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Trotta F, Petrosino F, Pucciarelli G, Alvaro R, Vellone E, Bartoli D. Reliability and validity of the training satisfaction questionnaire for family members (TSQ-FM) entering the ICU during an isolation disease outbreak. Heart Lung 2024; 66:37-45. [PMID: 38574598 DOI: 10.1016/j.hrtlng.2024.03.004] [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: 10/07/2023] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The presence of family members in an isolated ICU during an isolation disease outbreak is restricted by hospital policies because of the infectious risk. This can be overcome by conferring to family members the skill and the ability to safely don and doff the personal protective equipment (PPE) through a nurse-led training intervention and assess their satisfaction, to respond to the need to define a safe, effective and quality care pathway focused on Family-Centered Care (FCC) principles. OBJECTIVE the study aimed to build a valid and reliable instrument for clinical practice to assess family members' satisfaction to allow ICU nurses to restore family integrity in any case of infectious disease outbreak that requires isolation. METHODS A cross-sectional study was conducted to test the psychometric properties. The questionnaire was constructed based on a literature review on the needs of family members in the ICU. 76 family members were admitted to a COVID-ICU. Cronbach's coefficient, Geomin rotated loading, and EFA were applied to assess the reliability and validity of the instrument. RESULTS The Kaiser-Mayer-Olkin (KMO) measure was 0.662, the Bartlett sphericity test showed a significant p-value (χ²=448.33; df=45; p < 0.01), Cronbach's alpha coefficient was.896. A further CFA analysis confirmed that all fit indices were acceptable. The results showed satisfactory validity and reliability, which could be generalized and extended to any outbreak of isolation disease. CONCLUSIONS This study provides a valid and reliable instrument for clinical practice to maintain family integrity in the dyadic relationship between the patient and the family member, even during an emergency infectious disease outbreak that requires isolation.
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Affiliation(s)
- Francesca Trotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Francesco Petrosino
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Gianluca Pucciarelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Ercole Vellone
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Davide Bartoli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
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2
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Azoulay É, Kentish-Barnes N, Boulanger C, Mistraletti G, van Mol M, Heras-La Calle G, Estenssoro E, van Heerden PV, Delgado MCM, Perner A, Arabi YM, Myatra SN, Laake JH, De Waele JJ, Darmon M, Cecconi M. Family centeredness of care: a cross-sectional study in intensive care units part of the European society of intensive care medicine. Ann Intensive Care 2024; 14:77. [PMID: 38771395 PMCID: PMC11109056 DOI: 10.1186/s13613-024-01307-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/05/2024] [Indexed: 05/22/2024] Open
Abstract
PURPOSE To identify key components and variations in family-centered care practices. METHODS A cross-sectional study, conducted across ESICM members. Participating ICUs completed a questionnaire covering general ICU characteristics, visitation policies, team-family interactions, and end-of-life decision-making. The primary outcome, self-rated family-centeredness, was assessed using a visual analog scale. Additionally, respondents completed the Maslach Burnout Inventory and the Ethical Decision Making Climate Questionnaire to capture burnout dimensions and assess the ethical decision-making climate. RESULTS The response rate was 53% (respondents from 359/683 invited ICUs who actually open the email); participating healthcare professionals (HCPs) were from Europe (62%), Asia (9%), South America (6%), North America (5%), Middle East (4%), and Australia/New Zealand (4%). The importance of family-centeredness was ranked high, median 7 (IQR 6-8) of 10 on VAS. Significant differences were observed across quartiles of family centeredness, including in visitation policies availability of a waiting rooms, family rooms, family information leaflet, visiting hours, night visits, sleep in the ICU, and in team-family interactions, including daily information, routine day-3 conference, and willingness to empower nurses and relatives. Higher family centeredness correlated with family involvement in rounds, participation in patient care and end-of-life practices. Burnout symptoms (41% of respondents) were negatively associated with family-centeredness. Ethical climate and willingness to empower nurses were independent predictors of family centeredness. CONCLUSIONS This study emphasizes the need to prioritize healthcare providers' mental health for enhanced family-centered care. Further research is warranted to assess the impact of improving the ethical climate on family-centeredness.
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Affiliation(s)
- Élie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris-Cité University, 1 avenue Claude Vellefaux, Paris, 75010, France.
| | - Nancy Kentish-Barnes
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris-Cité University, 1 avenue Claude Vellefaux, Paris, 75010, France
| | - Carole Boulanger
- Royal Devon University NHS Foundation Trust, Barrack Road, Exeter, UK
| | - Giovanni Mistraletti
- Dipartimento di Fisiopatologia medico-chirurgica e dei trapianti. A.S.S.T. Ovest Milanese, Università degli Studi di Milano, Ospedale Civile di Legnano, Legnano, MI, Italy
| | | | - Gabriel Heras-La Calle
- International Research Project for the Humanisation of Intensive Care Units, Proyecto HU-CI, Madrid, Spain
- Humanizing Healthcare Foundation. Intensive Care Unit, Hospital Universitario de Jaén, Jaén, Spain
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos General San Martín, La Plata, Buenos Aires, Argentina
| | - Peter Vernon van Heerden
- Department of Anesthesiology, Critical Care and Pain medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Maria-Cruz Martin Delgado
- Department Intensive Care Medicine Hospital 12 de Octubre, Madrid, Spain
- Research Institute "Hospital 12 de Octubre (imas12)", Universidad Complutense de Madrid, Madrid, Spain
| | - Anders Perner
- Department of Intensive Care, Department of Clinical Medicine, Copenhagen University Hospital - Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Yaseen M Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard Health - Affairs, and College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute Mumbai, Mumbai, India
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Critical Care and Emergencies, Rikshopitalet Medical Centre, Oslo University Hospital, Oslo, Norway
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Gent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Michael Darmon
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris-Cité University, 1 avenue Claude Vellefaux, Paris, 75010, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Levi Montalcini, Pieve Emanuele, MI, Italy
- 2IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
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3
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Vendetta L, Vig E, Kross E, Merel SE. The Role of the Palliative Medicine Clinician in the Family Conference. Am J Hosp Palliat Care 2023; 40:5-9. [PMID: 35465731 DOI: 10.1177/10499091221093560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Facilitating a family conference is a core skill for a palliative medicine clinician, yet the role of the palliative medicine consultant in a family conference has not been clearly defined in the literature. Most educational articles describe a structured approach to a family conference that focuses on the role of the person leading the conference, who may be a palliative medicine specialist or a member of the primary team caring for the patient. For the palliative medicine clinician, balancing the roles of communication facilitator and palliative consultant is nuanced and requires a specific framework and set of skills. In this article, we review the literature on family conferences focusing on facilitation and communication by the palliative care consultant during the conferences, and outline specific ways the palliative medicine clinician can contribute to family conferences. Our hope is that this framework helps guide palliative medicine clinicians and others seeking more specialized training in palliative medicine to be more intentional with their contributions to family conferences in the future. We also hope that this framework will help palliative medicine educators training future specialists.
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Affiliation(s)
- Lindsay Vendetta
- 601956VA Puget Sound Geriatric Research Education and Clinical Center, Seattle, WA, USA.,205280University of Washington Department of Medicine, Division of Gerontology and Geriatric Medicine, Seattle, WA, USA
| | - Elizabeth Vig
- 205280University of Washington Department of Medicine, Division of Gerontology and Geriatric Medicine, Seattle, WA, USA.,UW Geriatrics and Extended Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Erin Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Susan E Merel
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA.,205280University of Washington Department of Medicine, Division of General Internal Medicine, Seattle, WA, USA
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Latour JM, Kentish-Barnes N, Jacques T, Wysocki M, Azoulay E, Metaxa V. Improving the intensive care experience from the perspectives of different stakeholders. Crit Care 2022; 26:218. [PMID: 35850700 PMCID: PMC9289931 DOI: 10.1186/s13054-022-04094-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 01/02/2023] Open
Abstract
The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel’s suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.
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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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6
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Andersen SK, Vincent G, Butler RA, Brown EHP, Maloney D, Khalid S, Oanesa R, Yun J, Pidro C, Davis VN, Resick J, Richardson A, Rak K, Barnes J, Bezak KB, Thurston A, Reitschuler-Cross E, King LA, Barbash I, Al-Khafaji A, Brant E, Bishop J, McComb J, Chang CCH, Seaman J, Temel JS, Angus DC, Arnold R, Schenker Y, White DB. ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults. J Pain Symptom Manage 2022; 63:e601-e610. [PMID: 35595373 PMCID: PMC9299559 DOI: 10.1016/j.jpainsymman.2022.02.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Each year, approximately one million older adults die in American intensive care units (ICUs) or survive with significant functional impairment. Inadequate symptom management, surrogates' psychological distress and inappropriate healthcare use are major concerns. Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative care (PC) specialists to address these needs, but convincing proof of efficacy has not yet been demonstrated. DESIGN We will conduct a multicenter patient-randomized efficacy trial of integrated specialty PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate decision-makers from five hospitals in Pennsylvania. INTERVENTION The intervention will follow recommended best practices for inpatient PC consultation. Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment that continues until hospital discharge or death. SPC clinicians will meet with patients, families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate in proactive family meetings according to a predefined schedule. Patients in the control arm will receive routine ICU care. OUTCOMES Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates' psychological symptom burden and health resource utilization. Other outcomes include patient survival, as well as interprofessional collaboration. We will also conduct prespecified subgroup analyses using variables such as PC needs, measured by the Needs of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale. CONCLUSIONS This trial will provide robust evidence about the impact of integrating SPC with critical care on patient, family, and health system outcomes.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Grace Vincent
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rachel A Butler
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elke H P Brown
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dave Maloney
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sana Khalid
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rae Oanesa
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James Yun
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carrie Pidro
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerie N Davis
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Resick
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aaron Richardson
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kimberly Rak
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jackie Barnes
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Karl B Bezak
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Thurston
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eva Reitschuler-Cross
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linda A King
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ian Barbash
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Emily Brant
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Bishop
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer McComb
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer Seaman
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Acute and Tertiary Care (J.S.), University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Temel
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston (J.S.T.), Massachusetts, USA
| | - Derek C Angus
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert Arnold
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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7
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Kruser JM, Schwarze ML. The Science of Context: Transforming Serious Illness Care Though In Situ Observation. J Pain Symptom Manage 2022; 63:e651-e653. [PMID: 35595382 PMCID: PMC10152965 DOI: 10.1016/j.jpainsymman.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jacqueline M Kruser
- Department of Medicine (J.M.K.), Division of Allergy, Pulmonary and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
| | - Margaret L Schwarze
- Department of Surgery (M.L.S), Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Drury A, Muscat DM, Wibrow B, Jacques A, Anstey M. Integrating the Choosing Wisely 5 Questions into Family Meetings in the Intensive Care Unit: A Randomized Controlled Trial Investigating the Effect on Family Perceived Involvement in Decision-Making. J Patient Exp 2022; 9:23743735221092623. [PMID: 35434292 PMCID: PMC9006367 DOI: 10.1177/23743735221092623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Family members often act as surrogate decision makers for patients in the intensive care unit (ICU). The use of printed prompts may assist with families feeling empowered to fulfill this role. Prospective, randomized controlled trial in 3 ICUs in Western Australia. In the intervention arm, families received the Choosing Wisely 5 questions as printed prompts prior to a family meeting, and the control arm did not receive prompts. The primary outcome was family perceived involvement in decision-making. Outcomes were measured using a survey. Sixty families participated in the study. The majority of families (87.1% control, 79.3% intervention; P = .334) reported feeling “very included” in decision-making. There was no difference in secondary outcomes, including minimal uptake of the questions by the intervention arm. This has been the first randomized trial evaluating the use of a decision-making tool for families in the ICU. Despite ceiling effects in outcome measures, these results suggest room for future study of the Choosing Wisely 5 questions in the ICU.
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Affiliation(s)
- Ashleigh Drury
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Danielle M Muscat
- Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
| | - Bradley Wibrow
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Angela Jacques
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Matthew Anstey
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Public Health, Curtin University, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Molinaro ML, Cheng A, Cristancho S, LaDonna K. Drawing on experience: exploring the pedagogical possibilities of using rich pictures in health professions education. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:1519-1535. [PMID: 34152494 DOI: 10.1007/s10459-021-10056-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/12/2021] [Indexed: 06/13/2023]
Abstract
In both clinical and health professions education research, rich pictures, or participant-generated drawings of complex phenomena, are gaining recognition as a useful method for exploring multifaceted and emotional topics in medicine. For instance, two recent studies used rich pictures to augment semi-structured interviews exploring trainees', health care professionals' (HCPs), and parents' experiences of difficult conversations in the Neonatal Intensive Care Unit (NICU)-an environment in which communication is often challenging, anxiety-provoking, and emotionally distressing. In both studies, participants were invited to draw a picture depicting how they experienced a difficult conversation in this setting. As part of the interview process, participants were asked to both describe how they engaged with rich pictures, and to share their perceptions about the affordances and limitations of this research method. Here, their perspectives are reported and the possibilities of using rich pictures to inform pedagogical innovations in health professions education and research are considered.
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Affiliation(s)
- Monica L Molinaro
- Health and Rehabilitation Sciences, University of Western Ontario, London, ON, Canada.
| | - Anita Cheng
- Department of Neonatal and Perinatal Medicine, London Health Sciences Centre, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Sayra Cristancho
- Department of Surgery, Faculty of Education, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Kori LaDonna
- Department of Innovation in Medical Education and Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Palliative care interventions in intensive care unit patients. Intensive Care Med 2021; 47:1415-1425. [PMID: 34652465 DOI: 10.1007/s00134-021-06544-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. METHODS We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. RESULTS Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. CONCLUSION Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
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Sleiman J, Savage DJ, Switzer B, Colbert CY, Chevalier C, Neuendorf K, Harris D. Teaching residents how to break bad news: piloting a resident-led curriculum and feedback task force as a proof-of-concept study. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2021; 7:568-574. [DOI: 10.1136/bmjstel-2021-000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2021] [Indexed: 11/04/2022]
Abstract
BackgroundBreaking bad news (BBN) is a critically important skill set for residents. Limited formal supervision and unpredictable timing of bad news delivery serve as barriers to the exchange of meaningful feedback.Purpose of studyThe goal of this educational innovation was to improve internal medicine residents’ communication skills during challenging BBN encounters. A formal BBN training programme and innovative on-demand task force were part of this two-phase project.Study designInternal medicine residents at a large academic medical centre participated in an interactive workshop focused on BBN. Workshop survey results served as a needs assessment for the development of a novel resident-led BBN task force. The task force was created to provide observations at the bedside and feedback after BBN encounters. Training of task force members incorporated video triggers and a feedback checklist. Inter-rater reliability was analysed prior to field testing, which provided data on real-world implementation challenges.Results148 residents were trained during the 2-hour communications skills workshop. Based on survey results, 73% (108 of 148) of the residents indicated enhanced confidence in BBN after participation. Field testing of the task force on a hospital ward revealed potential workflow barriers for residents requesting observations and prompted troubleshooting. Solutions were implemented based on field testing results.ConclusionsA trainee-led BBN task force and communication skills workshop is offered as an innovative model for improving residents’ interpersonal and communication skills in BBN. We believe the model is both sustainable and reproducible. Lessons learnt are offered to aid in implementation in other settings.
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Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France. Contemp Clin Trials 2021; 107:106465. [PMID: 34091062 DOI: 10.1016/j.cct.2021.106465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help. DESIGN AND INTERVENTION We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months. PARTICIPANTS We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less. OUTCOMES We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries. CONCLUSIONS We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.
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How to hold an effective NICU family meeting: capturing parent perspectives to build a more robust framework. J Perinatol 2021; 41:2217-2224. [PMID: 33883689 PMCID: PMC8058495 DOI: 10.1038/s41372-021-01051-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/01/2021] [Accepted: 03/29/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To record the content and parental perceptions of family meetings in a Neonatal Intensive Care Unit (NICU) to improve existing frameworks for facilitating these meetings. STUDY DESIGN A prospective, mixed-methods study. NICU family meetings were audio-recorded, transcribed, and analyzed by an iteratively derived coding framework until thematic saturation. We used descriptive statistics of parental post-meeting assessments. RESULTS Qualitative analysis of 21 meetings identified both Communication Facilitators and Barriers. Facilitators included use of visual-aids and participation of social workers to clarify information for parents. Barriers included staff rarely eliciting parental comprehension (3 meetings) or concerns (5) before providing new information, resulting in 39% of parents reporting they didn't ask questions they wanted to ask. In 33% of meetings an important participant was absent. CONCLUSIONS This novel qualitative and quantitative dataset of NICU family meetings highlights areas for improving communication. Attention to these components may improve parental perceptions of family meetings.
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Koszalinski RS, McCarthy JM. Patient communication in the intensive care unit: Background and future possibilities. Intensive Crit Care Nurs 2020; 63:102955. [PMID: 33139166 DOI: 10.1016/j.iccn.2020.102955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rebecca S Koszalinski
- University of Oklahoma Health Sciences Center, Fran and Earl Ziegler College of Nursing, Oklahoma City, OK 73117, United States.
| | - Jillian M McCarthy
- University of Tennessee Health Sciences Center, Audiology and Speech Pathology, Knoxville, TN 37996, United States.
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Burke RV, Rome R, Constanza K, Amedee M, Santos C, Leigh A. Addressing Palliative Care Needs of COVID-19 Patients in New Orleans, LA: A Team-Based Reflective Analysis. Palliat Med Rep 2020; 1:124-128. [PMID: 32856024 PMCID: PMC7446248 DOI: 10.1089/pmr.2020.0057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 11/30/2022] Open
Abstract
Background: New Orleans, Louisiana served as a central location for a surge of novel coronavirus cases during the months of March 2020 to May 2020. To provide guidance to palliative care teams naive to the palliative care demand associated with a surge of coronavirus cases, we document our protocol to best optimize palliative care resources. This report aims to present this information and reflect upon what was most beneficial/least beneficial to serve as a roadmap for palliative teams facing this pandemic. Objective: To pilot a team-based structured protocol to categorize severity of COVID-19 intensive care unit (ICU) admissions and subsequently collaborate with the palliative interdisciplinary team to assess physical, spiritual, and psychosocial needs. Design: New ICU consults were categorized into color-coded clinical severity “pots” during daily ICU interdisciplinary rounds. Clinical decision making and communication with patient/next of kin were based on “pot” classification. Settings/Subjects: Palliative medicine consults were placed on all COVID-19 positive patients admitted to the ICU between March 29, 2020, and May 1, 2020. Measurements: A retrospective chart review was performed to analyze the effect of palliative care consultation on completion of goals-of-care conversations and the life-sustaining treatment (LST) document, an advance directive form specific to the Veterans Affairs hospital system between March 29, 2020 and May 1, 2020. Results: Of the palliative consults evaluated by a palliative provider, 74% resulted in completion of a LST document, 58% resulted in video contact with family members, and 100% incorporated a goals-of-care discussion. Conclusions: We found that standardizing palliative care consultation on all COVID-19 positive ICU admissions subjectively alleviated the burden on ICU providers and staff in the midst of a crisis, resulted in increased documentation of patient goals-of-care preferences/LSTs, facilitated clinical updates to family members, and better distributed clinical burden among palliative team members.
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Affiliation(s)
- Rebecca V Burke
- Section of Geriatrics and Extended Care, Southeast Louisiana Veterans Health Care System (SLVHCS), New Orleans, Louisiana, USA.,Department of Internal Medicine, Tulane School of Medicine, New Orleans, Louisiana, USA
| | - Robin Rome
- Section of Geriatrics and Extended Care, Southeast Louisiana Veterans Health Care System (SLVHCS), New Orleans, Louisiana, USA
| | - Kelly Constanza
- Section of Geriatrics and Extended Care, Southeast Louisiana Veterans Health Care System (SLVHCS), New Orleans, Louisiana, USA
| | - Malaika Amedee
- Section of Geriatrics and Extended Care, Southeast Louisiana Veterans Health Care System (SLVHCS), New Orleans, Louisiana, USA
| | - Charles Santos
- Section of Geriatrics and Extended Care, Southeast Louisiana Veterans Health Care System (SLVHCS), New Orleans, Louisiana, USA
| | - Alexandra Leigh
- Section of Geriatrics and Extended Care, Southeast Louisiana Veterans Health Care System (SLVHCS), New Orleans, Louisiana, USA.,Department of Internal Medicine, Tulane School of Medicine, New Orleans, Louisiana, USA
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Fehnel CR, Armengol de la Hoz M, Celi LA, Campbell ML, Hanafy K, Nozari A, White DB, Mitchell SL. Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation. Chest 2020; 158:1456-1463. [PMID: 32360728 DOI: 10.1016/j.chest.2020.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence. RESEARCH QUESTION The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea. STUDY DESIGN AND METHODS This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6 h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation. RESULTS Among 822 patients undergoing PVW, 19% and 30% had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1 h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95% CI, 1.03-4.19), lung injury (aOR, 3.33; 95% CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95% CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95% CI, 1.19-3.00). INTERPRETATION Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.
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Affiliation(s)
- Corey R Fehnel
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA.
| | - Miguel Armengol de la Hoz
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA; Biomedical Engineering and Telemedicine Group, Biomedical Technology Centre CTB, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Leo A Celi
- Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts Institute of Technology, Cambridge, MA
| | | | - Khalid Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Ala Nozari
- Department of Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Douglas B White
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
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Glod SA, Kang A, Wojnar M. Family Meeting Training Curriculum: A Multimedia Approach With Real-Time Experiential Learning for Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10883. [PMID: 32175474 PMCID: PMC7062545 DOI: 10.15766/mep_2374-8265.10883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 10/14/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Effective communication skills are widely recognized as an important aspect of medical practice. Several tools and curricula for communications training in medicine have been proposed, with increasing attention to the need for an evidence-based curriculum for communication with families of patients in the intensive care unit (ICU). METHODS We developed a curriculum for internal medicine residents rotating through the medical ICU that consisted of a didactic session introducing basic and advanced communication skills, computer-based scenarios exposing participants to commonly encountered dilemmas in simulated family meetings, and experiential learning through the opportunity to identify potential communication challenges prior to facilitating actual family meetings, followed by structured peer debriefing. Seventeen residents participated in the study. RESULTS We administered the Communication Skills Attitude Scale to participants before and after participation in the curriculum, as well as a global self-efficacy survey, with some items based on the Common Ground rating instrument, at the end of the academic year. There were no significant changes in either positive or negative attitudes toward learning communication skills. Resident self-perceived efficacy in several content domains improved but did not reach statistical significance. DISCUSSION Our curriculum provided interactive preparatory training and an authentic experience for learners to develop skills in family meeting facilitation. Learners responded favorably to the curriculum. Use of the Family Meeting Behavioral Skills (FMBS) tool helped residents and educators identify and focus on specific skills related to the family meeting. Next steps include gathering and analyzing data from the FMBS tool.
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Affiliation(s)
- Susan A. Glod
- Associate Professor, Department of Medicine, Penn State College of Medicine
- Medicine Clerkship Director, Penn State College of Medicine
| | - Ashley Kang
- Resident, Internal Medicine Residency Program, Montefiore Medical Center
| | - Margaret Wojnar
- Professor, Department of Medicine, Penn State College of Medicine
- Pulmonary/Critical Care Fellowship Director, Penn State College of Medicine
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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: 97] [Impact Index Per Article: 19.4] [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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Azoulay E, Forel JM, Vinatier I, Truillet R, Renault A, Valade S, Jaber S, Durand-Gasselin J, Schwebel C, Georges H, Merceron S, Cariou A, Moussa M, Hraiech S, Argaud L, Leone M, Curtis JR, Kentish-Barnes N, Jouve E, Papazian L. Questions to improve family-staff communication in the ICU: a randomized controlled trial. Intensive Care Med 2018; 44:1879-1887. [PMID: 30374690 DOI: 10.1007/s00134-018-5423-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 10/17/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE Relatives of intensive care unit (ICU) patients suffer emotional distress that impairs their ability to acquire the information they need from the staff. We sought to evaluate whether providing relatives with a list of important questions was associated with better comprehension on day 5. METHODS Randomized, parallel-group trial. Relatives of mechanically ventilated patients were included from 14 hospitals belonging to the FAMIREA study group in France. A validated list of 21 questions was handed to the relatives immediately after randomization. The primary endpoint was comprehension on day 5. Secondary endpoints were satisfaction (Critical Care Family Needs Inventory, CCFNI) and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale, HADS). RESULTS Of 394 randomized relatives, 302 underwent the day-5 assessment of all outcomes. Day-5 family comprehension was adequate in 68 (44.2%) and 75 (50.7%) intervention and control group relatives (P = 0.30), respectively. Over the first five ICU days, median number of family-staff meetings/patient was 6 [3-9], median total meeting time was 72.5 [35-110] min, and relatives asked a median of 20 [8-33] questions including 11 [6-13] from the list, with no between-group difference. Satisfaction and anxiety/depression symptoms were not significantly different between groups. The only variable significantly associated with better day-5 comprehension by multivariable analysis was a higher total number of questions asked before day 5. CONCLUSIONS Providing relatives with a list of questions did not improve day-5 comprehension, secondary endpoints, or information time. Further research is needed to help families obtain the information they need. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02410538.
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Affiliation(s)
- Elie Azoulay
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, ECSTRA Team, and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France.
| | | | - Isabelle Vinatier
- Surgical ICUs From Montpellier or Marseille Hospitals, Medical-Surgical ICUs From La Roche sur Yon, La Roche sur Yon, France
| | - Romain Truillet
- Statistical Department of Marseille, AP-HM, Marseille, France
| | | | - Sandrine Valade
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, ECSTRA Team, and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Samir Jaber
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, ECSTRA Team, and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | | | | | | | | | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France
| | | | | | | | - Marc Leone
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, ECSTRA Team, and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, USA
| | - Nancy Kentish-Barnes
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, ECSTRA Team, and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Elisabeth Jouve
- Statistical Department of Marseille, AP-HM, Marseille, France
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Implementation of a Nurse-Led Family Meeting in a Neuroscience Intensive Care Unit. Dimens Crit Care Nurs 2018; 35:268-76. [PMID: 27487752 DOI: 10.1097/dcc.0000000000000199] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE/OBJECTIVES The aims of this study were to develop, implement, and evaluate the impact of early intensive care unit (ICU) nurse-led family meetings on nurse-family communication, family decision making, and satisfaction of family members. BACKGROUND Intensive care unit nurses are in an ideal position to meet family needs, and family members may cope better with the crisis of an ICU admission if consistent honest information is provided by nurses; however, there are no early ICU family meetings led by bedside nurses. METHODS This quality improvement project was implemented in a 10-bed neuroscience ICU over a 3-month period. A convenience sample of 23 nurses participated in the project. Following development of a communication protocol to facilitate nurse-led meetings, the nurses received education and then implemented the protocol. Thirty-one family members participated in the project. Family members were surveyed before and after the meetings. RESULTS Mean meeting time was 26 (SD, 14) minutes. Following implementation of the meetings, findings demonstrated that families felt that communication improved (P = .02 and P = .008), they had appropriate information for decision making allowing them to feel in control (P = .002), and there was an increase in family satisfaction (P = .001). CONCLUSION Early ICU nurse-led family meetings were feasible, improved communication between ICU nurses and family members, facilitated decision making in ICU families, and increased satisfaction of family members.
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Ambrosino N, Vitacca M. The patient needing prolonged mechanical ventilation: a narrative review. Multidiscip Respir Med 2018; 13:6. [PMID: 29507719 PMCID: PMC5831532 DOI: 10.1186/s40248-018-0118-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/07/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Progress in management has improved hospital mortality of patients admitted to the intensive care units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients, caregivers and health services, as well as high human and financial resources consumption, despite poor long-term outcomes. An effort should be made to improve the management of these patients. This narrative review summarizes the main concepts in this field. MAIN BODY There is great variability in terminology and definitions of prolonged mechanical ventilation.There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of protocols, early mobilisation and physiotherapy, specialised weaning units.There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival of these patients.Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised controlled trials on this critical issue. End of life decisions should result from appropriate communication among professionals, patients and surrogates and national legislations should give clear indications. CONCLUSION Present medical training of clinicians and locations like traditional intensive care units do not appear enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects of management are needed.
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Affiliation(s)
- Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, 27040 Montescano, PV Italy
| | - Michele Vitacca
- Istituti Clinici Scientifici Maugeri, IRCCS, Respiratory Unit, Istituto Scientifico di Lumezzane, Lumezzane, BS Italy
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Silva RSD, Trindade GSS, Paixão GPDN, Silva MJPD. Family conference in palliative care: concept analysis. Rev Bras Enferm 2018; 71:206-213. [DOI: 10.1590/0034-7167-2016-0055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/03/2017] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: to analyze the attributes, antecedents and consequents of the family conference concept. Method: Walker and Avante's method for concept analysis and the stages of the integrative review process, with a selection of publications in the PubMed, Cinahl and Lilacs databases focusing on the family conference theme in the context of palliative care. Results: the most cited antecedents were the presence of doubts and the need to define a care plan. Family reunion and working instrument were evidenced as attributes. With respect to consequents, to promote the effective communication and to establish a plan of consensual action were the most remarkable elements. Final considerations: the scarcity of publications on the subject was observed, as well as and the limitation of the empirical studies to the space of intensive therapy. Thus, by analyzing the attributes, antecedents and consequents of the concept it was possible to follow their evolution and to show their efficacy and effectiveness as a therapeutic intervention.
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Drago MJ. Making Sense of the Surreal: Guiding Families and Patients When Last-Ditch Medical Efforts Fail. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:30-31. [PMID: 29313772 DOI: 10.1080/15265161.2017.1401173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Ménard C, Libert Y, Canivet D, Van Achte L, Farvacques C, Liénard A, Merckaert I, Reynaert C, Slachmuylder JL, Durieux JF, Klastersky J, Razavi D. Development of the Multi-Dimensional Analysis of Patient Outcome Predictions (MD.POP) during medical encounters. PATIENT EDUCATION AND COUNSELING 2018; 101:52-58. [PMID: 28784286 DOI: 10.1016/j.pec.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 07/02/2017] [Accepted: 07/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Our first objective was to develop the Multi-Dimensional analysis of Patient Outcome Predictions (MD.POP), an interaction analysis system that assesses how HCPs discuss precisely and exclusively patient outcomes during medical encounters. The second objective was to study its interrater reliability. METHOD The MD.POP was developed by consensus meetings. Forty simulated medical encounters between physicians and an actress portraying a patient were analysed. Interrater reliability analysis was conducted on 20 of those simulated encounters. RESULTS The MD.POP includes six dimensions: object, framing, value, domain, probability and form of POP. The coding method includes four steps: 1) transcription of the encounter, 2) POP identification, 3) POP dimension coding and 4) POP scoring. Descriptive analyses show that the MD.POP is able to describe verbal expressions addressing the patient's outcomes. Statistical analyses show excellent interrater reliability (Cohen's Kappa ranging from 0.92 to 0.94). CONCLUSION The MD.POP is a reliable interaction analysis system that assesses how HCPs discuss patient medical, psychological or social outcomes during medical encounters. PRACTICAL IMPLICATION The MD.POP provides a measure for researchers to study how HCPs communicate with patients about potential outcomes. Results of such studies will allow to provide recommendations to improve HCP's communication about patients' outcomes.
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Affiliation(s)
- Catherine Ménard
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium.
| | - Yves Libert
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Institut Jules Bordet, Brussels, Belgium.
| | - Delphine Canivet
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Hôpital Universitaire Erasme, Brussels, Belgium
| | - Laetitia Van Achte
- Faculté de Psychologie, Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | | | | | - Isabelle Merckaert
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Institut Jules Bordet, Brussels, Belgium
| | - Christine Reynaert
- Faculté de Psychologie, Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | | | | | | | - Darius Razavi
- Unité de Recherche en Psychosomatique et en Psycho-oncologie, Université Libre de Bruxelles, Brussels, Belgium; Institut Jules Bordet, Brussels, Belgium
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Michelson K, Clayman ML, Ryan C, Emanuel L, Frader J. Communication During Pediatric Intensive Care Unit Family Conferences: A Pilot Study of Content, Communication, and Parent Perceptions. HEALTH COMMUNICATION 2017; 32:1225-1232. [PMID: 27612506 DOI: 10.1080/10410236.2016.1217450] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
While there is a robust literature describing family conferences (FCs) in adult intensive care units (ICUs), less information exists about FCs in pediatric ICUs (PICUs). We conducted a pilot study to describe the focus of discussion, communication patterns of health care team members (HTMs) and parents, and parents' perspectives about clinician communication during PICU FCs. We analyzed data from 22 video- or audiorecorded PICU FCs and post-FC questionnaire responses from 27 parents involved in 18 FCs. We used the Roter Interaction Analysis System (RIAS) to describe FC dialogue content. Our questionnaire included the validated Communication Assessment Tool (CAT). FCs were focused on care planning (n = 5), decision making (n = 6), and updates (n = 11). Most speech came from HTMs (mean 85%; range, 65-94%). Most HTM utterances involved medical information. Most parent utterances involved asking for explanations. The mean overall CAT score was 4.62 (using a 1-5 scale where 5 represents excellent and 1 poor) with a mean of 73.02% "excellent" responses. Update and care-planning FCs had lower CAT scores compared to decision-making FCs. The lowest scoring CAT items were "Involved me in decisions as much as I wanted," "Talked in terms I could understand," and "Gave me as much information as I wanted." These findings suggest that while health care providers spend most of their time during FCs relaying medical information, more attention should be directed at providing information in an understandable manner. More work is needed to improve communication when decision making is not the main focus of the FC.
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Affiliation(s)
- Kelly Michelson
- a Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics , Northwestern University Feinberg School of Medicine
| | | | | | - Linda Emanuel
- d The Buehler Center on Aging, Health & Society, Department of General Internal Medicine and Geriatrics, and Department of Psychiatry and Behavioral Sciences , Northwestern University Feinberg School of Medicine
| | - Joel Frader
- e Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics , Northwestern University Feinberg School of Medicine
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Hinkle LJ, Fettig LP, Carlos WG, Bosslet G. Twelve tips for just in time teaching of communication skills for difficult conversations in the clinical setting. MEDICAL TEACHER 2017; 39:920-925. [PMID: 28598711 DOI: 10.1080/0142159x.2017.1333587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The ability to communicate well with patients and other members of the healthcare team is a vital skill for physicians to have, but one that is often not emphasized in medical education. Learners of all levels can obtain and develop good communication skills regardless of their natural ability in this area, and the clinical setting represents an underutilized resource to accomplish this task. With this in mind, we have reviewed the growing body of literature on the subject and organized our findings into twelve tips to help educators capitalize on these missed opportunities. While our emphasis is helping learners with difficult discussions, these tips can be easily adapted to any other clinical encounter requiring clear communication. Teaching effective communication skills in the clinical setting requires some extra time, but the steps outlined should not take more than a few minutes to complete. Taking the time to develop these skills in our learners will make a significant difference not only their lives but also their patients and their families.
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Affiliation(s)
- Laura Jean Hinkle
- a Department of Medicine, Division of Pulmonary and Critical Care Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Lyle Patrick Fettig
- b Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - William Graham Carlos
- a Department of Medicine, Division of Pulmonary and Critical Care Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Gabriel Bosslet
- a Department of Medicine, Division of Pulmonary and Critical Care Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
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Abstract
OBJECTIVES To investigate family perceptions of having a nurse participating in family conferences and to assess the psychologic well being of the same families after ICU discharge. DESIGN Mixed-method design with a qualitative study embedded in a single-center randomized study. SETTING Twelve-bed medical-surgical ICU in a 460-bed tertiary hospital. SUBJECTS One family member for each consecutive patient who received more than 48 hours of mechanical ventilation in the ICU. INTERVENTION Planned proactive participation of a nurse in family conferences led by a physician. In the control group, conferences were led by a physician without a nurse. MEASUREMENTS AND MAIN RESULTS Of the 172 eligible family members, 100 (60.2%) were randomized; among them, 88 underwent semistructured interviews at ICU discharge and 86 completed the Peritraumatic Dissociative Experiences Questionnaire at ICU discharge and then the Hospital Anxiety Depression Questionnaire and the Impact of Event Scale (for posttraumatic stress-related symptoms) 3 months later. The intervention and control groups were not significantly different regarding the prevalence of posttraumatic stress-related symptoms (52.3 vs 50%, respectively; p = 0.83). Anxiety and depression subscale scores were significantly lower in the intervention group. The qualitative data indicated that the families valued the principle of the conference itself. Perceptions of nurse participation clustered into four main themes: trust that ICU teamwork was effective (50/88; 56.8%), trust that care was centered on the patient (33/88; 37.5%), trust in effective dissemination of information (15/88; 17%), and trust that every effort was made to relieve anxiety in family members (12/88; 13.6%). CONCLUSIONS Families valued the conferences themselves and valued the proactive participation of a nurse. These positive perceptions were associated with significant anxiety or depression subscale scores but not with changes in posttraumatic stress-related symptoms.
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van Mol MMC, Boeter TGW, Verharen L, Kompanje EJO, Bakker J, Nijkamp MD. Patient- and family-centred care in the intensive care unit: a challenge in the daily practice of healthcare professionals. J Clin Nurs 2017; 26:3212-3223. [DOI: 10.1111/jocn.13669] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Margo MC van Mol
- Department of Intensive Care Adults; Erasmus MC University Medical Center Rotterdam; Rotterdam the Netherlands
| | - Trudi GW Boeter
- Department of Intensive Care Adults; Erasmus MC University Medical Center Rotterdam; Rotterdam the Netherlands
| | | | - Erwin JO Kompanje
- Department of Intensive Care Adults; Erasmus MC University Medical Center Rotterdam; Rotterdam the Netherlands
| | - Jan Bakker
- Department of Intensive Care Adults; Erasmus MC University Medical Center Rotterdam; Rotterdam the Netherlands
- Division of Pulmonary, Allergy, and Critical Care Medicine; Department of Medicine; Columbia University Medical Center; New York NY USA
| | - Marjan D Nijkamp
- Faculty of Psychology and Educational Sciences; Open University of the Netherlands; Heerlen the Netherlands
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Cahill PJ, Lobb EA, Sanderson C, Phillips JL. What is the evidence for conducting palliative care family meetings? A systematic review. Palliat Med 2017; 31:197-211. [PMID: 27492159 DOI: 10.1177/0269216316658833] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Structured family meeting procedures and guidelines suggest that these forums enhance family-patient-team communication in the palliative care inpatient setting. However, the vulnerability of palliative patients and the resources required to implement family meetings in accordance with recommended guidelines make better understanding about the effectiveness of this type of intervention an important priority. Aim and design: This systematic review examines the evidence supporting family meetings as a strategy to address the needs of palliative patients and their families. The review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. DATA SOURCES Six medical and psychosocial databases and "CareSearch," a palliative care-specific database, were used to identify studies reporting empirical data, published in English in peer-reviewed journals from 1980 to March 2015. Book chapters, expert opinion, and gray literature were excluded. The Cochrane Collaboration Tool assessed risk of bias. RESULTS Of the 5051 articles identified, 13 met the inclusion criteria: 10 quantitative and 3 qualitative studies. There was low-level evidence to support family meetings. Only two quantitative pre- and post-studies used a validated palliative care family outcome measure with both studies reporting significant results post-family meetings. Four other quantitative studies reported significant results using non-validated measures. CONCLUSION Despite the existence of consensus-based family meeting guidelines, there is a paucity of evidence to support family meetings in the inpatient palliative care setting. Further research using more robust designs, validated outcome measures, and an economic analysis are required to build the family meeting evidence before they are routinely adopted into clinical practice.
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Affiliation(s)
- Philippa J Cahill
- 1 School of Medicine, The University of Notre Dame Australia, Sydney, NSW, Australia
| | - Elizabeth A Lobb
- 1 School of Medicine, The University of Notre Dame Australia, Sydney, NSW, Australia.,2 Calvary Health Care Sydney, Kogarah, NSW, Australia
| | - Christine Sanderson
- 1 School of Medicine, The University of Notre Dame Australia, Sydney, NSW, Australia.,2 Calvary Health Care Sydney, Kogarah, NSW, Australia.,3 CareSearch Palliative Care Knowledge Network, Department of Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia
| | - Jane L Phillips
- 4 Centre for Cardiovascular and Chronic Care, University of Technology Sydney, Ultimo, NSW, Australia.,5 School of Nursing, The University of Notre Dame Australia, Sydney, NSW Australia.,6 School of Medicine, The University of Sydney, Sydney, NSW, Australia
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Cousino MK, Rea KE, Mednick LM. Understanding the healthcare communication needs of pediatric patients through the My CHATT tool: A pilot study. ACTA ACUST UNITED AC 2017. [DOI: 10.1080/17538068.2017.1278637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Melissa K. Cousino
- Department of Psychiatry, Harvard Medical School and Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics and University of Michigan Transplant Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kelly E. Rea
- Department of Pediatrics and University of Michigan Transplant Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Lauren M. Mednick
- Department of Psychiatry, Harvard Medical School and Boston Children's Hospital, Boston, MA, USA
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Vincent JL, Berré J, Creteur J. Withholding and withdrawing life prolonging treatment in the intensive care unit: a current European perspective. Chron Respir Dis 2016; 1:115-20. [PMID: 16279270 DOI: 10.1191/1479972304cd021rs] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background:Many deaths are now preceded by an end of life decision, particularly in the intensive care unit (ICU), but such practices vary considerably between countries, ICUs and individuals, depending on many factors including cultural and religious background, family and peer pressure and local practice. Aims:In this review, we will discuss the application of the four key ethical principles-beneficence, nonmaleficence, autonomy and distributive justice - to withdrawing/withholding decisions. Methods: Drawing data from several national and international studies, we then summarize the current situation across Europe regarding such practices before making some suggestions as to how we could facilitate the often difficult decision making process by improved communication between staff, patient and relatives.
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Affiliation(s)
- J L Vincent
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium.
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Therapeutic Alliance between the Caregivers of Critical Illness Survivors and Intensive Care Unit Clinicians. Ann Am Thorac Soc 2016; 12:1646-53. [PMID: 26452172 DOI: 10.1513/annalsats.201507-408oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE Therapeutic alliance is a novel measure of the multifaceted caregiver-clinician relationship and a promising intervention target for improving patient-centered outcomes. However, therapeutic alliance has not been studied in an intensive care unit (ICU) setting. OBJECTIVES To explore the relationships among caregiver-reported therapeutic alliance and psychological distress as well as patient, caregiver, and ICU clinician factors. METHODS In this cross-sectional study, we enrolled consecutive patient caregivers of mechanically ventilated patients discharged from all ICUs at Duke University and the Medical University of South Carolina Hospitals between December 2013 and August 2014. MEASUREMENTS AND MAIN RESULTS Caregivers completed an in-person, hospital-based interview that included measures of therapeutic alliance with the ICU physicians (Human Connection Scale) as well as patient centeredness of care; symptoms of depression, anxiety, and post-traumatic stress; decisional conflict; and quality of communication. We performed a multivariate regression to characterize associations between Human Connection Scale scores and key variables. A total of 56 caregivers were included in these exploratory analyses. Patients were largely disabled (47%) and Medicare insured (53%). Caregivers were highly educated and generally had high therapeutic alliance (median, 55; interquartile range, 48-58) with the ICU clinicians. Therapeutic alliance was strongly correlated with patient centeredness (r = 0.78) and poorly correlated with psychological distress (r < 0.2). Stepwise multivariate modeling revealed that higher therapeutic alliance was associated with fewer baseline patient comorbidities as well as caregiver report of greater trust in the ICU team, better quality of communication, and less decisional conflict (all P < 0.012). CONCLUSIONS Therapeutic alliance encompasses measures of trust, communication, and cooperation, which are intuitive to forming a good working relationship. Therapeutic alliance among ICU caregivers is strongly associated with both modifiable and nonmodifiable factors. Our exploratory study highlights new intervention targets that may inform strategies for improving the quality of the caregiver-clinician interaction.
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Garrouste-Orgeas M, Vinatier I, Tabah A, Misset B, Timsit JF. Reappraisal of visiting policies and procedures of patient's family information in 188 French ICUs: a report of the Outcomerea Research Group. Ann Intensive Care 2016; 6:82. [PMID: 27566711 PMCID: PMC4999564 DOI: 10.1186/s13613-016-0185-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 08/15/2016] [Indexed: 12/02/2022] Open
Abstract
Background The relatives of intensive care unit (ICU) patients must cope with both the severity of illness of their loved one and the unfamiliar and stressful ICU environment. This hardship may lead to post-intensive care syndrome. French guidelines provide recommendations on welcoming and informing families of ICU patients. We questioned whether and how they are applied 5 years after their publication. Methods We conducted a large survey among French ICUs to evaluate their visiting policies and how information was provided to patient’s family. A questionnaire was built up by intensivists and nurses. French ICUs were solicited, and the questionnaire was sent to all participating ICUs, for being filled in by the unit medical and/or nursing head. Data regarding the hospital and ICU characteristics, the visiting policy and procedures, and the management of family information were collected. Results Among the 289 French ICUs, 188 (65 %) participated. Most ICUs have a waiting room 118/188 (62.8 %) and a dedicated room for meeting the family 152/188 (80.8 %). Of the 188 ICUs, 45 (23.9 %) were opened on a 24-h-a-day basis. In the remaining ICUs, the time period allowed for visits was 4.75 ± 1.83 h (median 5 h). In ICUs where visiting restrictions were reported, open visiting was allowed for end-of-life situations in 107/143 (74.8 %). Children are allowed to visit a patient in 164/188 (87.2 %) regardless of their age in 97/164 (59.1 %) of ICUs. Families received an information leaflet in 168/188 (89.3 %). Information was provided to families through structured meetings in 149/188 (79.2 %) of ICUs at patient admission with participation of nurses and nursing assistants in 133/188 (70.4 %) and 55/188 (29.2 %), respectively. Information delivered to the family was reported in the patient chart by only 111/188 ICUs (59 %). Participation in care was infrequent. Conclusions Although French ICUs do not follow the consensus recommendations, slow progress exists compared to previous reports. Implementation of these recommendations is largely needed to offer better welcome and information improvement. Further studies on that topic would enable evaluating remaining obstacles and increasing caregivers’ awareness, both critical for further progresses on that topic. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0185-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maité Garrouste-Orgeas
- IAME, UMR 1137, Sorbonne Paris Cité, Paris Diderot University, 75018, Paris, France. .,Outcomerea Research Group, 75020, Paris, France. .,Service de médecine intensive et de réanimation, Groupe Hospitalier Paris Saint Joseph, 185 rue Raymond Losserand, 75014, Paris, France.
| | - Isabelle Vinatier
- Medical-Surgical ICU, Les Oudaries Hospital, La Roche-Sur-Yon, France
| | - Alexis Tabah
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Burns, Trauma and Critical Care Research Centre, University of Queesland, Brisbane, Australia
| | - Benoit Misset
- Medical ICU, Charles Nicolle University Hospital, Rouen, France
| | - Jean-François Timsit
- IAME, UMR 1137, Sorbonne Paris Cité, Paris Diderot University, 75018, Paris, France.,Outcomerea Research Group, 75020, Paris, France.,Medical ICU, Bichat University Hospital, Paris, France
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Ayeh DD, Tak HJ, Yoon JD, Curlin FA. U.S. Physicians' Opinions About Accommodating Religiously Based Requests for Continued Life-Sustaining Treatment. J Pain Symptom Manage 2016; 51:971-8. [PMID: 27039013 DOI: 10.1016/j.jpainsymman.2015.12.337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 12/19/2015] [Accepted: 12/24/2015] [Indexed: 11/22/2022]
Abstract
CONTEXT Families of critically ill patients occasionally request that physicians continue life-sustaining treatment (LST), sometimes giving religious reasons. OBJECTIVES To examine whether U.S. physicians are more likely to accommodate requests for LST that are based on religious reasons. METHODS In 2010, we surveyed 1156 practicing U.S. physicians from specialties likely to care for adult patients with advanced illness. The questionnaire included two randomized experimental vignettes: one where a family asked that LST be continued for a patient that met brain death criteria and a second where the son of an elderly patient with cancer insists on continuing LST. In both, we experimentally varied the reasons that the family member gave to justify the request, to see if physicians are more likely to accommodate a request based on a religious requirement or hope for a miracle, compared to no mention of either. For physicians' religious characteristics, we assessed their religious affiliation and level of religiosity. RESULTS For the patient meeting brain death criteria, physicians were more likely to accommodate the request to continue LST when the family mentioned their Orthodox Jewish community (85% vs. 70%, P < 0.001). For the patient with metastatic cancer, physicians were more likely to accommodate the request when the son said his religious faith does not permit discontinuing LST (65% vs. 46%, P < 0.001), but not when he said he expected divine healing (50% vs. 46%). CONCLUSION Physicians appear more willing to accommodate requests to continue LST when those requests are based on particular religious communities or traditions, but not when based on expectations of divine healing.
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Affiliation(s)
| | - Hyo Jung Tak
- Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - John D Yoon
- Department of Medicine and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Farr A Curlin
- Trent Center for Bioethics, Humanities & History of Medicine, Duke University, Durham, North Carolina, USA.
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Coombs M, Tang J, Long-Sutehall T. Vigilant attentiveness in families observing deterioration in the dying intensive care patient: A secondary analysis study. Intensive Crit Care Nurs 2016; 33:65-71. [PMID: 26875444 DOI: 10.1016/j.iccn.2015.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Family support in intensive care is often focussed on what information is communicated to families. This is particularly important during treatment withdrawal and end of life care. However, this positions families as passive receivers of information. Less is known about what bereaved family members actually observe at end of life and how this is interpreted. AIM Secondary analysis study was conducted in order to explore the concept of vigilant attentiveness in family members of adult patients dying in intensive care. METHOD Secondary analysis of eight interviews sorted from two primary data sets containing 19 interviews with 25 bereaved family members from two intensive care units in England was undertaken. Directed content analysis techniques were adopted. FINDINGS Families are observant for physiological deterioration by watching for changes in cardiac monitors as well as paying attention to how their relative looks and sounds. Changes in treatment/interventions were also perceived to indicate deterioration. CONCLUSION Families are vigilant and attentive to deterioration, implying that families are active participants in information gathering. By clarifying what families notice, or do not notice during the dying trajectory in ICU, health care professionals can tailor information, helping to prepare families for the death of their relative.
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Affiliation(s)
- Maureen Coombs
- Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand; Capital and Coast District Health Board, Wellington, New Zealand.
| | - Juliana Tang
- Intensive Care Unit, Wellington Regional Hospital, Capital and Coast District Health Board, Wellington, New Zealand
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Abstract
OBJECTIVES Most deaths in U.S. PICUs occur after a decision has been made to limitation or withdrawal of life support. The objective of this study was to describe the clinical characteristics and outcomes of children whose families discussed limitation or withdrawal of life support with clinicians during their child's PICU stay and to determine the factors associated with limitation or withdrawal of life support discussions. DESIGN Secondary analysis of data prospectively collected from a random sample of children admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 4, 2011, and April 7, 2013. SETTING Seven clinical sites affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Ten thousand seventy-eight children less than 18 years old, admitted to a PICU, and not moribund at admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Families of 248 children (2.5%) discussed limitation or withdrawal of life support with clinicians. By using a multivariate logistic model, we found that PICU admission age less than 14 days, reduced functional status prior to hospital admission, primary diagnosis of cancer, recent catastrophic event, emergent PICU admission, greater physiologic instability, and government insurance were independently associated with higher likelihood of discussing limitation or withdrawal of life support. Black race, primary diagnosis of neurologic illness, and postoperative status were independently associated with lower likelihood of discussing limitation or withdrawal of life support. Clinical site was also independently associated with likelihood of limitation or withdrawal of life support discussions. One hundred seventy-three children (69.8%) whose families discussed limitation or withdrawal of life support died during their hospitalization; of these, 166 (96.0%) died in the PICU and 149 (86.1%) after limitation or withdrawal of life support was performed. Of those who survived, 40 children (53.4%) were discharged with severe or very severe functional abnormalities, and 15 (20%) with coma/vegetative state. CONCLUSIONS Clinical factors reflecting type and severity of illness, sociodemographics, and institutional practices may influence whether limitation or withdrawal of life support is discussed with families of PICU patients. Most children whose families discuss limitation or withdrawal of life support die during their PICU stay; survivors often have substantial disabilities.
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A Qualitative Exploration of a Clinical Ethicist's Role and Contributions During Family Meetings. HEC Forum 2016; 28:283-299. [PMID: 26790861 DOI: 10.1007/s10730-015-9300-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Despite the interpersonal nature of family meetings and the frequency in which they occur, the clinical ethics literature is devoid of any rich descriptions of what clinical ethicists should actually be doing during family meetings. Here, we propose a framework for describing and understanding "transitioning" facilitation skills based on a retrospective review of our internal documentation of 100 consecutive cases (June 01, 2013-December 31, 2014) wherein a clinical ethicist facilitated at least one family meeting. The internal documents were analyzed using qualitative methodologies, i.e., "codes", to identify emergent themes. We identified four different transitioning strategies clinical ethicists use to reach a meaningful resolution. These transitioning strategies serve as a jumping-off point for additional analyses, future research, evaluating clinical ethics consultation, and overall performance improvement of a consultation service.
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The effectiveness of communication-skills training interventions in end-of-life noncancer care in acute hospital-based services: A systematic review. Palliat Support Care 2015; 14:433-44. [PMID: 26675418 DOI: 10.1017/s1478951515001108] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A systematic review was conducted in order to explore the effectiveness of communication-skills training interventions in end-of-life care with noncancer acute-based healthcare staff. METHOD Articles were included if they (1) focused on communication-skills training in end-of-life/palliative care for noncancer acute-based staff and (2) reported an outcome related to behavior change with regard to communication. Sixteen online databases were searched, which resulted in 4,038 potential articles. Screening of titles left 393 articles that met the inclusion criteria. Abstracts (n = 346) and full-text articles (n = 47) were reviewed, leaving 10 papers that met the criteria for our review. All articles explored the effect of communication-skills training on aspects of staff behavior; one study measured the effect on self-efficacy, another explored the impact on knowledge and competence, and another measured comfort levels in discussing the end of life with patients/families. Seven studies measured a number of outcomes, including confidence, attitude, preparedness, stress, and communication skills. RESULTS Few studies have focused on end-of-life communication-skills training in noncancer acute-based services. Those that do have report positive effects on staff behavior with regard to communication about the end of life with patients and families. The studies varied in terms of the population studied and the health services involved, and they scored only moderately or weakly on quality. It is a challenge to draw a definite conclusion about the effectiveness of training interventions in end-of-life communication because of this. However, the findings from our review demonstrate the potential effectiveness of a range of training interventions with healthcare professionals on confidence, attitude, self-efficacy, and communication skills. SIGNIFICANCE OF RESULTS Further research is needed to fully explore the effectiveness of existing training interventions in this population, and evidence using objective measures is particularly needed. Ideally, randomized controlled trials or studies using control groups and longer follow-ups are needed to test the effectiveness of interventions.
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Singer AE, Ash T, Ochotorena C, Lorenz KA, Chong K, Shreve ST, Ahluwalia SC. A Systematic Review of Family Meeting Tools in Palliative and Intensive Care Settings. Am J Hosp Palliat Care 2015. [PMID: 26213225 DOI: 10.1177/1049909115594353] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Family meetings can be challenging, requiring a range of skills and participation. We sought to identify tools available to aid the conduct of family meetings in palliative, hospice, and intensive care unit settings. METHODS We systematically reviewed PubMed for articles describing family meeting tools and abstracted information on tool type, usage, and content. RESULTS We identified 16 articles containing 23 tools in 7 categories: meeting guide (n = 8), meeting planner (n = 5), documentation template (n = 4), meeting strategies (n = 2), decision aid/screener (n = 2), family checklist (n = 1), and training module (n = 1). We found considerable variation across tools in usage and content and a lack of tools supporting family engagement. CONCLUSION There is need to standardize family meeting tools and develop tools to help family members effectively engage in the process.
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Affiliation(s)
- Adam E Singer
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA RAND Corporation, Santa Monica, CA, USA
| | - Tayla Ash
- T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Claudia Ochotorena
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
| | - Karl A Lorenz
- RAND Corporation, Santa Monica, CA, USA Quality Improvement Resource Center, Greater Los Angeles VA Health Care System, Los Angeles, CA, USA Stanford University School of Medicine, Stanford, CA, USA VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Kelly Chong
- Quality Improvement Resource Center, Greater Los Angeles VA Health Care System, Los Angeles, CA, USA
| | - Scott T Shreve
- Quality Improvement Resource Center, Greater Los Angeles VA Health Care System, Los Angeles, CA, USA Pennsylvania State College of Medicine, Lebanon, PA, USA
| | - Sangeeta C Ahluwalia
- RAND Corporation, Santa Monica, CA, USA Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
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Fumis RRL, Ranzani OT, Martins PS, Schettino G. Emotional disorders in pairs of patients and their family members during and after ICU stay. PLoS One 2015; 10:e0115332. [PMID: 25616059 PMCID: PMC4304779 DOI: 10.1371/journal.pone.0115332] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 11/21/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Patients and family members undergo different experiences of suffering from emotional disorders during ICU stay and after ICU discharge. The purpose of this study was to compare the incidence of anxiety, depression and post-traumatic stress disorder (PTSD) symptoms in pairs (patient and respective family member), during stay at an open visit ICU and at 30 and 90-days post-ICU discharge. We hypothesized that there was a positive correlation with the severity of symptoms among pairs and different patterns of suffering over time. METHODS A prospective study was conducted in a 22-bed adult general ICU including patients with >48 hours stay. The Hospital Anxiety and Depression Scale (HADS) was completed by the pairs (patients/respective family member). Interviews were made by phone at 30 and 90-days post-ICU discharge using the Impact of Event Scale (IES) and the HADS. Multivariate models were constructed to predict IES score at 30 days for patients and family members. RESULTS Four hundred and seventy one family members and 289 patients were interviewed in the ICU forming 184 pairs for analysis. Regarding HADS score, patients presented less symptoms than family members of patients who survived and who deceased at 30 and 90-days (p<0.001). However, family members of patients who deceased scored higher anxiety and depression symptoms (p = 0.048) at 90-days when compared with family members of patients who survived. Patients and family members at 30-days had a similar IES score, but it was higher in family members at 90-days (p = 0.019). For both family members and patients, age and symptoms of anxiety and depression during ICU were the major determinants for PTSD at 30-days. CONCLUSIONS Anxiety, depression and PTSD symptoms were higher in family members than in the patients. Furthermore, these symptoms in family members persisted at 3 months, while they decreased in patients.
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Affiliation(s)
- Renata Rego Lins Fumis
- Intensive Care Unit, Hospital Sírio Libanês, Rua Dona Adma Jafet, 91, São Paulo 01308-050, Brazil
- * E-mail:
| | - Otavio T. Ranzani
- Respiratory Intensive Care Unit, Pulmonary Division, Heart Institute, Hospital das Clínicas, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255, São Paulo 05403-900, Brazil
| | - Paulo Sérgio Martins
- Intensive Care Unit, Hospital Sírio Libanês, Rua Dona Adma Jafet, 91, São Paulo 01308-050, Brazil
| | - Guilherme Schettino
- Intensive Care Unit, Hospital Sírio Libanês, Rua Dona Adma Jafet, 91, São Paulo 01308-050, Brazil
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Abstract
Family support in the intensive care units is a challenge for nurses who take care of dying patients. This article aimed to determine the Iranian nurses' experience of supporting families in end-of-life care. Using grounded theory methodology, 23 critical care nurses were interviewed. The theme of family support was extracted and divided into 5 categories: death with dignity; facilitate visitation; value orientation; preparing; and distress. With implementation of family support approaches, family-centered care plans will be realized in the standard framework.
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Abstract
The privileging of the substituted judgment standard as the gold standard for surrogate decision making in law and bioethics has constrained the research agenda in end-of-life decision making. The empirical literature is inundated with a plethora of "Newlywed Game" designs, in which potential patients and potential surrogates respond to hypothetical scenarios to see how often they "get it right." The preoccupation with determining the capacity of surrogates to accurately reproduce the judgments of another makes a number of assumptions that blind scholars to the variables central to understanding how surrogates actually make medical decisions on behalf of another. These assumptions include that patient preferences are knowable, surrogates have adequate and accurate information, time stands still, patients get the surrogates they want, patients want and surrogates utilize substituted judgment criteria, and surrogates are disinterested. This article examines these assumptions and considers the challenges of designing research that makes them problematic.
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Predicting death and disability, is it really possible? A medical ICU prognostication model study. Crit Care Med 2014; 42:2449-50. [PMID: 25319910 DOI: 10.1097/ccm.0000000000000577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Critical Care Communication project: improving fellows' communication skills. J Crit Care 2014; 30:250-4. [PMID: 25535029 DOI: 10.1016/j.jcrc.2014.11.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 11/25/2014] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of this study was to develop an evidence-based communication skills training workshop to improve the communication skills of critical care fellows. MATERIALS AND METHODS Pulmonary and critical care fellows (N = 38) participated in a 3-day communication skills workshop between 2008 and 2010 involving brief didactic talks, faculty demonstration of skills, and faculty-supervised small group skills practice sessions with simulated families. Skills included the following: giving bad news, achieving consensus on goals of therapy, and discussing the limitations of life-sustaining treatment. Participants rated their skill levels in a pre-post survey in 11 core communication tasks using a 5-point Likert scale. RESULTS Of 38 fellows, 36 (95%) completed all 3 days of the workshop. We compared pre and post scores using the Wilcoxon signed rank test. Overall, self-rated skills increased for all 11 tasks. In analyses by participant, 95% reported improvement in at least 1 skill; with improvement in a median of 10 of 11 skills. Ninety-two percent rated the course as either very good/excellent, and 80% recommended that it be mandatory for future fellows. CONCLUSIONS This 3-day communication skills training program increased critical care fellows' self-reported family meeting communication skills.
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Examining family meetings at end of life: The model of practice in a hospice inpatient unit. Palliat Support Care 2014; 13:1283-91. [PMID: 25358963 DOI: 10.1017/s1478951514001138] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Our purpose was to rigorously examine the nature of family meetings as conducted in an inpatient hospice care unit in order to generate an inductive theoretical model. METHOD In this two-phase project, we first interviewed eight members of the interdisciplinary care team who participated in multiple family meetings each week. Interview questions explored why and how they conducted family meetings. Using an observation template created from these interview data, we subsequently conducted ethnographic observations during family meetings. Using the methods of grounded theory, our findings were synthesized into a theoretical model depicting the structure and process of formal family meetings within this setting. RESULTS The core of the family meeting was characterized by cognitive and affective elements aimed at supporting the family and facilitating quality care by clarifying the past, easing the present, and protecting the future. This inductive model was subsequently found to be highly aligned with a sense of coherence, an important influence on coping, and adaptation to the stress of a life-limiting illness. SIGNIFICANCE OF RESULTS Provider communication with family members is particularly critical during advanced illness and end-of-life care. The National Consensus Project clinical practice guidelines for quality palliative care list regular family meetings among the recommended practices for excellent communication during end-of-life care, but do not provide specific guidance on how and when to provide such meetings. Our findings provide a theoretical model that can inform the design of a family meeting to address family members' needs for meaningful and contextualized information, validation of their important contributions to care, and preparation for the patient's death.
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Pattison N, Campbell ML. End-of-life care in critical care: where nursing can make the difference? A call for papers. Intensive Crit Care Nurs 2014; 30:303-5. [PMID: 25439142 DOI: 10.1016/j.iccn.2014.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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47
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Powazki R, Walsh D, Hauser K, Davis MP. Communication in Palliative Medicine: A Clinical Review of Family Conferences. J Palliat Med 2014; 17:1167-77. [DOI: 10.1089/jpm.2013.0538] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ruth Powazki
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Declan Walsh
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
- Cleveland Clinic Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Katherine Hauser
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mellar P. Davis
- Section of Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
- The Harry R. Horvitz Center for Palliative Medicine, A World Health Organization Demonstration Project in Palliative Medicine, An ESMO Designated Integrated Center of Supportive Oncology and Palliative Care, Cleveland Clinic Foundation, Cleveland, Ohio
- Cleveland Clinic Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Howell AA, Nielsen EL, Turner AM, Curtis JR, Engelberg RA. Clinicians' perceptions of the usefulness of a communication facilitator in the intensive care unit. Am J Crit Care 2014; 23:380-6. [PMID: 25179033 DOI: 10.4037/ajcc2014517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Despite its documented importance, communication between clinicians and patients' families in the intensive care unit often fails to meet families' needs, and interventions to improve communication are needed. Use of a communication facilitator-an additional staff member-to improve communication between clinicians and patients' families is the focus of an ongoing randomized trial. The clinical team's acceptance of the communication facilitator as an integral part of the team is important. OBJECTIVES To explore clinicians' perceptions of the usefulness of a communication facilitator in the intensive care unit. METHODS Fourteen semistructured qualitative interviews to assess perspectives of physicians, nurses, and social workers who had experience with the communication facilitator intervention on the intervention and the role of the facilitator. Methods based on grounded theory were used to analyze the data. RESULTS Clinicians perceived facilitators as (1) facilitating communication between patients' families and clinicians, (2) providing practical and emotional support for patients' families, and (3) providing practical and emotional support for clinicians. Clinicians were enthusiastic about the communication facilitator but concerned about overlapping or conflicting roles. CONCLUSIONS Clinicians in the intensive care unit saw the facilitator intervention as enhancing communication and supporting both patients' families and clinicians. They also identified the importance of the facilitator within the interdisciplinary team. Negative perceptions about the use of a facilitator should be addressed before the intervention is implemented, in order to ensure its effectiveness.
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Affiliation(s)
- Abigail A Howell
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - Elizabeth L Nielsen
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - Anne M Turner
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - J Randall Curtis
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle
| | - Ruth A Engelberg
- Abigail A. Howell and Elizabeth L. Nielsen are both researchers with the end-of-life care research program in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Ruth A. Engelberg is a research associate professor in the Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle. Anne M. Turner is an assistant professor in the Department of Health Services, School of Public Health, and an assistant professor in the Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle. J. Randall Curtis is a professor, the A. Bruce Montgomery-American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine in the Division of Pulmonary and Critical Care, Department of Medicine and an adjunct professor in the Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle.
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Abstract
OBJECTIVES To describe the quality of physician-family communication during interpreted and noninterpreted family meetings in the PICU. DESIGN Prospective, exploratory, descriptive observational study of noninterpreted English family meetings and interpreted Spanish family meetings in the pediatric intensive care setting. SETTING A single, university-based, tertiary children's hospital. SUBJECTS Participants in PICU family meetings, including medical staff, family members, ancillary staff, and interpreters. INTERVENTIONS Thirty family meetings (21 English and nine Spanish) were audio-recorded, transcribed, de-identified, and analyzed using the qualitative method of directed content analysis. MEASUREMENTS AND MAIN RESULTS Quality of communication was analyzed in three ways: 1) presence of elements of shared decision-making, 2) balance between physician and family speech, and 3) complexity of physician speech. Of the 11 elements of shared decision-making, only four occurred in more than half of English meetings, and only three occurred in more than half of Spanish meetings. Physicians spoke for a mean of 20.7 minutes, while families spoke for 9.3 minutes during English meetings. During Spanish meetings, physicians spoke for a mean of 14.9 minutes versus just 3.7 minutes of family speech. Physician speech complexity received a mean grade level score of 8.2 in English meetings compared to 7.2 in Spanish meetings. CONCLUSIONS The quality of physician-family communication during PICU family meetings is poor overall. Interpreted meetings had poorer communication quality as evidenced by fewer elements of shared decision-making and greater imbalance between physician and family speech. However, physician speech may be less complex during interpreted meetings. Our data suggest that physicians can improve communication in both interpreted and noninterpreted family meetings by increasing the use of elements of shared decision-making, improving the balance between physician and family speech, and decreasing the complexity of physician speech.
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What constitutes quality of family experience at the end of life? Perspectives from family members of patients who died in the hospital. Palliat Support Care 2014; 13:945-52. [PMID: 25003541 DOI: 10.1017/s1478951514000807] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Most palliative care efforts focus on assessing and improving the quality of life and quality of care for patients. Palliative care views the family as the unit of care; therefore, excellent comprehensive palliative care should also address the needs of the family and the caregiver(s). While the recent literature has offered detailed descriptions of caregiving needs in the home setting, it is crucial to describe the needs of family members who provide care for patients with advanced illness in an inpatient setting, where family members serve as the key intermediaries and decision makers. Therefore, we sought to define the relevant aspects of quality of experience for families of hospitalized patients. METHOD We convened a series of focus groups to identify the domains important for the quality of experience of dying patients' family members. Participants included bereaved family members of patients who had died at a Veterans Administration (VA) or private academic medical center. We conducted four in-depth follow-up interviews to probe for additional details and validate our interpretation of the focus group findings. RESULTS Participants (n = 14) ranged in age from 46 to 83, with a mean of 62. All were female; 64% were Caucasian, 21% African American, and 14% did not report their ethnicity. Content analysis yielded 64 attributes of quality of family experience constituting eight domains: completion, symptom impact, decision making, preparation, relationship with healthcare providers, affirmation of the whole person, post-death care, and supportive services. SIGNIFICANCE OF RESULTS Our data have implications for clinical guidance in assisting family members in the inpatient palliative setting, which often includes patient incapacity for communication and decision making. They suggest the importance of developing corresponding methods to assist families with the tasks involved with life completion, being prepared for a crisis and imminent death, and post-death care. Provider communications and relationships are central to the processes of meeting the clinical needs of family members. Our findings should inform the development of measures to assess family experience.
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