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unrealistic expectations; and theneed for more education fornurses who care for terminallyill patients.

Nurses also identified fivemajor areas of internal conflict:feeling relief when the care theyprovide is switched from curativeto palliative; wanting dying pa-tients to be comfortable and fam-ilies to have good final memoriesof their loved ones; feeling aban-doned while carrying out physi-cians orders to stop care andpowerless because theyre unableto save the patient; conflicted

about administering medicationto keep patients comfortable thatmay also cause them harm; anddisturbed by younger terminal pa-tients who remind them of theirown mortality.

Five coping strategies werehighlighted: building trust withfamily members, crying, humor,talking to others about termi-nal care, and avoiding caringfor terminally ill patients. Somenurses also talked about having

a crusty attitude as a copingmechanism.

Nurses also suggested thatimproved education, increasedstaff support, and better com-munication would be helpful.

Espinosa L, et al. Crit Care Nurs Q 2010;33(3):273-81.

PRENATAL AND POSTPARTUM

DEPRESSION IN FATHERS

According to this study: Healthcareprovidersshouldbeaware that fathers-to-be and newfathers experience depression.

Fathers may experience pre-natal and postpartum de-

pression just as mothers do. Ameta-analysis by Paulson andBazemore included 43 interna-tional studies (17 were U.S. stud-ies) published between January1980 and October 2009. All

but three of the trials used self-reporting scales to define cases;

the others used an interview.There was a wide range in sam-ple size, from 23 to 10,975, fora total of 28,004 mothers and fa-thers included in the analysis.

The overall rate of paternaldepression between the first tri-mester of pregnancy and one yearpostpartum was 10%, with thelowest rates observed betweenbirth and three months postpar-tum and the highest rates betweenthree and six months postpartum.A higher rate was observed in theUnited States (14%) than interna-tionally (8%). Lower prevalence

was seen when interviews ratherthan rating scales were used todefine cases; however, since onlya few studies used interviews, fur-ther research is needed to verifythis finding.

Mothers had an overall de-pression rate of 24%, with thehighest rates occurring three tosix months after giving birth. Aswith fathers, a higher rate of ma-ternal depression was also ob-served in the United States (30%)

than in other countries (20%).Depression in fathers also showeda moderate positive correlationwith depression in mothers.

The authors concluded thatbecause the rate of depression infathers in these trials (10%) wastwice as high as that in men ingeneral (5%), according to na-tional prevalence data, prenataland postpartum depression dooccur in this population.

Paulson JF, Bazemore SD.JAMA 2010;303(19):1961-9.

DELIRIUM DIRECTLY RELATED TO

COGNITIVE IMPAIRMENT

According to this study: Longerdeliriumduringcritical

illness may predict cognitivedecline.

This prospective cohort studyexamined the effect of de-

lirium duration on long-termcognitive impairment in patients

receiving mechanical ventilationin an ICU. The cohort was drawnfrom the Awakening and Breath-ing Controlled (ABC) randomizedtrial and included adults mechan-ically ventilated for more than12 hours and later discharged.

A total of 77 patients (medianage, 61) were included in theanalysis. Patients were severelyill at hospital admission, and9% showed signs of preexistingcognitive impairment. Eighty-fourpercent had delirium while hospi-talized, for a median of two days,with half the patients delirious for

at least two days, and one in fourfor at least five days.Patients cognitive outcomes

were determined by a neuropsy-chologist three and 12 monthsafter study enrollment. A total of80% and 72% of patients werecognitively impaired at three and12 months, respectively. Cogni-tive impairment was directly re-lated to the duration of delirium,with longer delirium associatedwith more severe impairment at

both three and 12 months. Fivedays of delirium was associatedwith a 5-point lower cognitivebattery mean score than one dayof delirium when assessed threemonths after enrollment. Simi-larly, at the 12-month assess-ment, an increase from one tofive days of delirium resultedin a decrease of almost 7 pointsin the cognitive battery meanscore. The authors noted thatduration of mechanical ventila-tion wasnt related to cognitiveimpairment when evaluated atthree or 12 months.

While the study has draw-backs, such as limited generaliz-ability and possible confoundingfactors, the authors suggest thattheres enough evidence to showthat cognitive decline occurredin most patients during their ill-ness. Thus, delirium may predictcognitive impairment.

Girard TD, et al. Crit Care Med2010;38(7):1513-20.t

By Subhashni D. Singh Joy

ajn@wolterskluwer.com AJNJanuary 2011Vol. 111, No. 1 65