Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial

Protocol for a randomised trial of an interprofessional team-delivered intervention to support surrogate decision-makers in ICUs

INTRODUCTION

Although shortcomings in clinician-family communication and decision making for incapacitated, critically ill patients are common, there are few rigorously tested interventions to improve outcomes. In this manuscript, we present our methodology for the Pairing Re-engineered Intensive Care Unit Teams with Nurse-Driven Emotional support and Relationship Building (PARTNER 2) trial, and discuss design challenges and their resolution.

METHODS AND ANALYSIS

This is a pragmatic, stepped-wedge, cluster randomised controlled trial comparing the PARTNER 2 intervention to usual care among 690 incapacitated, critically ill patients and their surrogates in five ICUs in Pennsylvania. Eligible subjects will include critically ill patients at high risk of death and/or severe long-term functional impairment, their main surrogate decision-maker and their clinicians. The PARTNER intervention is delivered by the interprofessional ICU team and overseen by 4-6 nurses from each ICU. It involves: (1) advanced communication skills training for nurses to deliver support to surrogates throughout the ICU stay; (2) deploying a structured family support pathway; (3) enacting strategies to foster collaboration between ICU and palliative care services and (4) providing intensive implementation support to each ICU to incorporate the family support pathway into clinicians' workflow. The primary outcome is surrogates' ratings of the quality of communication during the ICU stay as assessed by telephone at 6-month follow-up. Prespecified secondary outcomes include surrogates' scores on the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the modified Patient Perception of Patient Centredness scale, the Decision Regret Scale, nurses' scores on the Maslach Burnout Inventory, and length of stay during and costs of the index hospitalisation.We also discuss key methodological challenges, including determining the optimal level of randomisation, using existing staff to deploy the intervention and maximising long-term follow-up of participants.

ETHICS AND DISSEMINATION

We obtained ethics approval through the University of Pittsburgh, Human Research Protection Office. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02445937.

Validation of END-of-life ScorING-system to identify the dying patient: a prospective analysis

BACKGROUND

The "END-of-Life ScorING-System" (ENDING-S) was previously developed to identify patients at high-risk of dying in the ICU and to facilitate a practical integration between palliative and intensive care. The aim of this study is to prospectively validate ENDING-S in a cohort of long-term critical care patients.

MATERIALS AND METHODS

Adult long-term ICU patients (with a length-of-stay> 4 days) were considered for this prospective multicenter observational study. ENDING-S and SOFA score were calculated daily and evaluated against the patient's ICU outcome. The predictive properties were evaluated through a receiver operating characteristic (ROC) analysis.

RESULTS

Two hundred twenty patients were enrolled for this study. Among these, 21.46% died during the ICU stay. ENDING-S correctly predicted the ICU outcome in 71.4% of patients. Sensitivity, specificity, positive and negative predictive values associated with the previously identified ENDING-S cut-off of 11.5 were 68.1, 72.3, 60 and 89.3%, respectively. ROC-AUC for outcome prediction was 0.79 for ENDING-S and 0.88 for SOFA in this cohort.

CONCLUSIONS

ENDING-S, while not as accurately as in the pilot study, demonstrated acceptable discrimination properties in identifying long-term ICU patients at very high-risk of dying. ENDING-S may be a useful tool aimed at facilitating a practical integration between palliative, end-of-life and intensive care.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02875912; First registration August 4, 2016.

Family Care Rituals in the ICU to Reduce Symptoms of Post-Traumatic Stress Disorder in Family Members-A Multicenter, Multinational, Before-and-After Intervention Trial

OBJECTIVES

To assess the feasibility and efficacy of implementing "Family Care Rituals" as a means of engaging family members in the care of patients admitted to the ICU with a high risk of ICU mortality on outcomes including stress-related symptoms in family members.

DESIGN

Prospective, before-and-after intervention evaluation.

SETTING

Two U.S. academic medical ICU's, and one Italian academic medical/surgical ICU.

SUBJECTS

Family members of patients who had an attending predicted ICU mortality of greater than 30% within the first 24 hours of admission.

INTERVENTIONS

A novel intervention titled "Family Care Rituals" during which, following a baseline observation period, family members enrolled in the intervention phase were given an informational booklet outlining opportunities for engagement in care of the patient during their ICU stay.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was symptoms of post-traumatic stress disorder in family members 90 days after patient death or ICU discharge. Secondary outcomes included symptoms of depression, anxiety, and family satisfaction. At 90-day follow-up, 131 of 226 family members (58.0%) responded preintervention and 129 of 226 family members (57.1%) responded postintervention. Symptoms of post-traumatic stress disorder were significantly higher preintervention than postintervention (39.2% vs 27.1%; unadjusted odds ratio, 0.58; p = 0.046). There was no significant difference in symptoms of depression (26.5% vs 25.2%; unadjusted odds ratio, 0.93; p = 0.818), anxiety (41.0% vs 45.5%; unadjusted odds ratio, 1.20; p = 0.234), or mean satisfaction scores (85.1 vs 89.0; unadjusted odds ratio, 3.85; p = 0.052) preintervention versus postintervention 90 days after patient death or ICU discharge.

CONCLUSIONS

Offering opportunities such as family care rituals for family members to be involved with providing care for family members in the ICU was associated with reduced symptoms of post-traumatic stress disorder. This intervention may lessen the burden of stress-related symptoms in family members of ICU patients.

Survey on Barriers to Critical Care and Palliative Care Integration

PURPOSE

It has been shown that integrating palliative care (PC) in intensive care unit (ICU) improves end-of-life care (EOLC), but very few Canadian hospitals have adopted this practice. Our study aims to evaluate the perceived quality of EOLC at participating institutions and explore barriers toward ICU-PC integration.

MATERIALS AND METHODS

A self-administered questionnaire was developed by a multidisciplinary team. Survey items were extracted from published quality indicators in EOLC and barriers to ICU-PC integration. The study took place at 2 academic institutions. Participants consisted of physicians and nurses, ICU administrators, and allied health workers.

RESULTS

An overall response of 45% was achieved. Of total, 85% of the respondents were ICU nurses. The following main themes were identified: (1) There is a poor presence of PC in the ICU and 78% of respondents felt that increasing ICU-PC integration will improve quality of EOLC; (2) the main barrier to integration was unrealistic patient and/or family expectations; and (3) criteria-triggered consultation to PC was the most feasible way to achieve integration.

CONCLUSION

Our findings indicate that the majority of respondents perceive that the presence of PC in ICU will improve EOLC. Future quality improvement initiatives can focus on developing a set of criteria for triggering PC consults.

Intensive care unit length of stay is reduced by protocolized family support intervention: a systematic review and meta-analysis

PURPOSE

This study aimed to elucidate the impact of protocolized family support intervention on length of stay (LOS) in the intensive care unit (ICU) through a systematic review and meta-analysis.

METHODS

Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and other web-based databases were referenced since inception until November 26, 2018. We included randomized-controlled trials wherein protocolized family support interventions were conducted for enhanced communication and shared medical decision-making. LOS (in days) and mortality were evaluated using a random-effects model, and adjusted LOS was estimated using a mixed-effects model.

RESULTS

We included seven randomized-controlled trials with 3477 patients. Protocolized family support interventions were found to significantly reduce the ICU LOS {mean difference = - 0.89 [95% confidence interval (CI) = - 1.50 to - 0.27]} and hospital LOS [mean difference = - 3.78 (95% CI = - 5.26 to - 2.29)]; the results of the mixed-effect model showed that they significantly reduced ICU LOS after adjusting for the therapeutic goal [mean difference = - 1.30 (95% CI = - 2.35 to - 0.26)], methods of measurement [mean difference = - 0.89 (95% CI = - 1.55 to - 0.22)], and timing of intervention [mean difference = - 1.05 (95% CI = - 2.05 to - 0.05)]. Similar results were found after adjusting for patients' disease severity [mean difference = - 1.21 (95% CI = - 2.03 to - 0.39)] and the trim-and-fill method [mean difference = - 0.86 (95% CI = - 1.44 to - 0.28)]. There was no difference in mortality rate in ICU and hospital between the protocolized intervention and control groups.

CONCLUSIONS

Protocolized family support intervention for enhanced communication and shared decision-making with the family reduced ICU LOS in critically ill patients without impacting mortality.

Association of Surrogate Decision-making Interventions for Critically Ill Adults With Patient, Family, and Resource Use Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity.

OBJECTIVE

To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use.

DATA SOURCES

A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018.

STUDY SELECTION

Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms included surrogate or substitute decision-maker, critically ill, randomized controlled trials, and their respective related terms.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use).

RESULTS

Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08; P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, -2.11 days; 95% CI, -4.16 to -0.07; P = .04), but not in the overall population (mean difference, -0.79 days; 95% CI, -2.33 to 0.76 days; P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, -0.11; 95% CI, -0.29 to 0.08; P = .26; anxiety: ratio of means, -0.08; 95% CI, -0.25 to 0.08; P = .31; or posttraumatic stress disorder: ratio of means: -0.04; 95% CI, -0.21 to 0.13; P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention; P = .04).

CONCLUSIONS AND RELEVANCE

Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.

Evaluation of the Quality of Dying and Death Questionnaire in Kenya

PURPOSE

A culturally appropriate, patient-centered measure of the quality of dying and death is needed to advance palliative care in Africa. We therefore evaluated the Quality of Dying and Death Questionnaire (QODD) in a Kenyan hospice sample and compared item ratings with those from a Canadian advanced-cancer sample.

METHODS

Caregivers of deceased patients from three Kenyan hospices completed the QODD. Their QODD item ratings were compared with those from 602 caregivers of deceased patients with advanced cancer in Ontario, Canada, and were correlated with overall quality of dying and death ratings.

RESULTS

Compared with the Ontario sample, outcomes in the Kenyan sample (N = 127; mean age, 48.21 years; standard deviation, 13.57 years) were worse on 14 QODD concerns and on overall quality of dying and death (P values ≤ .001) but better on five concerns, including interpersonal and religious/spiritual concerns (P values ≤ .005). Overall quality of dying was associated with better patient experiences with Symptoms and Personal Care, interpersonal, and religious/spiritual concerns (P values < .01). Preparation for Death, Treatment Preferences, and Moment of Death items showed the most omitted ratings.

CONCLUSION

The quality of dying and death in Kenya is worse than in a setting with greater PC access, except in interpersonal and religious/spiritual domains. Cultural differences in perceptions of a good death and the acceptability of death-related discussions may affect ratings on the QODD. This measure requires revision and validation for use in African settings, but evidence from such patient-centered assessment tools can advance palliative care in this region.

Aligning use of intensive care with patient values in the USA: past, present, and future

For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.

How family caregivers of persons with advanced cancer assist with upstream healthcare decision-making: A qualitative study

Aims

Numerous healthcare decisions are faced by persons with advanced cancer from diagnosis to end-of-life. The family caregiver role in these decisions has focused on being a surrogate decision-maker, however, little is known about the caregiver’s role in supporting upstream patient decision-making. We aimed to describe the roles of family caregivers in assisting community-dwelling advanced cancer patients with healthcare decision-making across settings and contexts.

Methods

Qualitative study using one-on-one, semi-structured interviews with community-dwelling persons with metastatic cancer (n = 18) and their family caregivers (n = 20) recruited from outpatient oncology clinics of a large tertiary care academic medical center, between October 2016 and October 2017. Transcribed interviews were analyzed using a thematic analysis approach.

Findings

Caregivers averaged 56 years and were mostly female (95%), white (85%), and the patient’s partner/spouse (70%). Patients averaged 58 years and were mostly male (67%) in self-reported “fair” or “poor” health (50%) with genitourinary (33%), lung (17%), and hematologic (17%) cancers. Themes describing family member roles in supporting patients’ upstream healthcare decision-making were: 1) seeking information about the cancer, its trajectory, and treatments options; 2) ensuring family and healthcare clinicians have a common understanding of the patient’s treatment plan and condition; 3) facilitating discussions with patients about their values and the framing of their illness; 5) posing “what if” scenarios about current and potential future health states and treatments; 6) addressing collateral decisions (e.g., work arrangements) resulting from medical treatment choices; 6) originating healthcare-related decision points, including decisions about seeking emergency care; and 7) making healthcare decisions for patients who preferred to delegate healthcare decisions to their family caregivers.

Conclusions

These findings highlight a previously unreported and understudied set of critical decision partnering roles that cancer family caregivers play in patient healthcare decision-making. Optimizing these roles may represent novel targets for early decision support interventions for family caregivers.

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments

BACKGROUND

Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent.

METHODS

We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days.

RESULTS

Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001).

CONCLUSION

Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

Measuring the quality of dying and death in advanced cancer: Item characteristics and factor structure of the Quality of Dying and Death Questionnaire

Background:

Ensuring a good death in individuals with advanced disease is a fundamental goal of palliative care. However, the lack of a validated patient-centered measure of quality of dying and death in advanced cancer has limited quality assessments of palliative-care interventions and outcomes.

Aim:

To examine item characteristics and the factor structure of the Quality of Dying and Death Questionnaire in advanced cancer.

Design:

Cross-sectional study with pooled samples.

Setting/participants:

Caregivers of deceased advanced-cancer patients ( N = 602; mean ages = 56.39–62.23 years), pooled from three studies involving urban hospitals, a hospice, and a community care access center in Ontario, Canada, completed the Quality of Dying and Death Questionnaire 8–10 months after patient death.

Results:

Psychosocial and practical item ratings demonstrated negative skewness, suggesting positive perceptions; ratings of symptoms and function were poorer. Of four models evaluated using confirmatory factor analyses, a 20-item, four-factor model, derived through exploratory factor analysis and comprising Symptoms and Functioning, Preparation for Death, Spiritual Activities, and Acceptance of Dying, demonstrated good fit and internally consistent factors (Cronbach’s α = 0.70–0.83). Multiple regression analyses indicated that quality of dying was most strongly associated with Symptoms and Functioning and that quality of death was most strongly associated with Preparation for Death ( p < 0.001).

Conclusion:

A new four-factor model best characterized quality of dying and death in advanced cancer as measured by the Quality of Dying and Death Questionnaire. Future research should examine the value of adding a connectedness factor and evaluate the sensitivity of the scale to detect intervention effects across factors.

Guiding intensive care physicians' communication and behavior towards bereaved relatives: study protocol for a cluster randomized controlled trial (COSMIC-EOL)

Background

Providing appropriate support and care for end-of-life patients and their relatives is a major concern and a daily responsibility for intensivists. Bereaved relatives of non-surviving patients in intensive care units (ICUs) often suffer from prolonged grief, posttraumatic stress disorder, anxiety, and depression. A physician-driven intervention, consisting of three meetings with the family, might reduce the post-ICU burden of bereaved family members 6 month after death. The patient’s nurse is actively involved at each step. We hypothesize that this strategy will improve communication in the end-of-life setting and thus, should reduce the post-ICU burden for family members, specifically the development of prolonged grief 6 months after the death.

Methods/design

The COSMIC-EOL trial is a prospective, multicenter, cluster randomized controlled trial in which centers are allocated to two parallel arms: (1) intervention centers where relatives benefit from three-step physician-driven support during the dying and death process and (2) control centers where, during the dying and death process, relatives receive the standard of care practice. Each of the 36 participating centers will include 25 relatives of patients with a length of stay ≥2 days. Participating relatives will be followed up by phone at 1, 3, and 6 months after the patient’s death to complete questionnaires permitting evaluation of their post-ICU burden. The main outcome is prolonged grief measured 6 months after the death using the PG-13. Other outcomes include evaluation of quality of dying, quality of communication, anxiety, depression, and post-traumatic stress. The estimated duration of the study is 36 months.

Discussion

The results of the trial will provide information about the effectiveness of physician-driven support for relatives of patients dying in an ICU. The study is expected to demonstrate a decrease in the ICU burden for bereaved relatives who benefitted from this intervention.

Trial Registration

ClinicalTrials.gov, NCT02955992. Registered on November 3rd 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3084-7) contains supplementary material, which is available to authorized users.

Surrogates' Perceptions of Service Quality While Making Decisions for ICU Patients

A qualitative secondary analysis was undertaken to identify aspects of health care service quality in an intensive care unit from the perspective of surrogate decision makers (N = 19) who were making decisions for relatives at end of life. Directed content analysis was guided by the Donabedian model of health care quality. Nineteen participants averaged 59 years old and were over half female (53%) and patients' spouses (53%) and adult children (32%). Salient aspects of quality service included surrogate perceptions that clinicians conveyed honesty about the patient's condition and in an easily understandable way; staff were sensitive and responsive to emotions and practical needs; clinicians demonstrated a clear, confident understanding of the patient's condition; and support by clinicians was given for surrogates' choices. Surrogates also commented on the hospital and intensive care unit environment, including cleanliness, comfort, privacy, and noise level. Further research is needed to explore how decision-support strategies might include service quality concepts.

A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition

CONTEXT

Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers.

OBJECTIVES

The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

METHODS

Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel.

RESULTS

We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews).

CONCLUSION

A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.

Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU)

This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.

Complexity Analysis of Decision-Making in the Critically Ill

RATIONALE

Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life.

OBJECTIVE

To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness.

METHODS

A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death.

MEASUREMENTS

Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan.

MAIN RESULTS

Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential.

CONCLUSION

Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.

Palliative care team consultation and quality of death and dying in a university hospital: A secondary analysis of a prospective study

PURPOSE

Involvement of palliative care experts improves the quality of life and satisfaction with care of patients who are in the last stage of life. However, little is known about the relation between palliative care expert involvement and quality of dying (QOD) in the hospital. We studied the association between palliative care team (PCT) consultation and QOD in the hospital as experienced by relatives.

METHODS

We conducted a secondary analysis of data from a prospective study among relatives of patients who died from cancer in a university hospital and compared characteristics and QOD of patients for whom the PCT was or was not consulted.

RESULTS

175 out of 343 (51%) relatives responded to the questionnaire. In multivariable linear regression PCT was associated with a 1.0 point better QOD (95% CI 0.07-1.96). In most of the subdomains of QOD, we found a non-significant trend towards a more favorable outcome for patients for whom the PCT was consulted. Patients for whom the PCT was consulted had more often discussed their preferences for medical treatment, had more often been aware of their imminent death and had more often been at peace with their imminent death. Further, patients for whom the PCT was consulted and their relatives had more often been able to say goodbye. Relatives had also more often been present at the moment of death when a PCT had been consulted.

CONCLUSION

For patients dying in the hospital, palliative care consultation is associated with a favorable QOD.

Acceptability and feasibility of an interprofessional end-of-life/palliative care educational intervention in the intensive care unit: A mixed-methods study

OBJECTIVES

This study aimed to describe a seven hour End-of-Life/Palliative Care educational intervention including online content related to symptom management, communication and decision-making capacity and an in-person group integration activity, from the perspective of the interprofessional team in terms of its acceptability and feasibility.

RESEARCH DESIGN

A mixed-methods study design was used.

SETTING AND SAMPLE

The study was conducted in a medical-surgical Intensive Care Unit in Montreal, Canada. The sample consisted of 27 clinicians of the Intensive Care Unit interprofessional team who completed the End-of-Life/Palliative Care educational intervention, and participated in focus groups and completed a self-administered questionnaire.

MAIN OUTCOME MEASURES

The main outcomes were the acceptability and feasibility of the educational intervention.

FINDINGS

The intervention was perceived to be appropriate and suitable in providing clinicians with knowledge and skills in symptom management and communication through self-reflection and self-evaluation, provision of assessment tools and promotion of interprofessional teamwork. The online format was more feasible, but the in-person group activity was key for the integration of knowledge and the promotion of interprofessional discussions.

CONCLUSION

Findings suggest that an interprofessional educational intervention integrating on-line content with in-person training has the potential to support clinicians in providing quality End-of-Life/Palliative Care in the Intensive Care Unit.

AVALIAÇÃO DA SATISFAÇÃO DE FAMILIARES DE PACIENTES ATENDIDOS EM UNIDADES DE TERAPIA INTENSIVA: REVISÃO INTEGRATIVA

RESUMO Objetivo: analisar a produção científica relacionada às evidências acerca da satisfação de familiares de pacientes de UTI e os instrumentos utilizados para sua avaliação. Metodo: revisão integrativa na qual foram analisados artigos publicados entre 2005 e 2015, em inglês, português ou espanhol, nas bases de dados PUBMED/MEDLINE e LILACS e a biblioteca SciELO. Utilizou-se como estratégia de busca: personal satisfactional OR satisfaction AND family. Para coleta de dados dos artigos elaborou-se um instrumento com informações como: título, autores, ano de publicação e revista, objetivo do estudo, delineamento, participantes, local da pesquisa, temática principal e resultados. Resultados: atenderam aos critérios de inclusão 27 produções. Foram identificados quatro instrumentos utilizados para avaliar a satisfação de familiares de pacientes na UTI o Critical Care Family Satisfaction Survey, Family Satisfaction in the Intensive Care Unit, Critical Care Family Needs Inventory e o Quality of Dying and Death. Os estudos abordaram a satisfação dos familiares em relação às suas necessidades e tomadas de decisão, satisfação quanto a cuidados paliativos, evidenciou-se, ainda, estudos de adaptação transcultural e validação de instrumentos. Quanto ao nível de evidência, os estudos se concentram nos níveis II a VI. Conclusão: a análise da produção científica sobre a satisfação de familiares de pacientes de UTI permitiu evidenciar que o fator que mais contribui na promoção da satisfação da família foi a qualidade do atendimento.

The effectiveness of interventions to meet family needs of critically ill patients in an adult intensive care unit: a systematic review update

BACKGROUND

Attending to the needs of family members of critically ill patients is an important and necessary step in providing appropriate holistic care for both the patient and the family. Family interaction can significantly impact on the experience of critical illness, notwithstanding the challenge of meeting families' needs for many clinicians in the intensive care unit (ICU). Family needs have been extensively researched; however, a previous Joanna Briggs Institute (JBI) systematic review was the first published systematic review recommending effective interventions for addressing family needs of critically ill patients in an acute intensive care setting. Since its publication in 2011, additional research findings have been published and it was deemed appropriate to update the original systematic review.

OBJECTIVES

This systematic review aims to establish recent best practice in addressing the needs of family members with a relative or loved one admitted to an adult critical care unit.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Studies that included family members (including children) of adult patients in an ICU were considered for inclusion in this review. Patients with any clinical condition, length of stay or outcome were included.

TYPES OF INTERVENTION(S)

This review considered interventions that addressed the five previously identified categories of family needs: support - support groups, training in coping strategies and journal or diary writing; assurance - face-to-face meetings and participation in ward rounds; proximity - changes to visitation policies; information - staff and/or family education, handouts and brochures and the use of technology (e.g. SMS messages); and comfort - changes to the ICU physical environment.

TYPES OF STUDIES

This review considered any randomized controlled trials (RCTs) that evaluated the effectiveness of interventions in addressing family needs of critically ill patients in an adult ICU. In the absence of RCTs, other research designs such as quasi-experimental, as well as pre- and post-studies were considered for inclusion in the narrative summary to enable the identification of current approaches and possible future strategies for addressing family needs of critically ill patients.

TYPES OF OUTCOMES

This review considered studies that evaluated outcomes with a validated tool that measured information comprehension, coping mechanisms, anxiety, depression, stress and satisfaction.

SEARCH STRATEGY

An extensive search of the major databases was conducted. Databases searched included PubMed, CINAHL, psycINFO, Health source, Web of Science, EMBASE, the Cochrane Library and Database of Abstracts of Reviews of Effects. The original search of this review included published and unpublished studies and articles in English from 1980 to 2010. The updated search identified articles for inclusion from 2010 to 2014.

METHODOLOGICAL QUALITY

Quantitative articles selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer.

DATA EXTRACTION

Data was extracted from the articles included in this review using standardized data extraction tools from the JBI Meta Analysis of Statistics Assessment and Review Instrument package.

DATA SYNTHESIS

The studies included in this review were not suitable for meta-analysis and therefore the results are presented as a narrative summary.

RESULTS

Originally, 14 studies and one dissertation met the inclusion criteria and were included in the review. Of these, 12 were quasi-experimental studies and three were prospective randomized trials. In this current update, 14 new articles were identified for inclusion - one RCT, 10 quasi-experimental studies and three observational studies. The settings were in ICUs in Sweden, USA, United Kingdom, the Netherlands, France, Hong Kong, Saudi Arabia and Iran. The evidence identified from all studies in the review includes the use of support groups for family members of patients admitted to an ICU, structured communication and/or education programs for family members, the use of leaflets or brochures to meet family information needs, use of a diary, changes in the physical environment and open or more flexible visiting hours.

CONCLUSIONS

This current update of the original review makes several reiterative and new recommendations for clinical practice to address family needs of patients admitted to a critical care unit; however, the need for significant further research in this area is again highlighted. Future intervention studies focusing on family needs could include the use of technology such as DVDs (Digital Versatile Discs) and SMS (Short Message Service) for informing families and interventions specifically designed to improve family comfort.

IMPLICATIONS FOR PRACTICE

Communication interventions help promote family involvement in their loved one's care and facilitate their decision-making capacity, as well as improving clinician and family interaction, family comprehension of their loved one's condition and also reduce the development of post-traumatic stress-related symptoms (Grade A). Family satisfaction may be increased with the provision of comfortable physical environments with noise reduction measures (Grade B).

IMPLICATIONS FOR RESEARCH

More rigorous high-quality studies investigating interventions to meet the needs of family with a relative in ICU are needed. The majority of included studies in this updated review focused on family satisfaction wherein more robust data on family needs would better inform health professionals in their practice.

Implementation strategies for guidelines at ICUs: a systematic review

Purpose The purpose of this paper is to critically analyze empirical studies related to the implementation strategies for clinical practice guidelines (CPGs) in intensive care units (ICUs). Design/methodology/approach A systematic review with a narrative synthesis adapted from Popay et al.'s method for a narrative synthesis was conducted. A search using CINAHL, Google Scholar, Academic search complete, Cochrane Register for Randomized Controlled Trials, MEDLINE via PUBMED and grey literature was conducted in 2014 and updated in 2016 (August). After reading the abstracts, titles and full-text articles, 11 ( n=11) research studies met the inclusion criteria. Findings After critical appraisal, using the Joanna Briggs Critical Appraisal Tools, eight randomized controlled trials conducted in adult and neonatal ICUs using implementation strategies remained. Popay et al.'s method for narrative synthesis was adapted and used to analyze and synthesize the data and formulate concluding statements. Included studies found that multi-faceted strategies appear to be more effective than single strategies. Strategies mostly used were printed educational materials, information/ sessions, audit, feedback, use of champion leaders, educational outreach visits, and computer or internet usage. Practical training, monitoring visits and grand rounds were less used. Practical implications Findings can be used by clinicians to implement the best combination of multi-faceted implementation strategies in the ICUs in order to enhance the optimal use of CPGs. Originality/value No systematic review was previously done on the implementation strategies that should be used best for optimal CPG implementation in the ICU.

Using Cluster Bootstrapping to Analyze Nested Data With a Few Clusters

Cluster randomized trials involving participants nested within intact treatment and control groups are commonly performed in various educational, psychological, and biomedical studies. However, recruiting and retaining intact groups present various practical, financial, and logistical challenges to evaluators and often, cluster randomized trials are performed with a low number of clusters (~20 groups). Although multilevel models are often used to analyze nested data, researchers may be concerned of potentially biased results due to having only a few groups under study. Cluster bootstrapping has been suggested as an alternative procedure when analyzing clustered data though it has seen very little use in educational and psychological studies. Using a Monte Carlo simulation that varied the number of clusters, average cluster size, and intraclass correlations, we compared standard errors using cluster bootstrapping with those derived using ordinary least squares regression and multilevel models. Results indicate that cluster bootstrapping, though more computationally demanding, can be used as an alternative procedure for the analysis of clustered data when treatment effects at the group level are of primary interest. Supplementary material showing how to perform cluster bootstrapped regressions using R is also provided.

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes

BACKGROUND

Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members.

OBJECTIVE

The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps.

METHODS

We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future.

RESULTS

We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions.

CONCLUSIONS

The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.

Measuring Family Satisfaction With Care Delivered in the Intensive Care Unit

BACKGROUND

In our competitive health care environment, measuring the experience of family members of patients in the intensive care unit to ensure that health care providers are meeting families' needs is critical. Surveys from Press Ganey and the Centers for Medicare and Medicaid Services are unable to capture families' satisfaction with care in this setting.

OBJECTIVE

To implement a sustainable measure for family satisfaction in a 12-bed medical and surgical intensive care unit. To assess the feasibility of the selected tool for measuring family satisfaction and to make recommendations that are based on the results.

METHOD

A descriptive survey design using the Family Satisfaction in the Intensive Care Unit 24-item questionnaire to measure satisfaction with care and decision-making.

RESULTS

Forty family members completed the survey. Overall, the mean score for families' satisfaction with care was 72.24% (SD, 14.87%) and the mean score for families' satisfaction with decision-making was 72.03% (SD, 16.61%). Families reported that nurses put them at ease and provided understandable explanations. Collaboration, inclusion of families in clinical discussions, and timely information regarding changes in the patient's condition were the most common points brought up in free-text responses from family members. Written communication, including directions and expectations, would have improved the families' experience.

CONCLUSION

Although patients' family members reported being satisfied with their experience in the intensive care unit, there is room for improvement. Effective communication among the health care team, patients' families, and patients will be targeted for quality improvement initiatives.

Strategies used in improving and assessing the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions: A systematic review

BACKGROUND

Implementation fidelity is critical in evaluating effectiveness of interventions.

AIM

Identifying and summarising strategies to improve and assess the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions.

DESIGN

Systematic review.

DATA SOURCES

Published and completed randomised controlled trials from 2000 to current evaluating effectiveness of specialised palliative care services on patient-centred outcomes in adult patients were examined. MEDLINE was searched from 2008 to 29 September 2015 and supplemented by randomised controlled trials identified in a 2008 systematic review.

RESULTS

Altogether, 20 randomised controlled trials involving 8426 patients were reviewed using 40 subcomponents of five elements of implementation fidelity (resulting in 20 × 40 = 800 items). Over 88 strategies were identified, classified under the following elements: 'treatment design', 'training providers', 'delivery of treatment', 'receipt of treatment' and 'enactment of treatment skills'. No single overarching strategy was discovered. Strategies under 'treatment design' aimed to ensure equivalent treatment dose between and within intervention and control groups, and delivery of necessary ingredients. Ongoing 'training (of) providers' included supervision and ensuring skill acquisition. Use of treatment manuals and implementation checklists aimed to aid 'delivery of treatment'. Research teams aimed to improve 'receipt of treatment' by transmitting clear information and verifying understanding, while improving 'enactment of treatment skills' by reviewing and reinforcing prior content. Only 26% of the items received sufficient reporting; 34% were either not used or reported on.

CONCLUSION

Implementation fidelity in palliative care is under-recognised. A table to collate these strategies to improve implementation fidelity in palliative care research and clinical practice is proposed.

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Background

External change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings.

Methods

We searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.

Results

Academic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.

Conclusions

Our results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

Economic Feasibility of Staffing the Intensive Care Unit with a Communication Facilitator

RATIONALE

In the intensive care unit (ICU), complex decision making by clinicians and families requires good communication to ensure that care is consistent with the patients' values and goals.

OBJECTIVES

To assess the economic feasibility of staffing ICUs with a communication facilitator.

METHODS

Data were from a randomized trial of an "ICU communication facilitator" linked to hospital financial records; eligible patients (n = 135) were admitted to the ICU at a single hospital with predicted mortality ≥30% and a surrogate decision maker. Adjusted regression analyses assessed differences in ICU total and direct variable costs between intervention and control patients. A bootstrap-based simulation assessed the cost efficiency of a facilitator while varying the full-time equivalent of the facilitator and the ICU mortality risk.

MEASUREMENTS AND MAIN RESULTS

Total ICU costs (mean 22.8k; 95% CI, -42.0k to -3.6k; P = 0.02) and average daily ICU costs (mean, -0.38k; 95% CI, -0.65k to -0.11k; P = 0.006)] were reduced significantly with the intervention. Despite more contacts, families of survivors spent less time per encounter with facilitators than did families of decedents (mean, 25 [SD, 11] min vs. 36 [SD, 14] min). Simulation demonstrated maximal weekly savings with a 1.0 full-time equivalent facilitator and a predicted ICU mortality of 15% (total weekly ICU cost savings, $58.4k [95% CI, $57.7k-59.2k]; weekly direct variable savings, $5.7k [95% CI, $5.5k-5.8k]) after incorporating facilitator costs.

CONCLUSIONS

Adding a full-time trained communication facilitator in the ICU may improve the quality of care while simultaneously reducing short-term (direct variable) and long-term (total) health care costs. This intervention is likely to be more cost effective in a lower-mortality population.

Family and Nurse Prognostication in Chronic Critical Illness

AIMS

The aim of this study was to describe similarities and differences over time in expectations held by family members of long-term critically ill patients and the nurses caring for those patients.

MATERIALS

In addition to demographic data, outcome expectations of family decision makers and ICU nurses were obtained by asking each participant to indicate expectations for the patient, 6 months in the future, for survival, cognition, and functional status. Families also were asked what kind of information was most important in understanding the patient's condition and what was most important in making decisions.

METHODS

This was a descriptive correlational analysis. Nurses and family members were surveyed on the 3^rd-5^th day of the patient's stay, and every 5 days until discharge or death. Correlations between nurse and family predictions were examined using Pearson R. Repeated measures analysis of variance (RMANOVA) was used to explore the relationship between the family member's rating of what was most important in the care of the patient (survival vs. quality of life) and that individual's prediction of the likelihood of survival, over time.

RESULTS

Family members consistently predicted better outcomes than nurses, with >80% of families predicting a high likelihood of survival, while <50% of nurses thought survival probability was high. There were similar differences in expectations for functional status and cognition. Between 14% and 23% of families indicated it was talking with the nurses that were most important.

CONCLUSIONS

Results suggest a need for design and tests of nurse interventions aimed at improving family understanding of patient prognosis and future outcomes.

Palliative Care for Patients Dying in the Intensive Care Unit with Chronic Lung Disease Compared with Metastatic Cancer

RATIONALE

Palliative care has been focused largely on patients with cancer, and yet patients with chronic lung diseases also have high morbidity and mortality. The majority of deaths in intensive care units (ICUs) follow decisions to withhold or withdraw life-sustaining treatments, suggesting that palliative care is critically important in this setting.

OBJECTIVES

We explored differences in receipt of elements of palliative care among patients with interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) who die in ICUs compared with patients with cancer.

METHODS

We identified patients with COPD, ILD, or metastatic cancer who died in the ICUs of 15 Seattle-area hospitals between 2003 and 2008. We used robust multivariable logistic and linear regression to compare differences in receipt of elements of palliative care and length of stay.

MEASUREMENTS AND MAIN RESULTS

Compared with patients with cancer, patients with COPD were more likely to receive cardiopulmonary resuscitation before death and patients with ILD were less likely to have documentation of pain assessment in the last day of life. Patients with ILD and COPD were less likely to have a do-not-resuscitate order in place at the time of death and less likely to have documentation of discussions about prognosis than patients with cancer. Patients with COPD had longer hospital lengths of stay, and patients with COPD and ILD had longer ICU lengths of stay.

CONCLUSIONS

Among patients who die in the ICU, patients with ILD and COPD receive fewer elements of palliative care and have longer lengths of stay than patients with cancer. These findings identify areas for improvement in caring for patients with chronic lung diseases. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

Recovery after critical illness: putting the puzzle together-a consensus of 29

In this review, we seek to highlight how critical illness and critical care affect longer-term outcomes, to underline the contribution of ICU delirium to cognitive dysfunction several months after ICU discharge, to give new insights into ICU acquired weakness, to emphasize the importance of value-based healthcare, and to delineate the elements of family-centered care. This consensus of 29 also provides a perspective and a research agenda about post-ICU recovery.

Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on Intensive Care Unit Utilization and Costs from the Hospital and Healthcare System Perspective

Purpose of report: Understanding the impact of palliative care interventions on intensive care unit (ICU) costs and utilization is critical for demonstrating the value of palliative care. Performing these economic assessments, however, can be challenging. The purpose of this special report is to highlight and discuss important considerations when assessing ICU utilization and costs from the hospital perspective, with the goal of providing recommendations on methods to consider for future analyses.

FINDINGS

ICU length of stay (LOS) and associated costs of care are common and important outcome measures, but must be analyzed properly to yield valid conclusions. There is significant variation in costs by day of stay in the ICU with only modest differences between an ICU day at the end of a stay and the first day on the acute care floor; this variation must be appropriately accounted for analytically. Furthermore, reporting direct variable costs, in addition to total ICU costs, is needed to understand short-term and long-term impact of a reduction in LOS. Importantly, incentives for the hospital to realize savings vary depending on reimbursement policies.

SUMMARY

ICU utilization and costs are common outcomes in studies evaluating palliative care interventions. Accurate estimation and interpretation are key to understanding the economic implications of palliative care interventions.

Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine whether patient- and family-centered care interventions in the ICU improve outcomes.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.

STUDY SELECTION

We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.

DATA EXTRACTION

We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.

DATA SYNTHESIS

There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.

CONCLUSIONS

Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

Use of Improving Palliative Care in the ICU (Intensive Care Unit) Guidelines for a Palliative Care Initiative in an ICU

OBJECTIVE

For improved utilization of the existing palliative care team in the intensive care unit (ICU), a process was needed to identify patients who might need a palliative care consultation in a timelier manner.

METHODS

A systematic method to create a new program that would be compatible with our specific ICU environment and patient population was developed. A literature review revealed a fairly extensive array of reports and numerous clinical practice guidelines, which were assessed for information and strategies that would be appropriate for our unit.

RESULTS

The recommendations provided by the Center to Advance Palliative Care from its Improving Palliative Care in the ICU project were used to successfully implement a new palliative care initiative in our ICU.

CONCLUSION

The guidelines provided by the Improving Palliative Care in the ICU project were an important tool to direct the development of a new palliative care ICU initiative.

Primary Palliative Care Education: A Pilot Survey

The demand for palliative services is outpacing the availability of specialist palliative care clinicians. One strategy to fill this gap is to improve "primary palliative care" skills and knowledge of all clinicians who care for seriously ill patients. Previous educational efforts have shown mixed results, and one possible explanation is unrecognized discordance of educational goals between those offering education and potential primary palliative care learners. The article describes the results and feasibility of a needs assessment survey comparing interest in palliative care education topics and settings among both palliative care specialists (PCS) and nonpalliative care specialists (NPCS). This is the first attempt to measure the perceived importance of primary palliative care topics and preferences about learning settings from the perspectives of both NPCS and PCS. The results suggest substantial areas of both concordant and discordant opinions with respect to educational topics and learning settings. Such data are essential to guide primary palliative care educational efforts. Future work will be needed to determine whether these results are consistent across diverse health systems and what variables influence educational preferences.

Research Priorities in Subspecialty Palliative Care: Policy Initiatives

Palliative care demonstrably improves quality of life for the seriously ill in a manner that averts preventable health crises and their associated costs. Because of these outcomes, palliative care is now broadening its reach beyond hospitals, and hospice care for those near death, to patients and their families living in the community with chronic multimorbidities that have uncertain or long expected survival. In this article, we address research needed to enable policies supportive of palliative care access and quality, including changes in regulatory, accreditation, financing, and training approaches in the purview of policy makers. Mr. K. is an 86-year-old male with multimorbidities, including severe chronic obstructive pulmonary disease, congestive heart failure, peripheral vascular disease, and atrial fibrillation requiring anticoagulation therapy. He fell in his mobile home and was unable to reach the telephone to call for help. Six hours later, his neighbor found him lying on the bedroom floor in pain and confused, and called 911. On examination, he was found to have a cold blue foot complicated by a large hematoma. The vascular surgery service was consulted to evaluate Mr. K. for revascularization or amputation. Although Mr. K. had several risk factors complicating his candidacy for general anesthesia, the team thought the benefits of surgery would outweigh the risks. Mr. K's daughter agreed to surgery telling her father "the doctors know best." Mr. K. replied "I just want to be out of pain." Six months later, Mr. K. remains in a skilled nursing facility due to post-op complications, including pneumonia, worsened confusion, and the inability to recover to enough function to live safely at home. He now suffers from depression, cognitive deficits, and social isolation. His daughter has had to take on a second job because she is struggling to pay for his continued long-term care, which costs $6000 per month. Money she had saved for her own retirement and her daughter's college tuition is already gone. In retrospect, she realizes the surgical team did not discuss the possibility of his survival with chronic debility and long-term functional dependency, nor the fact that Medicare would not pay for the care he now requires.

Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study

OBJECTIVES

To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses (LLI) referred for intensive care management.

METHODS

Prospective before-and-after cohort study in a tertiary teaching hospital in Australia. The population was 222 adult patients with LLI referred to the intensive care unit (ICU). The study was divided into two periods, before (1 May to 31 July 2015) and after (15 September to 15December 2015) the intervention. The intervention was a 2-day, small group, simulated-patient, communication skills course, and process of care for patients with LLI. The primary outcome was documentation of patient-centred goals of care discussion (PCD) within 48 hours of referral to the ICU. Secondary outcomes included clinical outcomes and 90-day mortality.

RESULTS

The intervention was associated with increased documentation of a PCD from 50% to 69% (p=0.004) and 43% to 94% (p<0.0001) in patients deceased by day 90. A significant decrease in critical care as the choice of resuscitation goal (61% vs 42%, p=0.02) was observed. Although there was no decrease in admission to ICU, there was a significant decrease in medical emergency team call prevalence (87% vs 73%, p=0.009). The cancer and organ failure groups had a significant decrease in 90-day mortality (75% vs 44%, p=0.02; 42% vs 16%, p=0.01), and the frailty group had a significant decrease in 90-day readmissions (48% vs 19%, p=0.003).

CONCLUSIONS

The intervention was associated with increased PCD documentation and decrease in the choice of critical care as the resuscitation goal. Admissions to ICU did not decrease, and although limited by study design, condition-specific trajectory changes, clinical interventions and outcomes warrant further study.

Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness

OBJECTIVES

To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness.

DESIGN AND SETTING

Decision analysis using literature estimates and inpatient administrative data from Premier.

PATIENTS

Patients with chronic, life-limiting illness admitted to a hospital within the Premier network.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Using Premier data (2008-2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions' efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients.

CONCLUSIONS

In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers.

Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study

OBJECTIVES

Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain.

DESIGN

Qualitative study using a conventional thematic analysis.

SETTING

Nine ICUs across Alberta, Canada.

SUBJECTS

Nineteen focus groups (n = 122 participants).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization").

CONCLUSIONS

Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs

OBJECTIVE

Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment.

DESIGN

Mixed-methods study.

SETTING

Medical and surgical ICUs at three large academic hospitals.

PARTICIPANTS

Three hundred three nurses, intensivists, and advanced practice providers.

MEASUREMENTS AND MAIN RESULTS

Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships.

CONCLUSIONS

Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.

Formal Academic Training on Ethics May Address Junior Physicians' Needs

BACKGROUND

Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists' perceptions of triage and of the quality of the dying process before and after formal academic training.

METHODS

Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods.

RESULTS

More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician's age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members' reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process.

CONCLUSIONS

Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations.

The Frailty Phenotype and Palliative Care Needs of Older Survivors of Critical Illness

OBJECTIVES

To assess symptoms in older intensive care unit (ICU) survivors and determine whether post-ICU frailty identifies those with the greatest palliative care needs.

DESIGN

A prospective cohort study.

SETTING

Urban tertiary care hospital and community hospital.

PARTICIPANTS

Medical ICU survivors of mechanical ventilation aged 65 and older (N = 125).

MEASUREMENTS

Baseline measurements of the Edmonton Symptom Assessment Scale (ESAS), categorized as mild (0-3), moderate (4-6), and severe (7-10), and the frailty phenotype were made during the week before hospital discharge. Functional recovery was defined as a return to a Katz activity of daily living dependency count less than or equal to the prehospitalization dependency count within 3 months. In the last 29 participants recruited, we made additional assessments of fatigue and ESAS both at baseline and 1 month after discharge.

RESULTS

Fatigue was the most-prevalent moderate to severe symptom (74%), followed by dyspnea (53%), drowsiness (50%), poor appetite (47%), pain (45%), depression (42%), anxiety (36%), and nausea (17%). At 1-month follow-up, there were no significant differences in the proportions of participants with moderate to severe symptoms. Each increase in baseline ESAS fatigue severity category was associated with 55% lower odds of functional recovery (odds ratio = 0.45, 95% confidence interval = 0.24-0.84), independent of age, sex, comorbidities, and critical illness severity. Frail participants had a higher median baseline total ESAS symptom distress score (34, interquartile range (IQR) 23-44) than nonfrail participants (13, IQR 9-22) (P < .001).

CONCLUSION

Older ICU survivors have a high burden of palliative care needs that persist 1 month after discharge. Fatigue is the most-prevalent symptom and may interfere with recovery. Post-ICU frailty may be a useful trigger for palliative care consultation and a treatment target.