Studying communication about end-of-life care during the ICU family conference: Development of a framework

Prevalence and risk factors for post-traumatic stress disorder in relatives of out-of-hospital cardiac arrest patients

AIM

Prognostic uncertainty and surrogate decision-making demands associated with prolonged unconsciousness in out-of hospital cardiac arrest (OHCA) patients in the intensive care unit (ICU) may increase post-traumatic stress disorder (PTSD) risk in their relatives. Our aim was to study PTSD frequency and risk factors in relatives of OHCA patients.

METHODS

In this observational study 101 consecutive eligible adult relatives of OHCA patients were interviewed using validated questionnaires, the "Impact of Event Scale-Revised" to detect PTSD and the "Family-Satisfaction with Care in the ICU" to assess potential PTSD risk factors.

RESULTS

PTSD was detected in 40/101 relatives (40%). Multivariate logistic regression identified three significant PTSD predictors [odds ratio, 95% confidence interval]: female gender [3.30, 1.08-10.11], history of depression [3.63, 1.02-12.96], family perception of the patient's therapy as insufficient [18.40, 1.52-224.22]. Three other predictors were not significantly associated with PTSD (hypothermia treatment of the patient [2.86, 0.96-8.48]), delayed delivery of prognostic information by ICU staff [2.11, 0.83-5.38], family-ICU staff conflict [3.61, 0.71-18.40]). A prediction rule including six factors (p<0.15 each) showed high discrimination (area under the receiver-operating characteristic curve 0.74) with a stepwise increase in risk for PTSD from 0% (no risk factor) to 63% (≥3 risk factors). There was no evidence for effect modification either by survival status or neurological outcome.

CONCLUSION

Relatives of OHCA patients treated in the ICU are at increased risk of PTSD, which can be predicted based on six factors, three ICU-related and potentially at least partly modifiable. Further research is needed to validate our findings and to develop strategies to prevent PTSD in OHCA patients' relatives.

Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life

BACKGROUND

Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life.

OBJECTIVE

We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6 months of life for patients with chronic illness.

METHODS

Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6 months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service.

RESULTS

For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use.

CONCLUSIONS

We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

Limited family members/staff communication in intensive care units in the Czech and Slovak Republics considerably increases anxiety in patients' relatives--the DEPRESS study

BACKGROUND

Symptoms of anxiety and depression are common among family members of ICU patients and are culturally dependent. The aim of the study was to assess the prevalence of symptoms of anxiety and depression and associated factors in family members of ICU patients in two Central European countries.

METHODS

We conducted a prospective multicenter study involving 22 ICUs (250 beds) in the Czech and Slovak Republics. The Hospital Anxiety and Depression Scale (HADS) was used to assess symptoms of anxiety and depression in family members of ICU patients. Family member understanding of the patient's condition was assessed using a structured interview and a questionnaire was used to assess satisfaction with family member/ICU staff communication.

RESULTS

Twenty two intensive care units (both adult and pediatric) in academic medical centers and community hospitals participated in the study. During a 6 month period, 405 family members of 293 patients were enrolled. We found a high prevalence of anxiety and depression symptoms - 78% and 54%, respectively. Information leaflets distributed to family members did not lower incidences of anxiety/depression. Family members with symptoms of depression reported higher levels of satisfaction according to the modified Critical Care Family Needs Inventory. Extended contact between staff and family members was the only related factor associated with anxiety reduction (p = 0.001).

CONCLUSION

Family members of ICU patients in East European countries suffer from symptoms of anxiety and depression. We identified limited family member/ICU staff communication as an important health care professional-related factor associated with a higher incidence of symptoms of anxiety. This factor is potentially amenable to improvement and may serve as a target for proactive intervention proactive intervention.

Long-term persistence of quality improvements for an intensive care unit communication initiative using the VALUE strategy

PURPOSE

Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients.

MATERIALS AND METHODS

We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention.

RESULTS

Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities.

CONCLUSIONS

Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements.

Parents' perceptions of continuity of care in the neonatal intensive care unit: pilot testing an instrument and implications for the nurse-parent relationship

Nurse-parent relationships are a key aspect of high-quality family-centered care in the neonatal intensive care unit. Few studies have examined nursing continuity of care that includes (a) chronological continuity, that is, the number of nurses caring for an infant over time, (b) the consistency of information transferred to the parent and colleagues, and (c) the consistency of interactions between parent and nurse as an important factor in the nurse-parent relationship. The aims of this pilot study were to develop and test a scale of parental perceptions of nursing continuity of care in the newborn intensive care setting and to characterize the association between parents' perceptions and chronological nursing continuity. Fifty-four parents completed the Parents' Perceptions of Continuity Scale and a demographic questionnaire. Also, medical record and a count of the number of nurses caring for infant in past 7 days were collected. The Parents' Perceptions of Continuity Scale demonstrated good internal consistency (Cronbachα, 0.81). Parents' Perceptions of Continuity Scale scores were significantly associated with chronological nursing continuity, suggesting that the number of nurses caring for an infant plays a role in parents' perceptions of overall nursing continuity.

Characteristics of family conferences at the bedside versus the conference room in pediatric critical care

OBJECTIVE

To compare characteristics of family conferences at the bedside vs. the conference room in the PICU.

DESIGN

Single-site, cohort survey study.

SETTING

Thirty-three bed academic PICU in an urban setting.

PARTICIPANTS

Ten PICU physicians (90.9%) providing care to 29 patients whose families participated in 58 family conferences.

MEASUREMENTS AND MAIN RESULTS

Family conferences, defined as a meeting involving the parent(s) of a PICU patient and the critical care attending physician to discuss a treatment decision, redirection of care from curative to palliative, or deliver bad news, occurred most commonly among families of the sickest patients. Conferences were conducted at the bedside 20 times out of 58 (33%). Although physicians stated a general preference to discuss withdrawal or withholding care in the conference room, there was no difference in location during actual conferences. Physicians preferred the bedside when they wanted the patient to participate (p = 0.01) or because it was perceived to be easier (p < 0.0005) or faster (p = 0.016) to conduct, while the conference room was preferred when additional space was needed (p < 0.0005). Family conferences at the bedside were less likely to include a social worker (p < 0.0005), consultant physicians (p = 0.043), or father of the patient (p = 0.006) as compared with conferences in a conference room. Family conferences convened to discuss a treatment were followed by a decision within 24 hours (42% of the time) and a change in code status (32% of the time). In 32 of 58 family conferences (55%), the attending physician did not have a prior relationship with the family.

CONCLUSION

Family conferences in the PICU are common both at the bedside and in conference rooms in a subpopulation of the most critically ill children and frequently result in a treatment decision or change in code status.

Providing social support in a persuasive context: forms of social support reported by organ procurement coordinators

Eighty-five organ procurement coordinators (OPCs) completed face-to-face interviews designed to elicit the emotional and instrumental social support strategies communicated to potential donor families throughout the request for deceased organ donation. OPCs identified six forms of emotional support and eight forms of instrumental support, with greater reported use of instrumental support strategies. In terms of instrumental support, OPCs most frequently ensured in-hospital comfort (61.2%) or met the nutritional needs of family members (51.8%). With respect to emotional support, OPCs most often expressed sympathy (31.8%) to families and provided support in the form of physical contact (27.1%) with family members. Identifying the forms of social support used by OPCs is a first step toward understanding the strategies that are more (or less) effective in achieving persuasive and support goals.

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.

Application of the VALUE communication principles in ACTIVE hospice team meetings

BACKGROUND

The ACTIVE (Assessing Caregivers for Team Intervention through Video Encounters) intervention uses technology to enable family caregivers to participate in hospice interdisciplinary team (IDT) meetings from geographically remote locations. Previous research has suggested that effective communication is critical to the success of these meetings. The purpose of this study was to explore communication in ACTIVE IDT meetings involving family caregivers and to assess the degree to which hospice teams use specific communication principles (summarized in the mnemonic VALUE: value, acknowledge, listen, understand, and elicit), which have been supported in previous research in intensive care settings.

METHODS

Researchers analyzed team-family communication during 84 video- and/or audio-recorded care plan discussions that took place during ACTIVE team meetings, using a template approach to text analysis to determine the extent and quality of VALUE principles. The total content analyzed was 9 hours, 28 minutes in length.

RESULTS

Hospice clinicians routinely employed the VALUE communication principles in communication during ACTIVE IDT meetings with family caregivers, but the quality of this communication was frequently rated moderate or poor. The majority of such communication was task-focused. Less often, communication centered on emotional concerns and efforts to gain a more holistic understanding of patients and families.

CONCLUSIONS

This analysis suggests an opportunity for improving support for family members during ACTIVE IDT meetings. Members of hospice IDTs should remain aware of the opportunity for additional attention to the emotional realities of the hospice experience for family caregivers and could improve support for family caregivers during IDT meetings by ensuring that messages used to exemplify VALUE principles during team-family communication are of a high quality.

Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation

OBJECTIVE

Shared decision making is inadequate in intensive care units. Decision aids can improve decision making quality, though their role in an intensive care units setting is unclear. We aimed to develop and pilot test a decision aid for shared decision makers of patients undergoing prolonged mechanical ventilation.

SETTING

Intensive care units at three medical centers.

SUBJECTS

Fifty-three surrogate decision makers and 58 physicians.

DESIGN AND INTERVENTIONS

We developed the decision aid using defined methodological guidelines. After an iterative revision process, formative cognitive testing was performed among surrogate-physician dyads. Next, we compared the decision aid to usual care control in a prospective, before/after design study.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were physician-surrogate discordance for expected patient survival, comprehension of relevant medical information, and the quality of communication. Compared to control, the intervention group had lower surrogate-physician discordance (7 [10] vs. 43 [21]), greater comprehension (11.4 [0.7] vs. 6.1 [3.7]), and improved quality of communication (8.7 [1.3] vs. 8.4 [1.3]) (all p<.05) post-intervention. Hospital costs were lower in the intervention group ($110,609 vs. $178,618; p=.044); mortality did not differ by group (38% vs. 50%, p=.95). Ninety-four percent of the surrogates and 100% of the physicians reported that the decision aid was useful in decision making.

CONCLUSION

We developed a prolonged mechanical ventilation decision aid that is feasible, acceptable, and associated with both improved decision-making quality and less resource utilization. Further evaluation using a randomized controlled trial design is required to evaluate the decision aid's effect on long-term patient and surrogate outcomes.

An educational intervention to improve resident comfort with communication at the end of life

BACKGROUND

Approximately 20% of deaths in the United States occur in the intensive care unit (ICU). Physician trainees lack the practical communication skills required for end-of-life care, including establishing patient preferences, participating in shared decision making, discussing prognosis, and delivering bad news. Utilizing facilitated, case-based, peer interactions, we sought to assess the feasibility and impact of a novel resident curriculum in end-of-life education.

METHODS

The study took place at each of the three University of California, San Francisco (UCSF) teaching hospitals, and involved all internal medicine residents at UCSF. The curriculum consisted of two one-hour lunch conference sessions and six one-hour morning reports. A pre- and post-intervention electronic survey was administered.

RESULTS AND DISCUSSION

The teaching sessions offered in this study were well-attended and well-received by residents. Our curriculum impacted resident reports of comfort with specific topics in end-of-life care, including discussions of code status and comfort care. Furthermore, we found that this curriculum, although brief, demonstrated a small impact on resident reports of self-efficacy for communication. Our findings demonstrate the feasibility of incorporating end-of-life communication skills training into an existing internal medicine resident curriculum.

Prognostic communication of critical care nurses and physicians at end of life

Many critical care nurses express reluctance to communicate prognostic information to patients and family members, especially prior to physician communication of this information. Yet, the findings from this study indicate that critical care nurses play a crucial, complementary role to physicians in prognostic communication. Nurses' contributions result in a broader picture of prognosis to patients and family members and facilitate end-of-life discussions.

Struggling to do what is right for the child: pediatric life-support decisions among physicians and nurses in France and Quebec

This study examined (a) how physicians and nurses in France and Quebec make decisions about life-sustaining therapies (LSTs) for critically ill children and (b) corresponding ethical challenges. A focus groups design was used. A total of 21 physicians and 24 nurses participated (plus 9 physicians and 13 nurses from a prior secondary analysis). Principal differences related to roles: French participants regarded physicians as responsible for LST decisions, whereas Quebec participants recognized parents as formal decision-makers. Physicians stated they welcomed nurses' input but found they often did not participate, while nurses said they wanted to contribute but felt excluded. The LST limitations were based on conditions resulting in long-term consequences, irreversibility, continued deterioration, inability to engage in relationships and loss of autonomy. Ethical challenges related to: the fear of making errors in the face of uncertainty; struggling with patient/family consequences of one's actions; questioning the parental role and dealing with relational difficulties between physicians and nurses.

Family conference in the intensive care unit: a systematic review

For the past several decades, there has been an emphasis placed on family members of critically ill patients. Patients and families should not be excluded from learning about uncertainty, risks, and treatment choices. The purpose of this article was to review research studies related to family conferences and/or meetings that focus on both adult and pediatric patients in the intensive care unit.

The rapid response team nurse's role in end-of-life discussions during critical situations

Rapid response teams have been in existence in hospitals over the past decade. This team call may offer life-saving interventions that save lives but, in some cases, may prolong the dying process. There are times in which the rapid response team nurse and the intensive care nurses need to have an understanding of the families' perception of what is occurring and manage this situation through communication, empathy, and information sharing. The nurse must be involved during discussions surrounding end-of-life decisions. The nurse also has a role in supporting the family through this difficult time of making a decision to withhold life-supporting measures.

Do physicians disclose uncertainty when discussing prognosis in grave critical illness?

OBJECTIVE

Even when critically ill patients are almost certain to die from their illnesses, there is generally an element of prognostic uncertainty. Little is known about how physicians handle this uncertainty in conversations with surrogate decision makers. We sought to evaluate whether and how physicians discuss prognostic uncertainty with surrogate decision makers of patients who are highly likely, but not certain, to die.

DESIGN

We audiotaped and transcribed discussions between clinicians and surrogate decision makers at two major California teaching hospitals from 2006 through 2008. Physicians completed a questionnaire addressing their prognostic estimates for patients' survival to hospital discharge.

PARTICIPANTS

We included physicians and surrogates of 12 incapacitated, critically ill patients.

MEASUREMENTS

We analyzed transcripts of discussions in which physicians' estimates of patients' chances of hospital survival were 1% to 5%; we coded whether physicians disclosed the prognostic uncertainty and, if so, how they conveyed that death was highly likely but not certain.

RESULTS

Physicians' estimates of short-term survival were 1% to 5% for 12 of the 70 patients enrolled in the original study. In 8 of 12 cases, physicians conveyed prognostic uncertainty by using probabilistic language or by an explicit mention of uncertainty. In four cases, physicians made at least one statement that either implied or was ambiguous about whether death was certain.

CONCLUSION

We observed variability in how physicians handle prognostic uncertainty in their discussions with surrogates of patients who are highly likely, but not certain, to die, including some circumstances in which physicians stated or implied that death was certain.

Pediatric intensive care unit family conferences: one mode of communication for discussing end-of-life care decisions

OBJECTIVE

To examine clinicians' and parents' reflections on pediatric intensive care unit family conferences in the context of discussion about end-of-life care decision making.

DESIGN

Retrospective qualitative study.

SETTING

A university-based hospital.

PARTICIPANTS

Eighteen parents of children who died in the pediatric intensive care unit and 48 pediatric intensive care unit clinicians (physicians, nurses, social workers, child-life specialists, chaplains, and case managers).

INTERVENTIONS

In-depth, semistructured focus groups and one-on-one interviews designed to explore experiences in end-of-life care decision making.

MEASUREMENTS AND MAIN RESULTS

We identified comments about family conferences in all clinician focus groups/interviews, except one individual nurse interview, and in 13 of the 18 parent interviews. Comments from parents were sparse compared with those from clinicians. Four topics emerged: purpose, structural aspects, challenges, and suggestions for improvement. We identified three purposes for family conferences: communication between clinicians and parents; communication among clinicians; and support of families. Described structural aspects of family conferences included: preconference planning, communication during conferences, and postconference processing. Challenges noted involved communicating with parents during family conferences, such as: difficulties associated with having multiple services involved; balancing messages of hope and realism; using understandable language; and communicating with non-English-speakers. Participants described additional challenges related to the logistics of organizing family conferences. Suggestions focused on methods to improve communication in, organization of, and preparation for family conferences.

CONCLUSIONS

Pediatric intensive care unit clinicians in this study perceive family conferences as having an important role in end-of-life care decision making. The paucity of data from parents, an important finding itself, limits our ability to comment on parents' perceptions of family conferences. Prospective research of pediatric intensive care unit family conferences, with specific attention to parents' experiences and to all aspects of family conferences, including pre- and postconference events, should seek to understand the role and impact of this mode of communication on end-of-life care decision making and to determine the need for improvement to family conferences.

Qualitative analysis of an intensive care unit family satisfaction survey

OBJECTIVES

To describe the qualitative findings from a family satisfaction survey to identify and describe the themes that characterize family members' intensive care unit experiences.

DESIGN

As part of a larger mixed-methods study to determine the relationship between organizational culture and family satisfaction in critical care, family members of eligible patients in intensive care units completed a Family Satisfaction Survey (FS-ICU 24), which included three open-ended questions about strengths and weaknesses of the intensive care unit based on the family members' experiences and perspectives. Responses to these questions were coded and analyzed to identify key themes.

SETTING

Surveys were administered in 23 intensive care units from across Canada.

PARTICIPANTS

Surveys were completed by family members of patients who were in the intensive care unit for >48 hrs and who had been visited by the family member at least once during their intensive care unit stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 1381 surveys were distributed and 880 responses were received. Intensive care unit experiences were found to be variable within and among intensive care units. Six themes emerged as central to respondents' satisfaction: quality of staff, overall quality of medical care, compassion and respect shown to the patient and family, communication with doctors, waiting room, and patient room. Within three themes, positive comments were more common than negative comments: quality of the staff (66% vs. 23%), overall quality of medical care provided (33% vs. 2%), and compassion and respect shown to the patient and family (29% vs. 12%). Within the other three themes, positive comments were less common than negative comments: communication with doctors (18% vs. 20%), waiting room (1% vs. 8%), and patient rooms (0.4% vs. 5%).

CONCLUSIONS

The study provided improved understanding of why family members are satisfied or dissatisfied with particular elements of the intensive care unit and this knowledge can be used to modify intensive care units to better meet the physical and emotional needs of the families of intensive care unit patients.

The family conference in oncology: benefits for the patient, family, and physician

The family conference (FC) is a forum for communication with both the patient and family to discuss essential information about medical, educational, and psychosocial needs. It ensures appropriate decision-making, which is integral to comprehensive cancer care. Inclusion of the family creates opportunities and challenges. The main opportunities are for the family to share support for the patient and collaborate with the medical team. This can ease adaptation throughout the illness course with better adherence to recommended treatment plans and greater satisfaction with medical care. The challenge is to manage communication to evolve understanding when treatment outcomes are not curative, and to meet the medical information and psychosocial needs of the patient and family. The FC aim is to give the family confidence by: (1) providing a calm discussion and understanding the illness and treatment; (2) offering a sense of safety that patient's goals will be balanced by the impact on the family caregivers; (3) affording the opportunity to connect and sustain each other; (4) sharing hope and mutual empathy; and (5) maintaining self-efficacy to manage their needs. Using the FC to discuss the plan of care and at the same time assisting the family to process the impact of the illness optimizes benefit for the patient, family, and physician.

End-of-life care in an acute care hospital: linking policy and practice

The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be effective, health care professionals who provide hospital care will need to respond to its patient-centered purpose. Health services will also be called upon to train health care professionals to work with dying people in a more participatory way and to assist them to develop the clinical processes that support shared decision making. Health professionals who manage clinical workplaces become central in reshaping this practice environment by promoting patient-centered care policy objectives and restructuring health service systems to routinely incorporate patient and family preferences about care at key points in the patient's care episode.

Communication with families facing life-threatening illness: a research-based model for family conferences

BACKGROUND

Communication is an ongoing challenge for clinicians working with people facing life-threatening illnesses and end of life. Family conferences offer patient-focused, family-oriented care that brings together patients, family members, and health care providers.

OBJECTIVE

The aim of this study was to develop a research-based model for family conferences to help physicians and other health care providers conduct such conferences effectively and improve communication with patients and families.

DESIGN

We prospectively studied family conferences for patients facing life-threatening illness in two inpatient medical centers. We videotape and audiotape recorded real-life conferences and postconference interviews with participants.

PARTICIPANTS

Twenty-four family conferences were included in the study. Participants consisted of 24 patients, 10 of whom took part in the family conferences, 49 family members, and 85 health care providers.

APPROACH

A multidisciplinary team conducted a qualitative analysis of the videotaped and audiotaped materials using thematic analysis. The team used a multistage approach to independently and collectively analyze and integrate three data sources.

MAIN RESULTS

The resulting theoretical model for family conferences has 4 main components. These include the underlying structural context of conference organization and the key process components of negotiation and personal stance. Emotional engagement by health care providers, emotion work, appears central to the impact of these components on the successful outcome of the conference. In addition to the theoretical model, the authors found that family conference participants place specific value on the "simultaneous presence" of conference attendees that leads to being on the "same page."

CONCLUSIONS

Physicians and other health care professionals can use the model as a guide for conducting family conferences and strengthening communication with patients, families and colleagues.

Studying physician-patient communication in the acute care setting: the hospitalist rapport study

OBJECTIVE

To assess the feasibility of studying physician-patient communication in the acute care setting.

METHODS

We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked.

RESULTS

Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians' primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: (1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities and (2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges.

CONCLUSION

Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection.

PRACTICE IMPLICATIONS

These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment.

Cross-cultural communication and use of the family meeting in palliative care

Terminally-ill patients and their families often report poor communication and limited understanding of the patient's diagnosis, prognosis, and treatment plan; these deficits can be exacerbated by cross-cultural issues. Although family meetings are frequently recommended to facilitate provider-family communication, a more structured, evidence-based approach to their use may improve outcomes. Drawing on research and guidelines from critical care, palliative care, and cross-cultural communication, we propose a framework for conducting family meetings with consideration for cross-cultural issues.

Directly observed patient-physician discussions in palliative and end-of-life care: a systematic review of the literature

OBJECTIVES

To review studies that used direct observation (i.e., videotaping or audiotaping) methods in palliative/end-of-life care communication research.

DESIGN

Descriptive thematic analysis.

SETTING

Multinational studies were conducted in both the outpatient and inpatient setting.

MEASUREMENTS

Extensive bibliographic searches (January 1, 1998 to July 31, 2009) of English-language literature involving physician-patient (or physician-family) interactions were conducted and augmented by reviews of reference listings. Three investigators independently abstracted key information from each article.

RESULTS

Of the 20 retained articles, most enrolled young-old participants (mean age, 60 years) who were white and had a cancer diagnosis. Patient/family participation rates ranged from 68% to 89% demonstrating feasibility of this approach when studying palliative/end-of-life care communication issues. Four common themes were identified: (1) physicians focus on medical/technical and avoid emotional/quality of life issues; (2) sensitive topics are perceived by physicians to take longer to discuss and often do take longer to discuss; (3) physicians dominate discussions; and (4) patient/family satisfaction is associated with supportive physician behaviors.

CONCLUSIONS

This study demonstrates that direct observation methods can be feasibly used when studying physician-patient/physician-family communication in palliative/end-of-life care, but few investigations have utilized this approach. This article highlights areas that need improvement, including physicians' ability to address patient/family emotional issues and provide what patients and families find most satisfying (participation and support). A particular focus on older patients and patients with end-stage or late-stage chronic (noncancer) illness, the adaptation/application of existing communication measurement tools to capture palliative care communication issues, and development of corresponding outcome measures to assess impact is now needed.

Communication in critical care: family rounds in the intensive care unit

BACKGROUND

Communication with family members of patients in intensive care units is challenging and fraught with dissatisfaction.

OBJECTIVES

We hypothesized that family attendance at structured interdisciplinary family rounds would enhance communication and facilitate end-of-life planning (when appropriate).

METHODS

The study was conducted in the 26-bed medical intensive care unit of a tertiary care, academic medical center from April through October 2006. Starting in July 2006, families were invited to attend daily interdisciplinary rounds where the medical team discussed the plan for care. Family members were surveyed at least 1 month after the patient's stay in the unit, completing the validated "Family Satisfaction in the ICU" tool before and after implementation of family rounds.

RESULTS

Of 227 patients enrolled, 187 patients survived and 40 died. Among families of survivors, participation in family rounds was associated with higher family satisfaction regarding frequency of communication with physicians (P = .004) and support during decision making (P = .005). Participation decreased satisfaction regarding time for decision making (P = .02). Overall satisfaction scores did not differ between families who attended rounds and families who did not. For families of patients who died, participation in family rounds did not significantly change satisfaction.

CONCLUSIONS

In the context of this pilot study of family rounds, certain elements of satisfaction were improved, but not overall satisfaction. The findings indicate that structured interdisciplinary family rounds can improve some families' satisfaction, whereas some families feel rushed to make decisions. More work is needed to optimize communication between staff in the intensive care unit and patients' families, families' comprehension, and the effects on staff workload.

A randomized trial of two methods to disclose prognosis to surrogate decision makers in intensive care units

RATIONALE

Surrogate decision makers and clinicians often have discordant perceptions about a patient's prognosis. There is a paucity of empirical data to guide communication about prognosis.

OBJECTIVES

To assess: (1) whether numeric or qualitative statements more reliably convey prognostic estimates; and (2) whether surrogates believe physicians' prognostic estimates.

METHODS

A total of 169 surrogate decision makers for intensive care unit patients were randomized to view 1 of 2 versions of a video portraying a simulated family conference involving a hypothetical patient. The videos varied only by whether prognosis was conveyed in numeric terms ("10% chance of surviving") or qualitative terms ("very unlikely" to survive).

MEASUREMENTS AND MAIN RESULTS

We assessed: (1) surrogates' personal estimates of the patient's prognosis; and (2) surrogates' understanding of the physician's prognostic estimate. Neither surrogates' personal estimates nor their understanding of the physician's prognostication differed when prognosis was conveyed numerically versus qualitatively (surrogates' estimate, 22 ± 23% chance of survival versus 26 ± 24%, P = 0.26; understanding of physician's estimate, 17 ± 22% chance of survival versus 16 ± 17%, P = 0.62). One in five surrogates estimated the patient's prognosis was greater than 20% more optimistic than the physician's prognostication. Less trust in physicians was associated with larger discrepancies between surrogates' personal estimates and their understanding of the physician's estimate.

CONCLUSIONS

Neither numeric nor qualitative statements reliably convey news of a poor prognosis to surrogates in intensive care units. Many surrogates do not view physicians' prognostications as absolutely accurate. Factors other than ineffective communication may contribute to physician-surrogate discordance about prognosis.

Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU

BACKGROUND

Little information exists about the expected time to death after terminal withdrawal of mechanical ventilation. We sought to determine the independent predictors of time to death after withdrawal of mechanical ventilation.

METHODS

We conducted a secondary analysis from a cluster randomized trial of an end-of-life care intervention. We studied 1,505 adult patients in 14 hospitals in Washington State who died within or shortly after discharge from an ICU following terminal withdrawal of mechanical ventilation (August 2003 to February 2008). Time to death and its predictors were abstracted from the patients' charts and death certificates. Predictors included demographics, proxies of severity of illness, life-sustaining therapies, and International Classification of Diseases, 9th ed., Clinical Modification codes.

RESULTS

The median (interquartile range [IQR]) age of the cohort was 71 years (58-80 years), and 44% were women. The median (IQR) time to death after withdrawal of ventilation was 0.93 hours (0.25-5.5 hours). Using Cox regression, the independent predictors of a shorter time to death were nonwhite race (hazard ratio [HR], 1.17; 95% CI, 1.01-1.35), number of organ failures (per-organ HR, 1.11; 95% CI, 1.04-1.19), vasopressors (HR, 1.67; 95% CI, 1.49-1.88), IV fluids (HR, 1.16; 95% CI, 1.01-1.32), and surgical vs medical service (HR, 1.29; 95% CI, 1.06-1.56). Predictors of longer time to death were older age (per-decade HR, 0.95; 95% CI, 0.90-0.99) and female sex (HR, 0.86; 95% CI, 0.77-0.97).

CONCLUSIONS

Time to death after withdrawal of mechanical ventilation varies widely, yet the majority of patients die within 24 hours. Subsequent validation of these predictors may help to inform family counseling at the end of life.

Expanding the paradigm of the physician's role in surrogate decision-making: an empirically derived framework

BACKGROUND

Little is known about what role physicians take in the decision-making process about life support in intensive care units.

OBJECTIVE

To determine how responsibility is balanced between physicians and surrogates for life support decisions and to empirically develop a framework to describe different models of physician involvement.

DESIGN

Multi-centered study of audio-taped clinician-family conferences with a derivation and validation cohort.

SETTING

Intensive care units of four hospitals in Seattle, Washington, in 2000 to 2002 and two hospitals in San Francisco, California, in 2006 to 2008.

PARTICIPANTS

Four hundred fourteen clinicians and 495 surrogates who were involved in 162 life support decisions.

RESULTS

In the derivation cohort (n = 63 decisions), no clinician inquired about surrogates' preferred role in decision-making. Physicians took one of four distinct roles: 1) informative role (7 of 63) in which the physician provided information about the patient's medical condition, prognosis, and treatment options but did not elicit information about the patient's values, engage in deliberations, or provide a recommendation about whether to continue life support; 2) facilitative role (23 of 63), in which the physician refrained from providing a recommendation but actively guided the surrogate through a process of clarifying the patients' values and applying those values to the decision; 3) collaborative role (32 of 63), in which the physician shared in deliberations with the family and provided a recommendation; and 4) directive role (1 of 63), in which the physician assumed all responsibility for, and informed the family of, the decision. In 10 out of 20 conferences in which surrogates requested a recommendation, the physician refused to provide one. The validation cohort revealed a similar frequency of use of the four roles, and frequent refusal by physicians to provide treatment recommendations.

CONCLUSIONS

There is considerable variability in the roles physicians take in decision-making about life support with surrogates but little negotiation of desired roles. We present an empirically derived framework that provides a more comprehensive view of physicians' possible roles.

Improving clinical trials in the critically ill

OBJECTIVE

To propose ways in which clinical trials in intensive care can be improved.

METHODS

An international roundtable conference was convened focused on improvement in three broad areas: translation of new knowledge from bench to bedside; design and conduct of clinical trials; and clinical trial infrastructure and environment.

RESULTS

The roundtable recommendations were: improvement in clinical trials is a multistep process from better preclinical studies to better clinical trial methodology; new technologies should be used to improve models of critical illness; diseasomes and theragnostics will aid inpatient population selection and more appropriate targeting of interventions; broader study end points should include morbidity as well as mortality; more multicenter studies should be conducted by national and international networks or clinical trials groups; and better collaboration is needed with the industry.

CONCLUSIONS

There was broad agreement among the roundtable participants regarding a number of explicit opportunities for the improvement of clinical trials in critical care.

Bereaved hospice caregivers' views of the transition to hospice

This study was conducted to explore the communication process between patients, caregivers, and health care professionals, including social workers, through which the decision to choose hospice occurred. Ten bereaved hospice caregivers of patients over age 60 receiving home hospice services participated in this qualitative (phenomenological) study. They represented a range of patient and caregiver characteristics such as age, ethnicity, diagnoses, length of hospice service use, and caregiver relationship to patient. A semi-structured interview guide was used to capture key components in the end-of-life communication process, including discussions caregivers had with health care professionals regarding patients' diagnoses, prognoses, end-of-life care treatment options, and eventual referral to hospice. Themes that emerged included: involvement of health care professionals, relationship with physicians, involvement of patients in decisions, content of discussion, understanding of hospice, and suggestions for improvement. Physicians and social workers were noted to be most involved in the communication, decision making, and transition to hospice; however, a need exists for a more coordinated approach to discussing end-of-life care options with seriously ill patients and their families.

The "big picture": communicating with families about end-of-life care in intensive care unit

This article presents the findings of a qualitative study investigating how critical care nurses include families in end-of-life care. The major theme, "Supporting the Families' Journey Through the Dying Process," illustrates how critical care nurses organize information to construct the "big picture" of the patients' deteriorating status and artfully communicate this to families.

Are physicians' recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate

RATIONALE

Although there is a growing belief that physicians should routinely provide a recommendation to surrogates during deliberations about withdrawing life support, there is a paucity of empirical data on surrogates' perspectives on this topic.

OBJECTIVES

To understand the attitudes of surrogate decision-makers toward receiving a physician's recommendation during deliberations about whether to limit life support for an incapacitated patient.

METHODS

We conducted a prospective, mixed methods study among 169 surrogate decision-makers for critically ill patients. Surrogates sequentially viewed two videos of simulated physician-surrogate discussions about whether to limit life support, which varied only by whether the physician gave a recommendation.

MEASUREMENTS AND MAIN RESULTS

The main quantitative outcome was whether surrogates preferred to receive a physicians' recommendation. Surrogates also participated in an in-depth, semistructured interview to explore the reasons for their preference. Fifty-six percent (95/169) of surrogates preferred to receive a recommendation, 42% (70/169) preferred not to receive a recommendation, and 2% (4/169) felt that both approaches were equally acceptable. We identified four main themes that explained surrogates' preferences, including surrogates' perceptions of physicians' appropriate role in life or death decisions and their perceptions of the positive or negative consequences of a recommendation on the physician-surrogate relationship, on the decision-making process, and on long-term regret for the family.

CONCLUSIONS

There is no consensus among surrogates about whether physicians should routinely provide a recommendation regarding life support decisions for incapacitated patients. These findings suggest that physicians should ask surrogates whether they wish to receive a recommendation regarding life support decisions and should be flexible in their approach to decision-making.

End-of-life decision making and emotional burden: placing family meetings in context

BACKGROUND

Helping families make end-of-life care decisions can be challenging for health care providers in an intensive care unit (ICU). Family meetings facilitated by palliative care consult services (PCCS) have been recommended and found effective for improving support for families in these difficult situations. These services can be improved with a deeper understanding of factors associated with emotional burden in the aftermath of end-of-life decision making.

OBJECTIVE

This qualitative study seeks to provide a better understanding of family experiences and emotional burden surrounding end-of-life decision making.

PARTICIPANTS AND METHODS

We conducted in-depth, semistructured interviews with 23 family members following the death of a loved one in the ICU. All participants had been involved in a PCCS-led family meeting concerning end-of-life decisions about their loved one. Methodology from grounded theory was used to analyze the content of transcripts and to build a theoretical model.

RESULTS

From the perspective of the family, decision making at the end of life is described within a theoretical model of salient experiences that are relevant to families' emotional burdens. Three temporal stages were evident: (1) the illness experience, (2) decision making in the family meeting, and (3) the dying process. However, emotional burden in the form of lingering questions and resentment was more common when families reported having negative experiences during the final hospital stay.

CONCLUSIONS

Supportive responsiveness from the PCCS for families who have experienced critical incidents or who have unanswered questions or resentment about treatment may be an important consideration to alleviate later emotional burden.

Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients

PURPOSE

In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions.

MATERIALS AND METHODS

Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes.

RESULTS

Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P < .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5).

CONCLUSIONS

Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.

Life support decision making in critical care: Identifying and appraising the qualitative research evidence

OBJECTIVE

The objective of this study is to identify and appraise qualitative research evidence on the experience of making life-support decisions in critical care.

DATA SOURCES

In six databases and supplementary sources, we sought original research published from January 1990 through June 2008 reporting qualitative empirical studies of the experience of life-support decision making in critical care settings.

STUDY SELECTION

Fifty-three journal articles and monographs were included. Of these, 25 reported prospective studies and 28 reported retrospective studies.

DATA EXTRACTION

We abstracted methodologic characteristics relevant to the basic critical appraisal of qualitative research (prospective data collection, ethics approval, purposive sampling, iterative data collection and analysis, and any method to corroborate findings).

DATA SYNTHESIS

Qualitative research traditions represented include grounded theory (n = 15, 28%), ethnography or naturalistic methods (n = 15, 28%), phenomenology (n = 9, 17%), and other or unspecified approaches (n = 14, 26%). All 53 documents describe the research setting; 97% indicate purposive sampling of participants. Studies vary in their capture of multidisciplinary clinician and family perspectives. Thirty-one (58%) report research ethics board review. Only 49% report iterative data collection and analysis, and eight documents (15%) describe an analytically driven stopping point for data collection. Thirty-two documents (60%) indicated a method for corroborating findings.

CONCLUSIONS

Qualitative evidence often appears outside of clinical journals, with most research from the United States. Prospective, observation-based studies follow life-support decision making directly. These involve a variety of participants and yield important insights into interactions, communication, and dynamics. Retrospective, interview-based studies lack this direct engagement, but focus on the recollections of fewer types of participants (particularly patients and physicians), and typically address specific issues (communication and stress). Both designs can provide useful reflections for improving care. Given the diversity of qualitative research in critical care, room for improvement exists regarding both the quality and transparency of reported methodology.

Difficult conversations: improving communication skills and relational abilities in health care

BACKGROUND

Communication skills and relational abilities are essential core competencies that are associated with improved health outcomes, better patient adherence, fewer malpractice claims, and enhanced satisfaction with care. Yet, corresponding educational opportunities are sorely underrepresented and undervalued.

OBJECTIVE

To evaluate the impact of an interdisciplinary experiential learning paradigm to improve communication skills and relational abilities of pediatric critical care practitioners.

DESIGN

Prepost design, including baseline, immediate follow-up, and 5-month self-report questionnaires.

SETTING

Tertiary care pediatric hospital, Children's Hospital Boston.

PARTICIPANTS

One hundred six interdisciplinary clinicians with a range of experience levels and clinical specialties.

MEASUREMENTS

Participants rated their sense of preparation, communication and relational skills, confidence, and anxiety. Open-ended questions asked participants about lessons learned, aspects of the training they found most helpful, and suggestions to improve the training.

MAIN RESULTS

When questions were posed in a yes/no format, participants were nearly unanimous (93% to 98%) that the training had improved their sense of preparation, communication skills, and confidence immediately after and 5 months posttraining. Ninety percent of participants reported improvements in establishing relationships immediately after the training and 84% reported improvements 5 months posttraining. Eighty-two percent reported reduced anxiety immediately after training and 74% experienced reduced anxiety 5 months posttraining. On Likert items, 70% estimated their preparation had improved; 40% to 70% reported improvements in communication skills, confidence and anxiety, and 15% in relationship skills. Four qualitative themes emerged: identifying one's existing competence; integrating new communication skills and relational abilities; appreciating interdisciplinary collaboration; and valuing the learning itself.

CONCLUSIONS

A 1-day experiential learning paradigm focused on communication skills and relational abilities was highly valued, clinically useful, and logistically feasible. Participants reported better preparation, improved communication and relational skills, greater confidence, and reduced anxiety. Participants deepened their understanding of family perspectives, recognized valuable existing competencies, and strengthened their commitment to interdisciplinary teamwork.

Ethics review: end of life legislation--the French model

French law 2005-370 of April 22, 2005 (Leonetti's law) brings new rights to patients and clarifies medical practices regarding end of life care. This new law prohibits unreasonable obstinacy in investigations or therapeutics and authorizes the withholding or withdrawal of treatments when they appear "useless, disproportionate or having no other effect than solely the artificial preservation of life". Relief from pain is a fundamental right of patients. With regard to pain control, the law also allows doctors to dispense to patients "in an advanced or final phase of a serious and incurable affliction" anti-pain treatments as needed, even if these treatments, as a side effect, hasten their death. The drafting of advance directives regarding end of life constitutes a new right of patients. The decision to withdraw or withhold a treatment from a patient unable to express their will has to take into account the wishes they might have expressed through advance directives, and/or the wishes of a trusted person or, lastly, of the family. Before making any decision, physicians should respect a collegial medical procedure. Euthanasia defined as the act of terminating one's life on a patient's explicit request remains illegal.

Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences

OBJECTIVE

Family communication is important for delivering high quality end-of-life care in the intensive care unit, yet little research has been conducted to describe and evaluate clinician-family communication with non-English-speaking family members. We assessed clinician-family communication during intensive care unit family conferences involving interpreters and compared it with conferences without interpreters.

DESIGN

Cross-sectional descriptive study.

SETTING

Family conferences in the intensive care units of four hospitals during which discussions about withdrawing life support or delivery of bad news were likely to occur.

PARTICIPANTS

Seventy family members from ten interpreted conferences and 214 family members from 51 noninterpreted conferences. Nine different physicians led interpreted conferences and 36 different physicians led noninterpreted conferences.

MEASUREMENTS

All 61 conferences were audiotaped. We measured the duration of the time that families, interpreters, and clinicians spoke during the conference, and we tallied the number of supportive statements issued by clinicians in each conference.

RESULTS

The mean conference time was 26.3 +/- 13 mins for interpreted and 32 +/- 15 mins for noninterpreted conferences (p = 0.25). The duration of clinician speech was 10.9 +/- 5.8 mins for interpreted conferences and 19.6 +/- 10.2 mins for noninterpreted conferences (p = 0.001). The amount of clinician speech as a proportion of total speech time was 42.7% in interpreted conferences and 60.5% in noninterpreted conferences (p = 0.004). Interpreter speech accounted for 7.9 +/- 4.4 mins and 32% of speech in interpreter conferences. Interpreted conferences contained fewer clinician statements providing support for families, including valuing families' input (p = 0.01), easing emotional burdens (p < 0.01), and active listening (p < 0.01).

CONCLUSIONS

This study suggests that families with non-English-speaking members may be at increased risk of receiving less information about their loved one's critical illness as well as less emotional support from their clinicians. Future studies should identify ways to improve communication with, and support for, non-English-speaking families of critically ill patients.

Qualitative research: adding drive and dimension to clinical research

Qualitative research and its methods stem from the social sciences and can be used to describe and interpret complex phenomena that involve individuals' views, beliefs, preferences, and subjective responses to places and people. Thus, qualitative research explores the many subjective factors that may influence patient outcomes, staff well-being, and healthcare quality, yet fail to lend themselves to the hypothesis-testing approach that characterizes quantitative research. Qualitative research is valuable in the intensive care unit to explore organizational and cultural issues and to gain insight into social interactions, healthcare delivery processes, and communication. Qualitative research generates explanatory models and theories, which can then serve to devise interventions, whose efficacy can be studied quantitatively. Thus, qualitative research works synergistically with quantitative research, providing new impetus to the research process and a new dimension to research findings. Qualitative research starts with conceptualizing the research question, choosing the appropriate qualitative strategy, and designing the study; rigorous methods specifically designed for qualitative research are then used to conduct the study, analyze the data, and verify the findings. The researcher is the data-collecting instrument, and the data are the participants' words and behaviors. Data coding methods are used to describe experiences, discover themes, and build theories. In this review, we outline the rationale and methods for conducting qualitative research to inform critical care issues. We provide an overview of available qualitative methods and explain how they can work in close synergy with quantitative methods. To illustrate the effectiveness of combining different research methods, we will refer to recent qualitative studies conducted in the intensive care unit.

Empathy and life support decisions in intensive care units

BACKGROUND

Although experts advocate that physicians should express empathy to support family members faced with difficult end-of-life decisions for incapacitated patients, it is unknown whether and how this occurs in practice.

OBJECTIVES

To determine whether clinicians express empathy during deliberations with families about limiting life support, to develop a framework to understand these expressions of empathy, and to determine whether there is an association between more empathic statements by clinicians and family satisfaction with communication.

DESIGN

Multi-center, prospective study of audiotaped physician-family conferences in intensive care units of four hospitals in 2000-2002.

MEASUREMENTS

We audiotaped 51 clinician-family conferences that addressed end-of-life decisions. We coded the transcripts to identify empathic statements and used constant comparative methods to categorize the types of empathic statements. We used generalized estimating equations to determine the association between empathic statements and family satisfaction with communication.

MAIN RESULTS

There was at least one empathic statement in 66% (34/51) of conferences with a mean of 1.6 +/- 1.6 empathic statements per conference (range 0-8). We identified three main types of empathic statements: statements about the difficulty of having a critically ill loved one (31% of conferences), statements about the difficulty of surrogate decision-making (43% of conferences), and statements about the difficulty of confronting death (27% of conferences). Only 30% of empathic statements were in response to an explicit expression of emotion by family members. There was a significant association between more empathic statements and higher family satisfaction with communication (p = 0.04).

CONCLUSIONS

Physicians vary considerably in the extent to which they express empathy to surrogates during deliberations about life support, with no empathic statements in one-third of conferences. There is an association between more empathic statements and higher family satisfaction with communication.