Crit Care Nurse 2004 Aug; 24(4): 36-46
Clinical Article
Delirium Doulas
An Innovative Approach to Enhance Care for Critically Ill Older Adults
Michele C. Balas, RN, MSN, CCRN, CRNP, BC
Melissa Gale, RN, MSN, CRNP
Sarah H. Kagan, RN, PhD
Michele C. Balas, a recent recipient of the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholarship, is pursuing a doctorate in nursing at the University of Pennsylvania School of Nursing, Philadelphia, Pa. The focus of her investigation is variables that influence disparate outcomes of critically ill older adults.
Melissa Gale practices as a clinical faculty member, specializing in nursing care of older adults, at the University of Pennsylvania School of Nursing.
Sarah H. Kagan is an associate professor of gerontological nursing at the University of Pennsylvania School of Nursing. She teaches nursing of older adults and practices as gerontological clinical nurse specialist at the Hospital of the University of Pennsylvania in Philadelphia. She holds a secondary faculty appointment in the Department of Otorhinolaryngology: Head and Neck Surgery in the School of Medicine and collaborates with the University of Pennsylvania Cancer Center.
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Delirium is a healthcare issue that continues to challenge critical care nurses on a day-to-day basis. Management of patients with delirium is time intensive and costly, and poor outcomes are a risk. To maximize nursing care resources, critical care providers may need to work from novel perspectives and use new models to meet the care needs imposed by delirium. A doula (doó la) is traditionally described as a layperson who offers physical, emotional, and informational support to women in labor and the women’s partners. An innovative model for addressing the care needs of intensive care unit (ICU) patients includes using doulas to care for critically ill adults. In this article, we detail the application of the doula concept to delirium in critically ill older adults and explore the potential for improving the care of this frail, vulnerable population of patients. We review pertinent demographics, discuss delirium, and provide current options for care. Specific recommendations are made for the function of delirium doulas and implementation of a doula program.
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The Older Adult Population
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Our society is "graying" as older adults make up an increasingly larger percentage of the population. In the year 2002, adults 65 years and older numbered 35.6 million and accounted for approximately 12.3% of the population in the United States.1 Although this group is extremely diverse, some characteristics stand out. This segment of the population is getting older; among them, the frail old, persons older than 85 years, is the most rapidly growing group. Overall, older adults are more ethnically diverse than before, and their educational level is increasing.1 By the year 2030, the number of adults 65 years and over is expected to more than double.1
An analysis of the national hospital statistics for the year 2000, provided by the Agency of Healthcare Research and Quality, revealed that persons 65 years and older accounted for 12 736 530 (35%) of the total number of hospital discharges in the United States.2 Compared with younger patients, older adult patients had a longer mean length of hospital stay (5.8 days), higher mean charges ($118 116), and higher rates of death in the hospital, discharge to other institutions, and use of home health services after discharge.2 The Society of Critical Care Medicine reported that persons between the ages of 65 and 74 years used critical care services at a rate 4 times that of persons less than 65 years old, and the rate for persons 75 to 84 years old was 6 times higher.3
Because elderly patients have reduced compensatory mechanisms, increased illness severity, and more comorbid illnesses, hospitalized older adults appear to be at greater risk for iatrogenic medical injury than are their younger counterparts.4 It has been suggested that the development of delirium in hospitalized older adults is one indication of how the current healthcare delivery system is failing.5 As the acuity among patients in hospitals increases, staffing shortages and cost-cutting measures require flexibility, ingenuity, and "out of the box" thinking to address the care of critically ill older adults in the ICU.
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Delirium
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Delirium is defined as a disturbance of consciousness, attention, cognition, and perception that develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.6 It is a commonly encountered disturbance in the ICU. The development of delirium may complicate the hospital course of 2.3 million patients annually, at a cost of $4 billion.4 Although the true incidence and prevalence of delirium are unknown, a recent study7 indicated that more than 80% of patients experienced delirium during their hospitalization, and the majority of cases (74% of all cases of delirium) occurred initially in the ICU. Table 1
lists risk factors associated with the development of delirium in hospitalized older adults.
Often delirium in patients in the ICU may be misdiagnosed as "ICU psychosis." Some have argued that this term is dangerous because it implies that delirium is an expected outcome in ICU patients.8 Further, the use of this term may perpetuate the cycle of misdiagnosis, under-recognition, and inadequate treatment of delirium. Another possible reason for underrecognition is that nurses and physicians often expect delirious patients to be agitated, unruly, pulling at tubes, or actively hallucinating. However, the 3 clinical variants of delirium9 (Table 2) may have different behavioral manifestations. For example, in a recent study,7 94% of all episodes of delirium were the hypoactive, or quiet, type.
Associated mortality rates for patients in whom delirium develops range from 25% to 33%.5 Among hospitalized elderly patients, the development of delirium may double the risk of death and triple the risk that residential care (ie, nursing home care) will be required.10 The development of delirium is also associated with prolonged hospitalization, functional decline during hospitalization, increased risk for hospital-acquired complications, and increased admission to long-term–care facilities.11 Delirium is a strong predictor of hospital length of stay, even after severity of illness, age, sex, race, and days of psychoactive drug use are controlled for.7 The nature and prevalence of delirium and the potential to prevent its negative repercussions strongly suggest the need for an exploration of innovative approaches to this widespread problem.
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Care of Patients With Delirium
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Care of patients who have delirium has been described extensively.12–23 General goals of treatment for these patients include shortening the duration of delirium, preventing iatrogenic injury, offering emotional support to both patients and their families, maintaining prehospital functional status, and enhancing the quality of life after discharge from the hospital. Both pharmacological and nonpharmacological treatment options are available for patients with delirium. Early diagnosis and treatment of the underlying cause of the abnormality are essential first steps in management.
Because the behavioral manifestations of acute confusion and delirium often mimic each other, many treatment strategies used for confusion may be beneficial for patients with delirium. Researchers at the University of Iowa have developed guidelines for the treatment of acute confusion.24 Appropriate interventions for the care of patients who are acutely confused are divided into 10 domains. The interventions from the University of Iowa are either supported by research or commonly cited by authors despite a lack of research. The guidelines are intended to offer holistic support to those experiencing acute confusion.
A large amount of nursing and medical literature16,25–29 is devoted to the pharmacological management of ICU patients who are confused or delirious. Use of drugs for treatment of delirium often evokes strong debate about the potential risk-benefit ratio. Another method for controlling, or reversing, delirium in critically ill older adults is presented in the following sections.
Intuitively, one-to-one care, or constant observation, may be the ideal in the care of patients with delirium. Having someone stay with a delirious patient on a one-to-one basis allows constant supervision to prevent injury and provides respite for the patient’s family members when the patient experiences increased psychomotor agitation.30 Further, some of the characteristics of those who need one-to-one care are similar to those of patients who have delirium,31 including wandering, impulsive behavior, confusion in patients who can ambulate, and risk of falling.
Although few researchers have examined one-to-one care in the critical care setting, the efficacy of this strategy in other clinical settings has been investigated. One-to-one care by nursing students, in a variety of clinical settings, was deemed as an effective form of psychosocial intervention for patients.32 Counseling and information giving to patients on a one-to-one basis by nursing students were effective techniques for achieving improved clinical outcomes in a coronary care unit.33 The degree of trust in the nurse-patient relationship that developed throughout this care was also essential for active participation of the patients in therapies. In a study34 of alternatives to seclusion in psychiatric care, the use of one-toone nursing support was an effective strategy to deal with incidents of aggression.
Happ conducted a seminal study35 on how critical care nurses conceptualize the risk of treatment interference by patients, defined as disruption or removal of technological devices by patients, and the strategies the nurses use to avoid this problem. ICU nurses in the study assessed several factors when determining the risk for treatment interference from critically ill older adults (Table 3) and used several different strategies to decrease the interference, including verbal strategies, distraction, deception, comfort measures, use of fewer technological devices, monitoring by patients’ family members, and physical restraints. Most interesting are the comments made by experienced critical care nurses that use of physical restraints would be virtually unnecessary if the nurses could continuously "be with" high-risk patients. On the basis of these findings, Happ35 suggested that continuous observation to select high-risk patients should be explored and tested in the critical care setting.
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Use of Doulas in the Obstetric Setting
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Doulas provide physical, emotional, and informational assistance and support to pregnant women before, during, and after, childbirth.36 The care provided extends to the women’s partners, families, friends, and members of their support systems.37 It is not a big stretch to say that members of the healthcare team might also benefit from the use of doulas. With the current shortage of nurses and the increase in patients’ acuity, nurses and physicians often experience the strain of understaffing and are challenged in just meeting the basic physical needs of their patients. The use of doulas in the critical care setting would not supplant the care provided by the healthcare providers but rather would enhance it.
The earliest studies on the use of doulas to provide psychosocial support to women in labor were done in the 1980s.38,39 Since then, multiple trials of the use of doulas have been conducted in a variety of countries, including Canada, Guatemala, Belgium, France, Greece, Finland, South Africa, and the United States.39–44 Comparison of the effectiveness of doulas on an international basis is complicated by the diversity of practice settings, cultural variations in both providers and patients, and the organizational climate of the labor and delivery environment. In contrast to care in other countries, obstetric care in the United States is often more technologically advanced, sometimes allows the presence of support persons during delivery, and varies widely in the socioeconomic status of patients. Researchers in the United States have examined how these factors may interact with care delivery by doulas to influence maternal and fetal outcomes.
The Role of Doulas
Some of the skills that doulas provide for women in labor resemble parts of the University of Iowa guidelines for the care of patients with acute confusion.24 Physical comfort measures used by doulas for women in labor include using cool cloths or compresses, offering stroking or hand-holding, giving fluids to sip, assisting with positioning, and providing massage.45 Emotional support is given through reassurance, speaking in a soft and soothing voice, keeping the women company, offering encouragement, and providing continuity of care.45 Informational support may come in the form of advice or updates on the progress of labor.37 Finally, doulas advocate for the women in labor by interpreting the women’s needs to the healthcare staff, advocating on the women’s behalf, and supporting the women’s decisions.45
Doulas also may alter the hospital environment to make it more conducive to labor. They may dim the lights, play music, minimize distracting noises, use guided imagery or aromatherapy, or place meaningful items near the women in labor.46
Review of Research
Doula care has beneficial effects on a number of physical and psychosocial variables for both mothers and infants.38–41,44,45,47–49 The strength of these effects appears to be influenced by whether doula care is continuous or intermittent, if the doula is medically trained or a layperson, and various sociocultural and medical childbirth practices.50 A review of the pertinent research findings on the effects of doula care on maternal and infant outcomes is provided in Table 4.
The continuous presence of a doula during labor and delivery reduced the use of analgesics, forceps delivery, cesarean delivery, and duration of labor time.50 Intermittent support was not associated with these outcomes. One explanation for these findings was that in some of the studies the intermittent doulas were more likely to be experienced midwives or student midwives, who may have been more focused on providing medical care, experienced more distractions, or valued less the role of social support than did the lay doulas who provided continuous support.50
Women with lower incomes, less education, less preparation for childbirth, or no social support may particularly benefit from the use of doulas.47 Understanding why this population may benefit more than other women requires evaluating possible ways doulas may affect outcomes. For example, the sole presence of a doula in a busy labor area may decrease feelings of loneliness of the woman in labor, influence the staff to more closely follow unit protocols, and reduce the woman’s anxiety and hence decrease her circulating levels of catecholamines and enhance uterine contractility.41
Training, Certification, and Costs
Doula training programs often require some previous knowledge of childbirth. Training is generally formatted into an intensive 2- to 3-day seminar that includes hands-on practice of skills such as relaxation, breathing, positioning, movements to decrease pain and enhance the progress of labor, massage, and other comfort measures.37 For certification, most programs require a background of work and education in maternity or observation of a series of childbirth classes, a doula training course, background reading, and a written examination or essay that indicates understanding of methods for helping women during labor.37 Positive evaluations from patients, physicians, midwives, and nurses are also required.37 Certification is offered through local, national, and international organizations.37
Doulas are compensated for their work in different ways. The most common way is independent payment by the woman to whom doula services are provided or by the woman’s family. Most doulas charge a one-time fee of about $200 to $800.51 Other doula services are associated with or administered by a hospital or community service agency where the doulas may be volunteers or paid employees.37 Third-party reimbursement for doula services, via health maintenance organizations, has also been described.47
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A Proposed Role for Delirium Doulas in the Care of Critically Ill Older Adults
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The idea for tailoring the doula role to the care of critically ill older adults developed from interaction between faculty and students during the students’ geriatric clinical rotation. Third-year baccalaureate nursing students were asked to describe any previous experiences in the hospital setting. Several students were actively involved in developing a doula program at a local tertiary medical center. Unfamiliar with the role of doulas, the instructors asked the students to describe the students’ experiences with the program. Considering the parallels between doula support services and the ideal management of patients with delirium, this group of students and instructors suggested a program in which doulas are used for continuous, one-to-one care of patients with delirium in the ICU.
After reviewing the research on labor doulas, the group concluded that continual support in the areas of physical comfort measures, emotional support, informational support, and patient advocacy would be most applicable. Further, research24 indicates that maintaining physical comfort, enhancing social interactions, and improving environmental management are clearly linked to improved outcomes for patients who are acutely confused.24 The students and instructors envisioned that delirium doulas could work in conjunction with critical care nurses to provide support to elderly patients during the patients’ acute phase of illness. After further analysis, the group proposed that with appropriate training, delirium doulas would be able to initiate and implement many of the guidelines proposed by the researchers at the University of Iowa.24
Delirium doulas would provide care that differs objectively and philosophically from that of standard one-to-one care. Delirium doulas could provide physical, emotional, and informational assistance and support to patients who are experiencing delirium or acute confusion while in the ICU. The doulas would provide services not only to patients but to the patients’ families, friends, and healthcare providers. The overall goal would be to help patients achieve a safe passage from delirium to a state in which they could advocate for themselves.
Delirium doulas would not perform clinical tasks, diagnose medical conditions, offer second opinions, or give medical advice. They would not make decisions for patients with delirium or project the doulas’ own values and goals onto patients. Doulas would not take the place of nurses, physicians, nursing assistants, or patients’ family members; rather delirium doulas would be viewed as members of another discipline in the health-care team. The doulas and the health-care teams would work collectively to meet patients’ physical, emotional, and safety needs and the needs of the patients’ family members.
The doulas’ role would be supportive. Critical care nurses would assess each patient’s confusion and the need for supportive care and make appropriate recommendations to a doula. This practice would allow the doula to provide supportive care, such as hand-holding or minimizing distractions, and enable the nurses to focus on providing therapeutic nursing care. Delirium doulas would not view patients as patients but rather as frail, vulnerable persons in need of human contact and support.
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Potential Value of Doulas in the Critical Care Setting
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Although many of the recommendations from the University if Iowa listed under "Physiological Support/Pharmaceutical Interventions"24 appear to be purely within the domain of nursing, doulas may be able to add to this realm of care of critically ill older adults who have delirium. For example, doulas may be able to assist delirious patients with eating and drinking. This assistance might help establish or maintain normal fluid, electrolyte, and nutritional status. Doulas could provide patients with blankets or fans to achieve comfort in the environment and aid in maintenance of a normal body temperature. Doulas could help position patients more comfortably in bed or could inform nurses of patients’ complaints or nonverbal signals of pain or increased agitation that indicate a need for toileting, repositioning, or some other aspect of bodily comfort.
Doulas might also help create an environment more conducive to healing. They could assist patients with call lights when needed, tidy up patients’ rooms, and provide the needed supervision so use of restraints is reduced. Doulas could help ensure that all assistive devices patients need are available and ready to use. Simple, yet often-neglected services could be provided, such as cleaning patients’ glasses and making sure that hearing aids have batteries and that dentures are available when needed. Doulas could help maintain patients’ sleep-wake cycles by providing appropriate lighting, conversation, and possibly ambulation during the day. At night doulas could provide companionship and help maintain a quiet, sleep-enhancing atmosphere.
Doulas could be a source of support for patients and patients’ families. Doulas could encourage patients’ families to visit, provide the families with reassurance, and acknowledge family members’ fears and feelings. With proper training, doulas could use diversionary and reminiscing techniques with patients to facilitate resolution of delirium. Doulas could also be trained in reality orientation, validation, and resolution therapy skills. They could be a source of strength for patients’ families exhausted by the patients’ condition. Knowing that someone would "be there" at night with a patient might encourage the patient’s family to go home and rest themselves. Table 5 lists suggested ways delirium doulas could possibly help meet the guidelines proposed by the University of Iowa for care of patients with acute confusion.
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Potential Sources of Delirium Doulas
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The question arises of who will serve as delirium doulas? Volunteer programs, which have historically existed in hospitals across the United States, are an untapped resource for support for hospitalized older adults, many of whom may be contemporaries of persons who commonly volunteer. Local communities may be another source of volunteers. Among persons 65 years and older, 42% volunteer at least once a year.52
Components of successful volunteer programs should be applied to the development of volunteer delirium doula programs. Successful recruitment of delirium doulas would include an assessment of motivational characteristics common to persons who volunteer. The desire to serve, the opportunity to meet and be with people, and the chance to help others are all motivating factors for volunteers.52 We think that a delirium doula is likely to be a person of middle age, who may anticipate his or her own old age or who has experienced events similar to those critically ill elder patients may be enduring. Exploring the motivation of possible volunteers is crucial to the selection of potential doulas because of the demands of both the ICU environment and patients with delirium.
Furthermore, the experience of being a doula may be directly beneficial to a volunteer. Regular volunteering is associated with several important benefits, including increased life expectancy, improvement in physical and psychosocial well-being, and, possibly, enhancement of the immune system.52
Medical and nursing students are another group who might be excellent volunteers for a delirium doula program. These students may not have opportunities to work directly with patients in a critical care setting and may feel disadvantaged or overwhelmed during initial clinical rotations. The relationship could be beneficial for students because they could gain valuable practical experience in caring for patients and, perhaps, academic credit.
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Doula Training
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The training of delirium doulas needs careful consideration. We suggest that widespread use of their services should be implemented only after a carefully conducted trial to test both the safety and efficacy of using doulas in the ICU. Training would include information on the pathophysiology of delirium, critical care unit protocols, safety measures, and interpersonal skills and a specific foundation in the philosophical approach of doulas. The focus of the doula program would be emotional, physical, and psychological comfort measures for older ICU patients.
We envision an intensive 1- to 2-week seminar conducted by a program coordinator and experienced ICU nurses. During this time, the students in the program would practice hands-on skills such as relaxation techniques, assisting with positioning, and providing massage and other comfort measures. The students would be exposed to common ICU technology and instructed on the importance of close communication with the nursing staff. During the students’ first few sessions with patients, a mentor would be available for direct observation and for answering any questions that might arise. When the training is completed, certification might be an option.
A doula program would require a program coordinator and nursing liaison to ensure proper supervision and offer informational support for trainees when problems arise. To retain volunteers and prevent burnout, the program coordinator and nursing liaison would need to schedule regular meetings to foster group sharing and support. Finally, an evaluation method that incorporates input from staff, patients, delirium doulas, and patients’ family members would need to be designed and implemented.
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Limitations
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Despite the potential benefits of the proposed volunteer delirium doula program, possible barriers to implementation must be considered. After numerous discussions with students and instructors, we posit that the most important possible barriers are the legal and ethical issues associated with doula care. Other issues include selection of volunteers and conflicts with critical care staff.
As a hospital-sponsored program, the care provided by doulas must be explicitly endorsed by the institution. Thus, all proposed measures, especially hands-on care, must be carefully evaluated. Exploring liability and associated issues for the volunteers, the nurses, and the hospital is also essential. Volunteers usually work under the auspices of the volunteer department, yet they are not authorized to provide any hands-on care. Doulas working with critically ill patients with delirium would provide hands-on care in the form of stroking and hand-holding. Hospital medical departments would need to include coverage of doulas in the departments’ liability insurance, or volunteer services would need to expand their liability coverage.
Furthermore, an ethical issue associated with implementation of a doula program is the use of scarce resources. With research indicating that continuous doula care is more beneficial than intermittent doula care, how would the services of a single doula be used on a unit where several patients might benefit from doula care?
Selecting and training volunteers may be a challenge. Certainly persons who work closely with critically ill patients must have some knowledge of medical concepts related to delirium. The intensive training that would be required for an effective doula program requires that the volunteers be highly motivated to learn and relatively intelligent. Testing and screening protocols need to be developed to preselect interested volunteers to participate in the training. If a candidate went through the training but did not demonstrate proficiency as a doula, he or she would not be able to volunteer after a relatively large time investment. For this reason, traditional volunteers many not be a realistic source of doulas.
Implementation of a doula program also creates issues for clinical practice. In some high-intensity, high-acuity, high-technology hospital environments, a doula might be, or might be perceived to be, physically in the way of care. Moreover, in his or her capacity as an advocate for patients and patients’ families, particularly if he or she is very demanding or outspoken, a doula might not be welcomed by other care providers. Research53 on traditional doula programs indicates that many physicians, nurses, and midwives appreciate the extra attention given to their patients and the greater satisfaction experienced by women who are assisted by doulas.
Finally, financial support for the program must be considered. Possible sources of funding include grants, donations, and endowments. Once a delirium program is implemented, research will be required to evaluate the effectiveness of the program. If the results indicate that use of delirium doulas has a beneficial effect on patients’ outcomes, third-party reimbursement for the services of the doulas might be feasible.
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Conclusion
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Compared with current practice, a delirium doula program designed to assist in the care of critically ill older adults may offer vast advantages in the near and longer term. These advantages are supported by research in other groups of patients. Potential benefits of using doulas in the critical care setting include achieving a restraint-free, or least-restrictive, environment for care; reducing treatment interference; and, possibly, reducing older adults’ length of stay in the ICU. Freeing older adults of physical and chemical restraints alone may decrease the risk of functional loss and serious complications.54 These benefits may support better outcomes for patients, potentially reducing the morbidity and mortality rates in patients with delirium. Such a program may also help the nursing staff by increasing the time staff members have to work with other patients, consequently reducing staff members’ stress.
A delirium doula program can also be instrumental in providing support to patients’ families. By providing informational and emotional support, delirium doulas might reduce the stress experienced by patients’ families and caregivers. The societal benefits of the proposed program include likely decreases in the costs related to length of stay and promotion of the resolution of delirium, thus decreasing the number of patients who are delirious when discharged from critical care units and from the hospital to long-term care. Finally, a delirium doula program might offer an opportunity to enrich the lives of volunteers who would come to personally understand the rewards of therapeutic relationships with vulnerable ill older adults.
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Acknowledgments
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We thank the following for their contributions to the development of this article and the creativity and reflection they showed regarding the potential application of doulas in the critical care setting: Clinical Group Spring 1999: Lori Sherman, Lara Holbrook, Marisa Shea, Amelia Schutte, Benjamin Katz, Loren Wipff Fouts, and Katherine Hostvedt. Clinical Group Fall 2000: Christine Fenyus, Jessica Frounfelker, Jessica Schwarz, Kristin Roshelli, Wendy Black, and Katie Foster.
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The Older Adult Population
Delirium
