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

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.

The language of prognostication in intensive care units

Rationale. Although misunderstandings about prognosis are common in intensive care units (ICUs), little is known about how physicians actually communicate prognostic information.

OBJECTIVES

The authors sought to 1) develop a framework to describe the language physicians use to disclose prognosis, 2) determine whether physicians frame prognostic statements as estimates for populations or estimates for individual patients, and 3) determine whether physicians use the recommended ''ask-tell-ask'' approach when discussing prognosis.

METHODS

The authors conducted a multicenter, cross-sectional study of 51 audiotaped physician-family conferences about life support decisions in ICUs. They identified each prognostic statement and used grounded theory methods to develop a framework to understand the language physicians use to communicate prognosis.

MAIN RESULTS

Physicians prognosticated in 50 of 51 conferences. When discussing prognosis, physicians used qualitative probability statements in 72% (36/50) of conferences, numeric statements in 20% (10/50), absolute statements in 13% (4/32), and nonprobabilistic statements in 40% (20/50). Physicians exclusively used population-based language in 10% (5/50) of conferences, single-event probability statements in 62% (31/50), and both in 28% (14/ 50). In only 2% (1/50) of conferences did physicians ask whether the family wished to hear prognostic information prior to discussing it, and in only 14% of conferences (7/50) did physicians check to verify that families understood the prognostic information.

CONCLUSIONS

There is considerable variability in the language used by physicians to disclose prognosis, with only 20% of physicians using quantitative terms. Very few physicians checked whether families understood prognostic information. These findings may provide potential targets for interventions to improve communication about prognosis in ICUs.

Family satisfaction following the death of a loved one in an inner city MICU

This study examined family satisfaction with end-of-life care in a medical intensive care unit (MICU) before and after a palliative care intervention was implemented there. This intervention consisted of early communication, family meetings, and psychosocial support. Family members of patients who died in the MICU in 2005 and 2006 were contacted 2 to 16 months after the death of their relatives. Trained interviewers used the Family Satisfaction with Care Questionnaire to assess the families' perceptions of the care given to their family members. Minorities comprised 77% of the patient population. Comparison of the levels of family satisfaction in the preintervention and postintervention groups demonstrated that the intervention significantly improved the quality of end-of-life care, particularly through increases in family members' satisfaction with decision making, communication with physicians and nurses, and the death and dying process.

Responding to families' questions about the meaning of physical movements in critically ill patients

BACKGROUND

Families may have questions about the meaning of physical movement in critically ill patients for whom movements are likely involuntary. If unresolved, these questions may contribute to difficult communication around end-of-life care. This study used qualitative methods to describe physicians' responses to families' questions about the meaning of patients' movements in critically ill patients.

METHODS

Fifty-one family conferences in which withdrawal of life support or discussion of bad news was addressed were audiotaped and analyzed with a limited application of grounded theory techniques. Patients were identified from intensive care units in 4 Seattle area hospitals. Two hundred twenty-seven family members and 36 physicians participated in the study.

RESULTS

Family members' questions indicating lack of resolution about the meaning of patients' movements that were likely involuntary occurred in 6 (12%) of the 51 conferences. Physicians used 3 approaches to respond to the following questions: (1) providing clinical information, (2) acknowledging families' emotions, and (3) exploring the meaning of families' emotions. Physicians were most likely to provide clinical information in these situations and infrequently explored the meaning of families' emotions.

CONCLUSIONS

Physicians' responses to family questions indicating lack of resolution about the meaning of patients' movements that were likely involuntary can be categorized into 3 types. Physicians may be better able to respond to and resolve these questions by using all 3 types of communication approaches. Future studies should determine if such responses can improve families' experiences and other outcomes.

Alterations during medical interpretation of ICU family conferences that interfere with or enhance communication

RATIONALE

Many conferences in the ICU occur with the families of patients with limited English proficiency, requiring a medical interpreter. Despite the importance of medical interpretation, little is known about the alterations that occur and their effect on communication.

OBJECTIVES

This study characterizes the types, prevalence, and potential effects of alterations in interpretation during ICU family conferences involving end-of-life discussions.

METHODS

We identified ICU family conferences in two hospitals in which a medical interpreter was used. Ten conferences were audiotaped; 9 physicians led these conferences, and 70 family members participated. Research interpreters different from those attending the conference translated the non-English language portions of the audiotaped conferences. We identified interpretation alterations, grouped them into four types, and categorized their potential effects on communication.

RESULTS

For each interpreted exchange between clinicians and family, there was a 55% chance that an alteration would occur. These alterations included additions, omissions, substitutions, and editorializations. Over three quarters of alterations were judged to have potentially clinically significant consequences on the goals of the conference. Of the potentially significant alterations, 93% were likely to have a negative effect on communication; the remainder, a positive effect. The alterations with potentially negative effects included interference with the transfer of information, reduced emotional support, and reduced rapport. Those with potential positive effects included improvements in conveying information and emotional support.

CONCLUSIONS

Alterations in medical interpretation seem to occur frequently and often have the potential for negative consequences on the common goals of the family conference. Further studies examining and addressing these alterations may help clinicians and interpreters to improve communication with family members during ICU family conferences.

Establishing terminal status in end-of-life discussions

The communicative purpose of an end-of-life discussion is to change the goals of treatment for a terminal patient from therapeutic to comfort care. In this study, the authors present a comparative discourse analysis of end-of-life discussions that reached a consensus to change the goals of treatment and discussions that did not. They found that the presentation of medical information was subtly different across these discussions: Decision-making discussions were based on a consistent accumulation of negative evidence, whereas non-decision-making discussions were inconsistent in this respect, including mention of positive rather than negative outcomes of medical problems, discussion of possible treatment options, and mitigating summary statements. The authors note that end-of-life discussions with these specific features do not progress to a decision to change the goals of treatment to comfort care.

How qualitative research can contribute to research in the intensive care unit

A qualitative research design can provide unique contributions to research in the intensive care unit. Qualitative research includes the entire process of research: the methodology (conceptualization of the research question, choosing the appropriate qualitative strategy, designing the protocol), methods (conducting the research using qualitative methods within the chosen qualitative strategy, analysis of the data, verification of the findings), and writing the narrative. The researcher is the instrument and the data are the participants' words and experiences that are collected and coded to present experiences, discover themes, or build theories. A number of strategies are available to conduct qualitative research and include grounded theory, phenomenology, case study, and ethnography. Qualitative methods can be used to understand complex phenomena that do not lend themselves to quantitative methods of formal hypothesis testing. Qualitative research may be used to gain insights about organizational and cultural issues within the intensive care unit and to improve our understanding of social interaction and processes of health care delivery. In this article, we outline the rationale for, and approaches to, using qualitative research to inform critical care issues. We provide an overview of qualitative methods available and how they can be used alone or in concert with quantitative methods. To illustrate how our understanding of social phenomena such as patient safety and behavior change has been enhanced we use recent qualitative studies in acute care medicine.

End-of-life decisions: family views on advance directives

A cross-sectional survey was administered to family members of patients who died at 1 of the 5 Catholic institutions comprising Mercy Health Partners, a health care system in Ohio, to determine their opinions about patient and family participation in decisions about end-of-life care. Among 165 respondents, 118 (86%) of 138 agreed that the family was encouraged to join in decisions and 133 (91%) of 146 that their family member's health care choices were followed. Most agreed that nurses answered their questions (93%, 141/151) and that the doctor communicated well with family members (83%, 128/155). Seventy percent (107/152) indicated that their family member had at least 1 advance directive. There were no differences in whether health care choices were followed when patients with formal advance directives (92%, 92/100) were compared with patients without formal advance directives (88%, 35/40). A unique survey instrument can be used to measure family perceptions and opinions of participation in decisions about end-of-life care.

Prognostication during physician-family discussions about limiting life support in intensive care units

OBJECTIVE

Prognostic information is important to the family members of incapacitated, critically ill patients, yet little is known about what prognostic information physicians provide. Our objectives were to determine the types of prognostic information provided to families of critically ill patients when making major end-of-life treatment decisions and to identify factors associated with more physician prognostication.

DESIGN

Multiple-center, cross-sectional study.

SETTING

ICUs of four hospitals.

SUBJECTS

Thirty-five physicians, 51 patients, and 169 family members.

INTERVENTIONS

We audiotaped 51 physician-family conferences in which there were deliberations about major end-of-life treatment decisions at four hospitals in 2000-2002. Conferences were coded to identify the types of prognostic information provided by physicians. We used a mixed-effects regression model to identify factors associated with more prognostication by physicians.

MEASUREMENTS AND MAIN RESULTS

The mean number of prognostic statements per conference was 9.4+/-6.4 (range 0-29). Eighty-six percent of conferences contained discussion of the patient's anticipated functional status or quality of life, compared with 63% in which the chances for survival were discussed (p=.01). There were significantly more statements about prognosis for functional outcomes per conference compared with statements about prognosis for survival (median 4 [interquartile range 2-8] vs. 1 [interquartile range 0-3]; p<.001). Increasing educational level of the family was independently associated with more prognostic statements by physicians (p<.001) as was the degree of physician-family conflict about withdrawing life support (p<.001) and the physician's race being white (p=.009).

CONCLUSIONS

Prognostication occurred frequently during physician-family deliberations about whether to forego life support, but physicians did not discuss the patient's prognosis for survival in more than one third of conferences. Less educated families received less information about prognosis. Future studies should address whether these observations partially explain the high prevalence of family misunderstandings about prognosis in intensive care units.

End-of-life family conferences: rooted in the evidence

Critical care clinicians no longer consider family members as visitors in the intensive care unit. Family-centered care has emerged from the results of qualitative and quantitative studies evaluating the specific needs of families of patients dying in the intensive care unit. In addition, interventional studies have established that intensive and proactive communication empowers family members of dying patients, helping them to share in discussions and decisions, if they so wish. In addition to intensive communication, interventional studies have highlighted the role of nurses, social workers, and palliative care teams in reducing family burden, avoiding futile life-sustaining therapies, and providing effective comfort care. End-of-life family conferences are formal, structured meetings between intensivists and family members. Guidelines for organizing these conferences take into account the specific needs of families, including reassurance that the patient's symptoms will be adequately managed; honest clear information about the patient's condition and treatment; a willingness on the part of physicians to listen and respond to family members and to address their emotions; attention to patient preferences; clear explanations about surrogate decision making; and continuous, compassionate, and technically proficient attention to the patient's needs until death occurs. Means of improving end-of-life care have been identified in epidemiologic and interventional studies. End-of-life family conferences constitute the keystone around which excellent end-of-life care can be built.

Psychometric characteristics of a quality of communication questionnaire assessing communication about end-of-life care

The importance of good clinician-patient communication to quality end-of-life care has been well documented yet there are no validated measures that allow patients to assess the quality of this communication. Using a sample of hospice patients (n = 83) and patients with chronic obstructive pulmonary disease (COPD) (n = 113), we evaluated the psychometric characteristics of a 13-item patient-centered, patient-report questionnaire about the quality of end-of-life communication (QOC). Our purpose was to explore the measurement structure of the QOC items to ascertain if the items represent unitary or multidimensional constructs and to describe the construct validity of the QOC score(s). Analyses included: principal component analyses to identify scales, internal consistency analyses to demonstrate reliability, and correlational and group comparisons to support construct validity. Findings support the construction of two scales: a six-item "general communication skills" scale and a seven-item, "communication about end-of-life care" scale. The two scales meet standards of scale measurement, including good factor convergence (values >or= 0.63) and discrimination (values different >or= 0.25), percent of variance explained (69.3%), and good internal consistency (alpha >or= 0.79). The scales' construct validity is supported by significant associations (p <or= 0.01) with items assessing overall quality of doctor communication and quality of care, number and type of end-of-life discussions, and doctor's awareness of patient's treatment preferences. The general communication skills scale correlates more strongly with the general communication items while the communication about end-of-life care scale correlates more strongly with items addressing end-of-life topics. While further validation studies are needed, this assessment of the QOC represents an important step toward providing a measure of the quality of end-of-life communication.

Measuring the quality of dying and death: methodological considerations and recent findings

PURPOSE OF REVIEW

While the need to improve the quality of dying and death in critical settings has been well accepted, there is less agreement on which measures and criteria are best used to assess it. In this article, we present methodological considerations and recent findings that pertain to the measurement of the quality of dying and death.

RECENT FINDINGS

Research evaluating the quality of dying and death employs measures based on professionally determined criteria as well as measures relying on patient and family-centered standards. Professionally determined measures include assessments of resource consumption (e.g., length of stay, costs of care, technology utilization) and processes of care (e.g., do-not-resuscitate orders, family conferences). Studies of interventions designed to improve end-of-life care have shown positive changes in these outcomes. Patient and family-centered measures (e.g., quality of dying and death questionnaires, quality of end-of-life care questionnaires) have been used less often in intervention studies but, in descriptive studies, have shown important associations with factors related to a 'good death'.

SUMMARY

These findings suggest a need to integrate both types of measures in research on the quality of end-of-life experiences. This integration, with attention to important methodological issues, may represent a significant step toward improving patients' experiences at the end-of-life.

Bereaved Hospice Caregivers' Perceptions of the End-of-Life Care Communication Process and the Involvement of Health Care Professionals

BACKGROUND

This study was conducted to gain an understanding of bereaved hospice family caregivers' perceptions of the communication process from initial discussion of the need for end-of-life care and hospice through the decision to choose hospice and the transition home.

METHODS

One hundred eight bereaved hospice caregivers that were 36 months postpatient death responded to a quantitative mailed survey. Aspects of the end-of-life care communication process, including involvement of health care professionals at each step, were assessed.

RESULTS

Serious illness and the need for hospice care were first mentioned to patients and caregivers by physicians. Often the caregivers recalled only one meeting in which hospice was discussed. Other than the physicians, social workers were the professionals most often present in at least one of these meetings. Nurses and social workers were both perceived to be helpful in the transition to home hospice. Social workers were reported to be most comfortable with discussion of end-of-life care, most knowledgeable, and most available during the communication process that led to a decision about end-of-life care. Suggestions that these caregivers had to improve communication with health care professionals were categorized from responses to an open-ended survey question as: the need to discuss vital information earlier and what to expect for care at end stage; be more forthcoming about reality of death; and treat people as individuals.

CONCLUSIONS

Although many health care professionals play a role in the communication and transition to hospice care, physicians and social workers were found to be pivotal participants in this process. A coordinated team approach to end-of-life communication and decision-making may facilitate the process and possibly lead to increased and earlier referral to hospice.

Contradictions and communication strategies during end-of-life decision making in the intensive care unit

PURPOSE

The aim of this study was to identify inherent tensions that arose during family conferences in the intensive care unit, and the communication strategies clinicians used in response.

MATERIALS AND METHODS

We identified 51 clinician-family conferences in the intensive care unit from 4 hospitals in which the attending physician believed discussion of withdrawing life-sustaining treatments or delivery of bad news would occur. The communication between clinicians and family members was analyzed using a dialectic perspective.

RESULTS

The tension of choosing whether to "let the patient die now" versus to "not let the patient die now" was the central contradiction within the conferences. Under this overriding theme were 5 categories: killing or allowing to die; death as a benefit or a burden; honoring the patient's wishes or following the family's wishes; weighing contradictory versions of the patient's wishes; and choosing an individual family member as decision maker or the family as a unit as decision maker. In response to these contradictions, clinicians used 2 clusters of communication strategies: decision-centered strategies and information-seeking strategies.

CONCLUSIONS

This study offered insights into end-of-life decision making, prompting clinicians to be conscious of the contradictions that arise and to use specific strategies to address these contradictions in their communication with families.

Transfer of the hematopoietic stem cell transplant patient to the intensive care unit: does it really matter?

We critically reviewed published English language literature and concluded that from 1998 onward the survival of hematopoietic stem cell transplant (SCT) patients who experienced intensive care unit (ICU) transfer has improved. The factors associated with increased mortality during ICU stay included increased patient age, allogeneic transplant, intubation/mechanical ventilation, multiorgan system failure (MOSF), presumed/documented infection, graft-versus-host disease, and higher APACHE and O-PRISM score at ICU transfer. This encouraging outcome trend reflects evolving advances such as use of recombinant hematopoietic growth factors, use of mobilized blood cells rather than marrow, protective strategies for acute lung injury and early goal-directed therapy for sepsis syndrome. Patient selection bias (which patients were transferred and which were not sent to an ICU) also plays a role in ICU survival rates. New strategies to improve upon SCT patient outcome include use of a scoring system to predict mortality, better therapies for MOSF and integration of ICU components and multispecialist involvement earlier in the clinical course to prevent severe complications such as respiratory failure. SCT recipients comprise a heterogeneous group; to further advance this field, prospective multicenter trials involving larger populations from many centers are needed to reduce the biases of retrospective and single-center reports.

Clinician statements and family satisfaction with family conferences in the intensive care unit

OBJECTIVES

The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians' communication behaviors providing emotional support to families during intensive care unit conferences would be associated with increased family satisfaction.

DESIGN

We audiotaped 51 intensive care unit family conferences in which withholding or withdrawing life support was discussed or bad news was delivered. Emotional support techniques used by clinicians during each conference were identified and coded using grounded theory.

SETTING

Four Seattle hospitals.

SUBJECTS

Family members of critically ill patients.

INTERVENTIONS

Questionnaires rating satisfaction with communication were completed by 169 family members.

MEASUREMENTS AND MAIN RESULTS

Linear regression with generalized estimating equation methods was used to analyze the association between the frequency of clinicians' emotionally supportive statements and family satisfaction. Increasing frequency of three types of clinicians' statements during family conferences was associated with increased family satisfaction: a) assurances that the patient will not be abandoned before death (p=.015); b) assurances that the patient will be comfortable and will not suffer (p=.029); and c) support for family's decisions about end- of-life care, including support for family's decision to withdraw or not to withdraw life-support (p=.005).

CONCLUSIONS

Most family members participating in this study were quite satisfied with the communication in the family conferences. Specific clinician communication behaviors are associated with increased family satisfaction during family conferences among family members who are willing to have a family conference recorded. Our results suggest that clinicians in the intensive care unit may improve the experiences of families of critically ill patients by providing explicit support for decisions made by a family with regard to end-of-life care and by assuring families continuity of high-quality care with particular attention to the patient's comfort.

Care at the end of life in critically ill patients: the European perspective

PURPOSE OF REVIEW

Care surrounding end-of-life has become a major topic in the intensive care medicine literature. Cultural and regional variations are associated with transatlantic debates about decisions to forego life-sustaining therapies and lead to recent international statements. The aim of this review is to provide insight into the decisions to forego life sustaining therapies and end-of-life care in Europe.

RECENT FINDINGS

Although decisions to forego life-sustaining therapies are increasingly made in European countries, frequency and characteristics of end-of-life care are still heterogeneous. Moreover, even though many determinants of these variations have been identified, epidemiologic and interventional studies still provide additional information. In agreement with public opinions, recent European laws have emphasized the patient's autonomy. In real life, advance care planning is rarely used. Decisions are often made by caregivers (physicians and nurses) or families, these latter being less involved than in North America. Not only ethic divergences between physicians but also cultural variations account for this disparity.

SUMMARY

To optimize end-of-life care in the intensive care unit, there is an urgent need for the development of palliative and multidisciplinary care in Europe. Furthermore, it highlights the need for culturally competent care, adapted to needs and values of every single patient and family. In addition, a lack of communication with families and within the medical team, an uninformed public about end-of-life issues, and insufficient training of intensive care unit staff are crucial barriers to end-of-life care development. Special awareness of professionals and innovative research are needed to promote a high-standard of end-of-life care in the intensive care unit.

Improving the quality of end-of-life care in the pediatric intensive care unit: parents' priorities and recommendations

OBJECTIVE

Despite recognition that dying children and their families have unique palliative care needs, there has been little empirical inquiry of parent perspectives to improve the quality of end-of-life care and communication. The purpose of this study was to identify and describe the priorities and recommendations for end-of-life care and communication from the parents' perspective.

METHODS

This was a qualitative study based on parental responses to open-ended questions on anonymous, self-administered questionnaires, conducted at 3 pediatric ICUs in Boston, Massachusetts. Fifty-six parents whose children had died in PICUs after withdrawal of life support participated in this study. We measured parent-identified priorities for end-of-life care and communication.

RESULTS

Parents identified 6 priorities for pediatric end-of-life care including honest and complete information, ready access to staff, communication and care coordination, emotional expression and support by staff, preservation of the integrity of the parent-child relationship, and faith.

CONCLUSIONS

Parental priorities and recommendations offer simple yet compelling guidance to improve pediatric end-of-life clinical practice and research.

Withdrawal of Life-Sustaining Therapy After Sudden, Unexpected Life-Threatening Illness or Injury: Interactions Between Patients’ Families, Healthcare Providers, and the Healthcare System

• Background Withdrawal of life-sustaining therapy in intensive care units is increasing. Patients’ families are intimately involved in this process because the patients are usually unable to participate. Little is known about family members’ interactions with healthcare providers and the healthcare system during this process.

• Objective To describe the interactions between patients’ family members, healthcare providers, and the healthcare system during withdrawal of life-sustaining therapy after a sudden, unexpected illness or injury.

• Methods The investigation was part of a larger interpretative phenomenological study. Nineteen families (56 family members) who participated in the process of withdrawal of life-sustaining therapy for a family member were interviewed and observed. An inductive approach to data analysis was used to discover units of meaning, clusters, and categories.

• Results The families’ experiences involved a variety of dimensions, including issues with healthcare providers (bonds and consistency with nurses and physicians, physicians’ presence, information, coordination of care, family meetings, sensitivity to time, and preparation for the dying process) and issues with the healthcare system (parking, struggles with finding privacy, and transfers of patients).

• Conclusions Patients’ families need information, guidance, and support as the families participate in the process of withdrawal of life-sustaining therapy. The results of this study have important implications for clinical practice and future research.

Preparing professionals for family conferences in palliative care: evaluation results of an interdisciplinary approach

BACKGROUND

Patients, families, and health care professionals recognize the need for better communication in palliative and end-of-life care. Family conferences are a powerful clinical tool for communicating with patients and family members. Although family conferences are often used in medical care, few clinicians are prepared to conduct them effectively. An innovative palliative care educational model that included specific attention to family conferences was developed and evaluated. To intervene early in the process of professional socialization, the interactive and interdisciplinary training included medical and social work students.

METHOD

A quasi-experimental longitudinal design was employed to evaluate the educational intervention. Survey measures were administered before, immediately after, and three months after training. Questions addressed experience, education, and attitudes about family conferences. A standardized scale was used to measure change in students' confidence in their ability to lead family conferences.

RESULTS

For both professions, the intervention group demonstrated a significant increase in confidence in the ability to lead family conferences compared with the control group. Three-month follow-up data suggested that subjects in the intervention group maintained these gains.

CONCLUSION

This pilot intervention showed that an interdisciplinary educational approach improves confidence in the ability to lead family conferences when students are exposed early in the process of professional socialization. Early intervention increases the propensity and skills needed to conduct family conferences and advances communication in palliative care. Future research on interdisciplinary education should evaluate effects on clinical practice behaviors, satisfaction with communication and collaboration, and patients' and families' perceptions of quality of care.

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.

Expressions of nonabandonment during the intensive care unit family conference

PURPOSE

Palliative care consultants play an increasing role in assisting critical care clinicians with end-of-life communication in the intensive care unit (ICU). One of the ethical principles these consultants may apply to such communication is nonabandonment of the patient. Limited data exist concerning expressions of nonabandonment in the ICU family conference. This analysis examines expressions of nonabandonment during ICU family conferences. Our goal was to categorize these expressions and develop a conceptual model for understanding this issue as it arises in the ICU setting.

METHODS

We identified family conferences in the ICUs of four hospitals. Conferences were eligible if the attending physician believed that discussion about withholding or withdrawing life support or the delivery of bad news was likely to occur. Fifty-one conferences were audiotaped, transcribed, and analyzed using grounded theory.

RESULTS

We identified categories capturing expressions of nonabandonment in the ICU family conference. Clinicians expressed nonabandonment of the patient or family in three ways: alleviating suffering/ensuring comfort, allowing family members to be present at the bedside for the death, and being accessible to patients and families. Families expressed their own nonabandonment of the patient or concern about abandonment of the patient by the health care team in five ways: ensuring the patient's suffering is eased, being present at the bedside, ensuring the patient's end-of-life preferences are respected, ensuring that everything possible be done to cure the patient, and "letting go." These categories were placed into a conceptual model that differentiates explicit and implicit statements of nonabandonment.

CONCLUSIONS

This paper describes categories and a conceptual model for understanding expressions of nonabandonment that may allow palliative care consultants to help critical care clinicians express nonabandonment and respond to families' expressions of nonabandonment in the ICU family conference. Future studies could use this model to develop a communication intervention for the ICU family conference.

Risk of Post-traumatic Stress Symptoms in Family Members of Intensive Care Unit Patients

RATIONALE

Intensive care unit (ICU) admission of a relative is a stressful event that may cause symptoms of post-traumatic stress disorder (PTSD).

OBJECTIVES

Factors associated with these symptoms need to be identified.

METHODS

For patients admitted to 21 ICUs between March and November 2003, we studied the family member with the main potential decision-making role.

MEASUREMENTS

Ninety days after ICU discharge or death, family members completed the Impact of Event Scale (which evaluates the severity of post-traumatic stress reactions), Hospital Anxiety and Depression Scale, and 36-item Short-Form General Health Survey during a telephone interview. Linear regression was used to identify factors associated with the risk of post-traumatic stress symptoms.

MAIN RESULTS

Interviews were obtained for family members of 284 (62%) of the 459 eligible patients. Post-traumatic stress symptoms consistent with a moderate to major risk of PTSD were found in 94 (33.1%) family members. Higher rates were noted among family members who felt information was incomplete in the ICU (48.4%), who shared in decision making (47.8%), whose relative died in the ICU (50%), whose relative died after end-of-life decisions (60%), and who shared in end-of-life decisions (81.8%). Severe post-traumatic stress reaction was associated with increased rates of anxiety and depression and decreased quality of life.

CONCLUSION

Post-traumatic stress reaction consistent with a high risk of PTSD is common in family members of ICU patients and is the rule among those who share in end-of-life decisions. Research is needed to investigate PTSD rates and to devise preventive and early-detection strategies.

Palliative Care in the Surgical ICU

Palliative care for the critically ill has become an increasingly important component of care in the SICU. As the population ages, medical technology continues to offer new treatments that can prolong life, and more and more Americans die in the hospital in critical care settings, the appropriate management of the end-of-life must be part of the clinical expertise of surgeons and intensivists. Part of this expertise must include the components of palliative care (eg, pain and symptom management, psychosocial support, communication skills, shared decision-making) and specialized areas of withdrawal and withholding of life support. Integrating palliative care expertise into the SICU is not straightforward; understanding when and how to make the transition from curative to palliative care can be fraught with uncertainty regarding prognosis and patient preferences. Attention to the principles of good pain management, communication with patient and family, and discussion of goals of care are not just for patients who are at the end-of-life, but are appropriate care for all critically ill patients, regardless of prognosis. In this framework, "intensive care"encompasses palliative and curative care.

Opportunities and Challenges to Improving End-of-Life Care for Seriously Ill Elderly Patients: A Qualitative Study of Generalist Physicians

BACKGROUND

End-of-life care quality deficiencies have in part been linked to inadequate physician skill in the technical and communication domains of palliative care. Yet few studies have examined physicians' perspectives regarding their experiences caring for patients approaching the end of life.

OBJECTIVE

To understand generalist physicians' perspectives regarding their care of seriously ill elderly patients in order to identify challenges to improving end-of-life communication and decision-making.

DESIGN

Qualitative study using in-depth ethnographic interviews.

SETTING

Puget Sound region of Washington State.

PARTICIPANTS

Thirteen community-based generalist physicians who routinely care for elderly patients and represent a range of practice styles and experiences.

RESULTS

The physicians described a "revolving door syndrome" in which elderly patients are repeatedly hospitalized with chronic illness exacerbations. Three themes influenced physicians' interactions with "revolving door" patients: (1) physicians' use of decision-making heuristics, characterized as "internal gauges," to promote care consistent with their own values; (2) families' "unreasonable expectations" that patients would return to their previous health after treatment of an acute illness; and (3) families' reluctance to accept end-of-life decision-making responsibility.

CONCLUSIONS

Our findings suggest that physician values and physician-family interactions impact decision-making for chronically ill elderly patients. The influence of physicians' internal gauges on end-of-life care can facilitate or hinder use of palliative care as well as decision-making consistent with patients' preferences. Disparate physician and family expectations regarding their division of decision-making responsibility and patients' care outcomes may also affect decision-making. The use of communication strategies that promote alignment of these expectations may improve decision-making quality for incapacitated elderly patients.

Pediatric Post-resuscitation Care

Current literature demonstrates a paucity of information on post-resuscitation care of pediatric clients. This lack of information is somewhat understandable in light of the relatively low incidence of occurrence and the statistically poor outcome. Nurses must be aware, however, of many issues when dealing with pediatric clients and their families after an arrest episode. This article explores key concepts involved with post-resuscitation care, including the outcome of cardiopulmonary resuscitation, immediate post-resuscitation needs, emotional outcomes for the child, and family stress and grief.

The teleo-affective limits of end-of-life care in the intensive care unit

This paper explores the relevance of a specific kind of sensed connectedness or 'teleo-affectivity' to the organisation and enactment of end-of-life care. Referred to as heedful inter-relating, this teleo-affective connectedness has been found to occur among employees as they carry out their highly complex and dangerous work. This paper focuses on the proposals put in the literature for confronting the complexity of end-of-life care in the intensive care unit (ICU), and inquires into the positionings incurred in and around end-of-life care in one specific unit, with the aim of gauging the pertinence of heedful inter-relating to end-of-life care in ICU. The paper argues that while several commentators appear to be calling for enhanced heedful conduct in end-of-life care, ICU practices may not admit the kind of heedful inter-relating that is evident in high-reliability organisations such as nuclear aircraft carriers. We suggest it may be unwise to gauge intensive care units' complexity purely against the brief of realising cultural scripts of the dying, and that ICU in fact manifests a broader societal concern necessitating a more variegated composition: to devise multiple ways to contain the impression and impact of (the meaning) death for society (societies) generally.

Coordination in nurses' listening activities and communication about patient-nurse relationships

The purpose of this analysis was to examine whether nurses' listening behavior, especially the coordination of their nonverbal involvement activities with those of their patients, communicates information about patient-nurse relationships. Participants were 126 college women who responded to a 30-item instrument measuring relational information that was communicated to them by nurses' behavior in videotaped segments of interactions between a patient/actress and 12 nurses. Participants' responses to two consecutive interaction segments were selected for this analysis. The research team coded the patient's and nurses' listening activities, and they calculated coordination and activity rates for all interaction segments. Multiple regression analysis revealed that nurses' verbal listening activities, such as reflection, their nonverbal involvement activities, and their simultaneous coordination of nonverbal involvement activities with those of the patient predicted relational information dimensions of trust/receptivity, depth/similarity/affection, composure, and non-formality. Thus, nurses' listening behavior, including coordination, may contribute to communication about patient-nurse relationships.

Missed opportunities during family conferences about end-of-life care in the intensive care unit

BACKGROUND

Improved communication with family members of critically ill patients can decrease the prolongation of dying in the intensive care unit (ICU), but few data exist to guide the conduct of this communication.

OBJECTIVE

Our objective was to identify missed opportunities for physicians to provide support for or information to family during family conferences.

METHODS

We identified ICU family conferences in four hospitals that included discussions about withdrawing life support or delivery of bad news. Fifty-one conferences were audiotaped, including 214 family members. Thirty-six physicians led the conferences and some physicians led more than one. We used qualitative methods to identify and categorize missed opportunities, defined as an occurrence when the physician had an opportunity to provide support or information to the family and did not.

MAIN RESULTS

Fifteen family conferences (29%) had missed opportunities identified. These fell into three categories: opportunities to listen and respond to family; opportunities to acknowledge and address emotions; and opportunities to pursue key principles of medical ethics and palliative care, including exploration of patient preferences, explanation of surrogate decision making, and affirmation of nonabandonment. The most commonly missed opportunities were those to listen and respond, but examples from other categories suggest value in being aware of these opportunities.

CONCLUSIONS

Identification of missed opportunities during ICU family conferences provides suggestions for improving communication during these conferences. Future studies are needed to demonstrate whether addressing these opportunities will improve quality of care.

Family-physician interactions in the intensive care unit

Surrogate designation has the potential to represent the patient's wishes and promote successful family involvement in decision making when options exist as to the patient's medical management. In recent years, intensive care unit physicians and nurses have promoted family-centered care on the basis that adequate and effective communication with family members is the key to substitute decision making, thereby protecting patient autonomy. The two-step model for the family-physician relationship in the intensive care unit including early and effective provision of information to the family followed by family input into decision making is described as well as specific needs of the family members of dying patients. A research agenda is outlined for further investigating the family-physician relationship in the intensive care unit. This agenda includes a) improvement of communication skills for health care workers; b) research in the area of information and communication; c) interventions in non-intensive care unit areas to promote programs for teaching communication skills to all members of the medical profession; d) research on potential conflict between medical best interest and the ethics of autonomy; and e) publicity to enhance society's interest in advance care planning and surrogate designation amplified by debate in the media and other sounding boards. These studies should focus both on families and on intensive care unit workers. Assessments of postintervention outcomes in family members would provide insights into how well family-centered care matches family expectations and protects families from distress, not only during the intensive care unit stay but also during the ensuing weeks and months.

Medical education research at the University of Washington School of Medicine: lessons from the past and potential for the future

Faculty in the Department of Medical Education and Biomedical Informatics at the University of Washington School of Medicine received over $1.2 million in direct grant and contract support in 2003. In this case study, the authors provide some of the history and background of the evolution of the department's structure and its role in providing leadership in medical education research at the university, as well as regionally, nationally, and internationally. The authors offer their observations and reflections on what has helped and hindered the department's success, and end with some predictions on medical education research in the future. The University of Washington's five-state regional WWAMI educational program, establishing a single medical school for the states of Washington, Wyoming, Alaska, Montana, and Idaho, has been an important environmental influence on the direction of the department's educational and research activities. External support has helped the department to create the Northwest Consortium for Clinical Performance Assessment, the Center for Medical Education Research, the Teaching Scholars Program, and a Biomedical and Health Informatics graduate and fellowship training program, as well as a number of international programs.

Communicating about end-of-life care with patients and families in the intensive care unit

Discussing end-of-life care and death with patients and their families is an extremely important part of providing a good quality care in the intensive care unit (ICU). Although there is little empiric research to guide ICU clinicians in the most effective way to have these conversations, there is a developing literature and experience and an increasing emphasis on making this an important part of the care we provide. Much like other ICU procedures or skills,providing sensitive and effective communication about end-of-life care requires training, practice, and supervision, as well as planning and preparation. Although different clinicians may have different approaches and should change their approach to match the needs of individual patients and their families, this article reviews some of the fundamental components to discussing end-of-life care in the ICU that should be part of the care of patients with life-threatening illnesses in the ICU.

The dying patient in the ICU: role of the interdisciplinary team

Expert opinion supports the application of broad interdisciplinary team approaches to the care of the dying patient in the intensive care unit (ICU). Current literature contains many suggestions about how core team members-physicians, nurses, and patients/family members-could systematically enhance interdisciplinary collaboration in the care of the dying patient. In the few studies of ICU interdisciplinary collaborative care of the dying patient, investigator shave demonstrated improvement in care. In addition, ethics consultants and interdisciplinary palliative care teams, working with the core team members, have improved care for the dying. Further studies are needed to document alternative interdisciplinary models for achieving improved and durable patient, family,and provider outcomes in the care of the dying ICU patient.

Caring for the family of the critically ill patient

Family's needs and considerations are an essential component of intensive care unit (ICU) care. Family satisfaction is related to clinician communication and decision making. Indeed, timely, honest communication is vital to the psychosocial health and satisfaction of the family. Conflict often arises within the family and between the family and the clinicians, over decision making. Again, good communication skills are critical to family satisfaction with decision making and comfort with the care received. Family members have numerous psychosocial changes, and may experience depression,anxiety, or anticipatory grief while their family member is dying in the ICU. Awareness of these conditions, providing support to the families, and allowing family access to the dying individual can assist with meeting the family's desire to see their family member have a peaceful death.

Family satisfaction with family conferences about end-of-life care in the intensive care unit: Increased proportion of family speech is associated with increased satisfaction*

OBJECTIVE

Family members of critically ill patients report dissatisfaction with family-clinician communication about withdrawing life support, yet limited data exist to guide clinicians in this communication. The hypothesis of this analysis was that increased proportion of family speech during ICU family conferences would be associated with increased family satisfaction.

DESIGN

Cross-sectional study.

SETTING

We identified family conferences in intensive care units of four Seattle hospitals during which discussions about withdrawing life support were likely to occur.

PARTICIPANTS

Participants were 214 family members from 51 different families. There were 36 different physicians leading the conferences, as some physicians led more than one conference.

INTERVENTIONS

Fifty-one conferences were audiotaped.

MEASUREMENTS

We measured the duration of time that families and clinicians spoke during the conference. All participants were given a survey assessing satisfaction with communication.

RESULTS

The mean conference time was 32.0 mins with an sd of 14.8 mins and a range from 7 to 74 mins. On average, family members spoke 29% and clinicians spoke 71% of the time. Increased proportion of family speech was significantly associated with increased family satisfaction with physician communication. Increased proportion of family speech was also associated with decreased family ratings of conflict with the physician. There was no association between the duration of the conference and family satisfaction.

CONCLUSIONS

This study suggests that allowing family members more opportunity to speak during conferences may improve family satisfaction. Future studies should assess the effect of interventions to increase listening by critical care clinicians on the quality of communication and the family experience.

Clinician predictions of intensive care unit mortality*

OBJECTIVE

Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients.

DESIGN

Prospective cohort study.

SETTING

Fifteen tertiary care centers.

PATIENTS

Consecutive mechanically ventilated patients > or = 18 yrs of age with expected intensive care unit stay > or = 72 hrs.

INTERVENTIONS

We recorded baseline characteristics at intensive care unit admission. Daily we measured multiple organ dysfunction score (MODS), use of advanced life support, patient preferences for life support, and intensivist and bedside intensive care unit nurse estimated probability of intensive care unit survival.

MEASUREMENTS AND MAIN RESULTS

The 851 patients were aged 61.2 (+/- 17.6, mean + SD) yrs with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.7 (+/- 8.6). Three hundred and four patients (35.7%) died in the intensive care unit, and 341 (40.1%) were assessed by a physician at least once to have a < 10% intensive care unit survival probability. Independent predictors of intensive care unit mortality were baseline APACHE II score (hazard ratio, 1.16; 95% confidence interval, 1.08-1.24, for a 5-point increase) and daily factors such as MODS (hazard ratio, 2.50; 95% confidence interval, 2.06-3.04, for a 5-point increase), use of inotropes or vasopressors (hazard ratio, 2.14; 95% confidence interval, 1.66-2.77), dialysis (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), patient preference to limit life support (hazard ratio, 10.22; 95% confidence interval, 7.38-14.16), and physician but not nurse prediction of < 10% survival. The impact of physician estimates of < 10% intensive care unit survival was greater for patients without vs. those with preferences to limit life support (p < .001) and for patients with less vs. more severe organ dysfunction (p < .001). Mechanical ventilation, inotropes or vasopressors, and dialysis were withdrawn more often when physicians predicted < 10% probability of intensive care unit survival (all ps < .001).

CONCLUSIONS

Physician estimates of intensive care unit survival < 10% are associated with subsequent life support limitation and more powerfully predict intensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.

Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003

The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.

Junior versus Senior Physicians for Informing Families of Intensive Care Unit Patients

To compare the effectiveness of information delivered to family members of critically ill patients by junior and senior physicians, we performed a prospective randomized multicenter trial in 11 French intensive care units. Patients (n = 220) were allocated at random to having their family members receive information by only junior or only senior physicians throughout the intensive care unit stay; there were 92 and 93 evaluable cases in the junior and senior groups, respectively, with no significant differences in baseline characteristics. Between Days 3 and 5, one family representative per patient was evaluated for comprehension of the diagnosis, prognosis, and treatment in the patient; satisfaction with information and care; and presence of symptoms of anxiety and depression. No significant differences were found between the two groups for any of these three criteria. Family members informed by a junior physician were more likely to feel they had not been given enough information time (additional time wanted: 3 [0-6.5] vs. 0 [0-5] minutes, p = 0.01) and to have sought additional explanations from their usual doctor (48.9 vs. 34.4%, p = 0.004). Specialty residents, if given opportunities for acquiring experience, can become proficient in communicating with families and share this task with senior physicians.

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.

Beyond ethical dilemmas: improving the quality of end-of-life care in the intensive care unit

Consensus guidelines on providing optimal end-of-life care in the intensive care unit (ICU) are important tools. However, despite 30 years of ethical discourse and consensus on many of the principles that guide end-of-life care in the ICU, care remains inadequate. Although consensus on the most challenging ethical aspects of some cases will remain elusive, this need not deter clinicians from engaging in practical quality improvement, best practice, and educational interventions to provide compassionate care to all critically ill patients, including those who ultimately die.