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Reifarth E, Garcia Borrega J, Kochanek M. How to communicate with family members of the critically ill in the intensive care unit: A scoping review. Intensive Crit Care Nurs 2023; 74:103328. [PMID: 36180318 DOI: 10.1016/j.iccn.2022.103328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To map the existing approaches to communication with family members of the critically ill in the intensive care unit and the corresponding implementation requirements and benefits. METHODS We conducted a scoping review in February 2022 by searching PubMed, CINAHL, APA PsycINFO, and Cochrane Library for articles published between 2000 and 2022. We included records of all designs that met our inclusion criteria and applied frequency counts and qualitative coding. RESULTS The search yielded 3749 records, 63 met inclusion criteria. The included records were of an interventional (43 %) or observational (14 %) study design or review articles (43 %), and provided information in three categories: communication platforms, strategies, and tools. For implementation in the intensive care unit, the approaches required investing time and resources. Their reported benefits were an increased quality of communication and satisfaction among all parties involved, improved psychological outcome among family members, and reduced intensive care unit length of stay and costs. CONCLUSION The current approaches to communication with patients' family members offer insights for the development and implementation of communication pathways in the intensive care unit of which the benefits seem to outweigh the efforts. Structured interprofessional frameworks with standardised tools based on empathic communication strategies are encouraged.
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Affiliation(s)
- Eyleen Reifarth
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Jorge Garcia Borrega
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Matthias Kochanek
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
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Curtis JR, Lee RY, Brumback LC, Kross EK, Downey L, Torrence J, Heywood J, LeDuc N, Mallon Andrews K, Im J, Weiner BJ, Khandelwal N, Abedini NC, Engelberg RA. Improving communication about goals of care for hospitalized patients with serious illness: Study protocol for two complementary randomized trials. Contemp Clin Trials 2022; 120:106879. [PMID: 35963531 PMCID: PMC10042145 DOI: 10.1016/j.cct.2022.106879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/26/2022] [Accepted: 08/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although goals-of-care discussions are important for high-quality palliative care, this communication is often lacking for hospitalized older patients with serious illness. Electronic health records (EHR) provide an opportunity to identify patients who might benefit from these discussions and promote their occurrence, yet prior interventions using the EHR for this purpose are limited. We designed two complementary yet independent randomized trials to examine effectiveness of a communication-priming intervention (Jumpstart) for hospitalized older adults with serious illness. METHODS We report the protocol for these 2 randomized trials. Trial 1 has two arms, usual care and a clinician-facing Jumpstart, and is a pragmatic trial assessing outcomes with the EHR only (n = 2000). Trial 2 has three arms: usual care, clinician-facing Jumpstart, and clinician- and patient-facing (bi-directional) Jumpstart (n = 600). We hypothesize the clinician-facing Jumpstart will improve outcomes over usual care and the bi-directional Jumpstart will improve outcomes over the clinician-facing Jumpstart and usual care. We use a hybrid effectiveness-implementation design to examine implementation barriers and facilitators. OUTCOMES For both trials, the primary outcome is EHR documentation of a goals-of-care discussion within 30 days of randomization; additional outcomes include intensity of end-of-life care. Trial 2 also examines patient- or family-reported outcomes assessed by surveys targeting 3-5 days and 4-8 weeks after randomization including quality of goals-of-care communication, receipt of goal-concordant care, and psychological symptoms. CONCLUSIONS This novel study incorporates two complementary randomized trials and a hybrid effectiveness-implementation approach to improve the quality and value of care for hospitalized older adults with serious illness. CLINICAL TRIALS REGISTRATION STUDY00007031-A and STUDY00007031-B.
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Affiliation(s)
- J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America.
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lyndia C Brumback
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Nicole LeDuc
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Kasey Mallon Andrews
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Jennifer Im
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States of America
| | - Bryan J Weiner
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States of America; Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States of America
| | - Nauzley C Abedini
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
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Jennerich AL, Hobler MR, Sharma RK, Engelberg RA, Curtis JR. Unplanned Admission to the ICU: A Qualitative Study Examining Family Member Experiences. Chest 2020; 158:1482-1489. [PMID: 32502593 DOI: 10.1016/j.chest.2020.05.554] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/30/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Transfers to the ICU from acute care are common, and it is essential to understand how family members of critically ill patients experience these transitions of care. RESEARCH QUESTION Can we enhance our understanding of family members' experiences during hospital stays complicated by a patient's unplanned admission to the ICU? STUDY DESIGN AND METHODS Qualitative interviews were conducted with family members of patients were transferred from acute care to the ICU at a level I trauma center in Seattle, WA (n = 17). To organize data, we used thematic analysis, coupled with a validated conceptual model of clinician-surrogate communication. RESULTS Drawing from a validated conceptual model, we used two domains to frame our coding: "information processing" and "relationship building." Within information processing, we coded information disclosure, sensemaking, and expectations; within relationship building, we coded emotional support, trust, and consensus and conflict. Family members wanted timely, accurate information about the patient's condition both during and after transfer. An unplanned ICU admission was a stressful event for family members, who looked to clinicians for emotional support. Developing trust was challenging, because family members struggled to feel like integrated members of the medical team when patients transitioned from one setting to another. INTERPRETATION Family of patients who experience an unplanned ICU admission want high-quality communication both during and after a patient's transfer to the ICU. This communication should help family members make sense of the situation, address unmet expectations, and provide emotional support. In addition, interventions that foster family-clinician trust can help family members feel like integrated members of the care team as they face the challenge of navigating multiple different environments within the hospital.
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Affiliation(s)
- Ann L Jennerich
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
| | - Mara R Hobler
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA; Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Ruth A Engelberg
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - J Randall Curtis
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
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Anderson RJ, Bloch S, Armstrong M, Stone PC, Low JT. Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence. Palliat Med 2019; 33:926-941. [PMID: 31184529 PMCID: PMC6691601 DOI: 10.1177/0269216319852007] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Effective communication between healthcare professionals and relatives of patients approaching the end-of-life is vital to ensure patients have a 'good death'. To improve communication, it is important to first identify how this is currently being accomplished. AIM To review qualitative evidence concerning characteristics of communication about prognosis and end-of-life care between healthcare professionals and relatives of patients approaching the end-of-life. DESIGN Qualitative systematic review (PROSPERO registration CRD42017065560) using thematic synthesis. Peer-reviewed, English language articles exploring the content of conversations and how participants communicated were included. No date restrictions were applied. Quality of included studies was appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. DATA SOURCES An electronic database search of CINAHL, MEDLINE, PsycINFO and EMBASE was performed. RESULTS Thirty-one papers were included. Seven themes were identified: highlighting deterioration; involvement in decision-making, post-decision interactional work, tailoring, honesty and clarity, specific techniques for information delivery and roles of different healthcare professionals. Varied levels of family involvement in decision-making were reported. Healthcare professionals used strategies to aid understanding and collaborative decision-making, such as highlighting the patient's deterioration, referring to patient wishes and tailoring information delivery. Doctors were regarded as responsible for discussing prognosis and decision-making, and nurses for providing individualized care. CONCLUSION Findings suggest training could provide healthcare professionals with these strategies to improve communication. Interventions such as question prompt lists could help relatives overcome barriers to involvement in decision-making. Further research is needed to understand communication with relatives in different settings and with different healthcare professionals.
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Affiliation(s)
- Rebecca J Anderson
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Steven Bloch
- 2 Department of Language and Cognition, Division of Psychology and Language Sciences, University College London, London, UK
| | - Megan Armstrong
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Patrick C Stone
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Joseph Ts Low
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med 2015; 43:1964-77. [PMID: 26154929 DOI: 10.1097/ccm.0000000000001131] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. DATA SOURCES A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury." DATA EXTRACTION AND SYNTHESIS We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. CONCLUSIONS Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.
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Cooke CR, Hotchkin DL, Engelberg RA, Rubinson L, Curtis JR. Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU. Chest 2010; 138:289-97. [PMID: 20363840 DOI: 10.1378/chest.10-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Little information exists about the expected time to death after terminal withdrawal of mechanical ventilation. We sought to determine the independent predictors of time to death after withdrawal of mechanical ventilation. METHODS We conducted a secondary analysis from a cluster randomized trial of an end-of-life care intervention. We studied 1,505 adult patients in 14 hospitals in Washington State who died within or shortly after discharge from an ICU following terminal withdrawal of mechanical ventilation (August 2003 to February 2008). Time to death and its predictors were abstracted from the patients' charts and death certificates. Predictors included demographics, proxies of severity of illness, life-sustaining therapies, and International Classification of Diseases, 9th ed., Clinical Modification codes. RESULTS The median (interquartile range [IQR]) age of the cohort was 71 years (58-80 years), and 44% were women. The median (IQR) time to death after withdrawal of ventilation was 0.93 hours (0.25-5.5 hours). Using Cox regression, the independent predictors of a shorter time to death were nonwhite race (hazard ratio [HR], 1.17; 95% CI, 1.01-1.35), number of organ failures (per-organ HR, 1.11; 95% CI, 1.04-1.19), vasopressors (HR, 1.67; 95% CI, 1.49-1.88), IV fluids (HR, 1.16; 95% CI, 1.01-1.32), and surgical vs medical service (HR, 1.29; 95% CI, 1.06-1.56). Predictors of longer time to death were older age (per-decade HR, 0.95; 95% CI, 0.90-0.99) and female sex (HR, 0.86; 95% CI, 0.77-0.97). CONCLUSIONS Time to death after withdrawal of mechanical ventilation varies widely, yet the majority of patients die within 24 hours. Subsequent validation of these predictors may help to inform family counseling at the end of life.
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Affiliation(s)
- Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, University of Michigan, 6 Ann Arbor, MI 48109-5604, USA.
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Physician communication with families in the ICU: evidence-based strategies for improvement. Curr Opin Crit Care 2010; 15:569-77. [PMID: 19855271 DOI: 10.1097/mcc.0b013e328332f524] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Skilled physician-family communication in the ICU has been shown to improve patient outcomes, but until now little attention has been given to the effect of communication on family satisfaction and bereavement outcomes. The aim of this review is to outline the recent evidence that effective physician communication with families, and proactive palliative care interventions, can improve outcomes for both patients and family members in the ICU. RECENT FINDINGS New data from the ICU correlates physician ability to identify and respond to emotion and to effectively share prognostic information with improved outcomes. Furthermore, proactive palliative care interventions that promote family meetings, use of empathic communication skills, and targeted palliative care consultations can improve family satisfaction, reduce length of stay in the ICU and reduce adverse family bereavement outcomes. SUMMARY Empathic communication, skilful discussion of prognosis, and effective shared decision-making are core elements of quality care in the ICU, represent basic competencies for the ICU physician, and should be emphasized in future educational and clinical interventions.
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