences of next-of-kin was lacking. Moreover, there seem to be ambiguities and unspoken expectations within and between the professions in the allocation of responsibilities regarding weaning.Furthermore, the teamwork dynamic influenced the weaning process, decision-making, and the prerequisites for person-centred weaning.These findings contribute to new, current, and in-depth knowledge of the weaning process. Based on this thesis's four perspectives, the concept of person-centred weaning appeared, which means to strive to retain and consider the patient as a capable person despite failing vital functions, voicelessness, vulnerability, and extended need for support and assistance. Furthermore, HCP need to be aware of the dynamic within the weaning process and the impact of the care culture on the quality and experience of the weaning. There is a need to optimise the team's prerequisites, collaboration, and resources at an organisational level to perform person-centred weaning and maybe optimise the weaning process.