End-of-life care in the intensive care unit: a research agenda

Interventions Performed in Children With Immunocompromised Conditions in the Pediatric Intensive Care Unit Within 48 Hours of Death

Background: Understanding interventions preceding death in children with immunocompromised conditions is important to ensure a peaceful and dignified perideath experience. The aim of this study was to describe the number of interventions performed in the pediatric intensive care unit (PICU) within the 48 hours before death in this population. Methods: This was a single-center, retrospective cohort study of all children with an underlying oncologic, hematologic, or immunologic diagnosis admitted to the PICU for at least 72 hours between 2014 and 2021. Medical records were reviewed for interventions within 48 hours preceding death and for palliative care involvement. Interventions were defined as new or escalations in respiratory support, cardiopulmonary resuscitation (CPR), vascular access, drains, and radiographic studies. Associations were evaluated using simple logistic regression. Results: A total of 55 patients were included in this study. The predominant PICU admission diagnoses were respiratory (51%), followed by shock (25%), and neurologic diagnoses (9%). These predominant diagnoses were similar perideath. At PICU admission, only 1 patient had a do-not-resuscitate (DNR) order. Forty-six percent had a DNR order 48 hours preceding death, and 91% had DNR orders in place at time of death. During the 48-hour period preceding death, 80% of children received at least one intervention. Radiographic studies were the most common, used in 78% of children, followed by respiratory (20%), vascular (16%), CPR (13%), and drain placement (7%). Palliative care was involved in 38% of cases and was associated with a decrease in the number of radiologic interventions (p = 0.028) and CPR (p = 0.026). Conclusions: Children in the PICU with underlying immunocompromised conditions frequently receive interventions within the 48-hour period preceding death. Palliative care involvement was associated with fewer radiographic studies and fewer occurrences of CPR. The impact of interventions on the dying experience warrants further investigation.

Giving a voice to patients at high risk of dying in the intensive care unit: a multiple source approach

PURPOSE

Data are scarce regarding the experience of critically ill patients at high risk of death. Identifying their concerns could allow clinicians to better meet their needs and align their end-of-life trajectory with their preferences and values. We aimed to identify concerns expressed by conscious patients at high risk of dying in the intensive care unit (ICU).

METHODS

Multiple source multicentre study. Concerns expressed by patients were collected from five different sources (literature review, panel of 50 ICU experts, prospective study in 11 ICUs, in-depth interviews with 17 families and 15 patients). All qualitative data collected were analyzed using thematic content analysis.

RESULTS

The five sources produced 1307 concerns that were divided into 7 domains and 41 sub-domains. After removing redundant items and duplicates, and combining and reformulating similar items, 28 concerns were extracted from the analysis of the data. To increase accuracy, they were merged and consolidated, and resulted in a final list of 15 concerns pertaining to seven domains: concerns about loved-ones; symptom management and care (including team competence, goals of care discussions); spiritual, religious, and existential preoccupations (including regrets, meaning, hope and trust); being oneself (including fear of isolation and of being a burden, absence of hope, and personhood); the need for comforting experiences and pleasure; dying and death (covering emotional and practical concerns); and after death preoccupations.

CONCLUSION

This list of 15 concerns may prove valuable for clinicians as a tool for improving communication and support to better meet the needs of patients at high risk of dying.

Palliative Care in the Intensive Care Unit: Past, Present, and Future

In this article, the authors review the origins of palliative care within the critical care context and describe the evolution of symptom management, shared decision-making, and comfort-focused care in the ICU from the 1970s to the early 2000s. The authors also review the growth of interventional studies in the past 20 years and indicate areas for future study and quality improvement for end-of-life care among the critically ill.

Implementation lessons learnt when trialling palliative care interventions in the intensive care unit: relationships between determinants, implementation strategies, and models of delivery-a systematic review protocol

BACKGROUND

Heterogeneity amongst palliative care interventions in the intensive care unit (ICU) and their outcomes has meant that, even when found to be effective, translation of evidence into practice is hindered. Previous evidence reviews have suggested that the field of ICU-based palliative care would benefit from well-designed, targeted interventions, with explicit knowledge translation research demonstrating valid implementation strategies. Reviewing effectiveness studies alongside process evaluations for these interventions will give insight into the implementation barriers or constraints identified, and the implementation strategies adopted.

METHODS

A systematic review to identify and synthesise knowledge on how models of integrating palliative care into the ICU have been implemented and provide critical recommendations for successful future development and implementation of complex interventions in the field. The search will be carried out using MEDLINE, Embase, Cochrane, CINAHL, and PsycINFO. The search strategy will combine terms related to palliative care, intensive care, and implementation. Only full-text articles will be considered and conference abstracts excluded. There will be no date or language restrictions. The Implementation Research Logic Model will be used as a framework for synthesis. Findings will be reported following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

DISCUSSION

This review will provide understanding of implementation facilitators, barriers, and strategies, when employing palliative care interventions within the ICU. This will provide valuable recommendations for successful future development of complex interventions using implementation frameworks or theories. This can increase the potential for sustained change in practice, reduce heterogeneity in interventions, and therefore help produce measurable and comparable outcomes.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic reviews PROSPERO (CRD42022311052).

Promoting Readiness for Residency: Embedding Simulation-Based Mastery Learning for Breaking Bad News Into the Medicine Subinternship

PURPOSE

It is challenging to add rigorous, competency-based communication skills training to existing clerkship structures. The authors embedded a simulation-based mastery learning (SBML) curriculum into a medicine subinternship to demonstrate feasibility and determine the impact on the foundational skill of breaking bad news (BBN).

METHOD

All fourth-year students enrolled in a medicine subinternship at Northwestern University Feinberg School of Medicine from September 2017 through August 2018 were expected to complete a BBN SBML curriculum. First, students completed a pretest with a standardized patient using a previously developed BBN assessment tool. Learners then participated in a 4-hour BBN skills workshop with didactic instruction, focused feedback, and deliberate practice with simulated patients. Students were required to meet or exceed a predetermined minimum passing standard (MPS) at posttest. The authors compared pretest and posttest scores to evaluate the effect of the intervention. Participant demographic characteristics and course evaluations were also collected.

RESULTS

Eighty-five students were eligible for the study, and 79 (93%) completed all components. Although 55/79 (70%) reported having personally delivered serious news to actual patients, baseline performance was poor. Students' overall checklist performance significantly improved from a mean of 65.0% (SD = 16.2%) items correct to 94.2% (SD = 5.9%; P < .001) correct. There was also statistically significant improvement in scaled items assessing quality of communication, and all students achieved the MPS at mastery posttest. All students stated they would recommend the workshop to colleagues.

CONCLUSIONS

It is feasible to embed SBML into a required clerkship. In the context of this study, rigorous SBML resulted in uniformly high levels of skill acquisition, documented competency, and was positively received by learners.

Clinical Practice Guidelines and Consensus Statements About Pain Management in Critically Ill End-of-Life Patients: A Systematic Review

OBJECTIVES

To identify and synthesize available recommendations from scientific societies and experts on pain management at the end-of-life in the ICU.

DATA SOURCES

We conducted a systematic review of PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and Biblioteca Virtual en Salud from their inception until March 28, 2019.

STUDY SELECTION

We included all clinical practice guidelines, consensus statements, and benchmarks for quality.

DATA EXTRACTION

Study selection, methodological quality, and data extraction were performed independently by two investigators. A quality assessment was performed by four investigators using the Appraisal of Guidelines for Research and Evaluation II instrument. The recommendations were then synthesized and categorized.

DATA SYNTHESIS

Ten publications were included. The Appraisal of Guidelines for Research and Evaluation II statement showed low scores in various quality domains, especially in the applicability and rigor of development. Most documents were in agreement on five topics: 1) using a quantitative tool for pain assessment; 2) administering narcotics for pain relief and benzodiazepines for anxiety relief; 3) against prescribing neuromuscular blockers during withdrawal of life support to assess pain; 4) endorsing the use of high doses of opioids and sedatives for pain control, regardless of the risk that they will hasten death; and 5) using quality indicators to improve pain management during end-of-life in the ICU.

CONCLUSIONS

In spite of the lack of high-quality evidence, recommendations for pain management at the end-of-life in the ICU are homogeneous and are justified by ethical principles and agreement among experts. Considering the growing demand for the involvement of palliative care teams in the management of the dying patients in the ICU, there is a need to clearly define their early involvement and to further develop comprehensive evidence-based pain management strategies. Based on the study findings, we propose a management algorithm to improve the overall care of dying critically ill patients.

Developing and testing a comprehensive tool to assess family meetings: Empirical distinctions between high- and low-quality meetings

BACKGROUND

The heterogeneity with regard to findings on family meetings (or conferences) suggests a need to better understand factors that influence family meetings. While earlier studies have explored frequency or timing of family meetings, little is known about how factors (such as what is said during meetings, how it is said, and by whom) influence family meeting quality.

OBJECTIVES

(1) To develop an evaluation tool to assess family meetings (Phase 1); (2) to identify factors that influence meeting quality by evaluating 34 family meetings (Phase 2).

MATERIALS AND METHODS

For Phase 1, methods included developing a framework, cognitive testing, and finalizing the evaluation tool. The tool consisted of Facilitator Characteristics (i.e., gender, experience, and specialty of the person leading the meeting), and 22 items across 6 Meeting Elements (i.e., Introductions, Information Exchanges, Decisions, Closings, Communication Styles, and Emotional Support) and sub-elements. For Phase 2, methods included training evaluators, assessing family meetings, and analyzing data. We used Spearman's rank-order correlations to calculate meeting quality. Qualitative techniques were used to analyze free-text.

RESULTS

No Facilitator Characteristic had a significant correlation with meeting quality. Sub-elements related to communication style and emotional support most strongly correlated with high-quality family meetings, as well as whether "next steps" were outlined (89.66%) and whether "family understanding" was elicited (86.21%). We also found a significant and strong positive association between overall proportion scores and evaluators' ratings (r_s=0.731, p<0.001).

CONCLUSIONS

We filled a gap by developing an evaluation tool to assess family meetings, and we identified how what is said during meetings impacts quality.

Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life care

PURPOSE

This study critically examines the available policy guidelines on integration of palliative and end-of-life care in Indian intensive care units to appraise their congruence with Indian reality.

MATERIALS AND METHODS

Six position statements and guidelines issued by the Indian Society for Critical Care Medicine and the Indian Association of Palliative Care from 2005 till 2015 were examined. The present study reflects upon the recommendations suggested by these texts.

RESULT

Although the policy documents conform to the universally set norms of introducing palliative and end-of-life care in intensive care units, they hardly suit Indian reality. The study illustrates local complexities that are not addressed by the policy documents. This include difficulties faced by intensivists and physicians in arriving at a consensus decision, challenges in death prognostication, hurdles in providing compassionate care, providing "culture-specific" religious and spiritual care, barriers in effective communication, limitations of documenting end-of-life decisions, and ambiguities in defining modalities of palliative care. Moreover, the policy documents largely dismiss special needs of elderly patients.

CONCLUSION

The article suggests the need to reexamine policies in terms of their attainability and congruence with Indian reality.

Key stakeholders' perceptions of the acceptability and usefulness of a tablet-based tool to improve communication and shared decision making in ICUs

PURPOSE

Although barriers to shared decision making in intensive care units are well documented, there are currently no easily scaled interventions to overcome these problems. We sought to assess stakeholders' perceptions of the acceptability, usefulness, and design suggestions for a tablet-based tool to support communication and shared decision making in ICUs.

METHODS

We conducted in-depth semi-structured interviews with 58 key stakeholders (30 surrogates and 28 ICU care providers). Interviews explored stakeholders' perceptions about the acceptability of a tablet-based tool to support communication and shared decision making, including the usefulness of modules focused on orienting families to the ICU, educating them about the surrogate's role, completing a question prompt list, eliciting patient values, educating about treatment options, eliciting perceptions about prognosis, and providing psychosocial support resources. The interviewer also elicited stakeholders' design suggestions for such a tool. We used constant comparative methods to identify key themes that arose during the interviews.

RESULTS

Overall, 95% (55/58) of participants perceived the proposed tool to be acceptable, with 98% (57/58) of interviewees finding six or more of the seven content domains acceptable. Stakeholders identified several potential benefits of the tool including that it would help families prepare for the surrogate role and for family meetings as well as give surrogates time and a framework to think about the patient's values and treatment options. Key design suggestions included: conceptualize the tool as a supplement to rather than a substitute for surrogate-clinician communication; make the tool flexible with respect to how, where, and when surrogates can access the tool; incorporate interactive exercises; use video and narration to minimize the cognitive load of the intervention; and build an extremely simple user interface to maximize usefulness for individuals with low computer literacy.

CONCLUSION

There is broad support among stakeholders for the use of a tablet-based tool to improve communication and shared decision making in ICUs. Eliciting the perspectives of key stakeholders early in the design process yielded important insights to create a tool tailored to the needs of surrogates and care providers in ICUs.

Sedatives and Analgesics Given to Infants in Neonatal Intensive Care Units at the End of Life

OBJECTIVE

To describe the administration of sedatives and analgesics at the end of life in a large cohort of infants in North American neonatal intensive care units.

STUDY DESIGN

Data on mortality and sedative and analgesic administration were from infants who died from 1997-2012 in 348 neonatal intensive care units managed by the Pediatrix Medical Group. Sedatives and analgesics of interest included opioids (fentanyl, methadone, morphine), benzodiazepines (clonazepam, diazepam, lorazepam, midazolam), central alpha-2 agonists (clonidine, dexmedetomidine), ketamine, and pentobarbital. We used multivariable logistic regression to evaluate the association between administration of these drugs on the day of death and infant demographics and illness severity.

RESULTS

We identified 19 726 infants who died. Of these, 6188 (31%) received a sedative or analgesic on the day of death; opioids were most frequently administered, 5366/19 726 (27%). Administration of opioids and benzodiazepines increased during the study period, from 16/283 (6%) for both in 1997 to 523/1465 (36%) and 295/1465 (20%) in 2012, respectively. Increasing gestational age, increasing postnatal age, invasive procedure within 2 days of death, more recent year of death, mechanical ventilation, inotropic support, and antibiotics on the day of death were associated with exposure to sedatives or analgesics.

CONCLUSIONS

Administration of sedatives and analgesics increased over time. Infants of older gestational age and those more critically ill were more likely to receive these drugs on the day of death. These findings suggest that drug administration may be driven by severity of illness.

From persistence to palliation: limiting active treatment in the ICU

PURPOSE OF REVIEW

End-of-life care and communication deficits are important sources of conflicts within ICU teams and with patients or families. This narrative review describes recent studies on how to improve palliative care and surrogate decision-making in ICUs and compares the results with previously published literature on this topic.

RECENT FINDINGS

Awareness and use of end-of-life recommendations is still low. Education about end-of-life is beneficial for end-of-life decisions. Residency and nurses training programmes start to integrate palliative care education in critical care. Integration of palliative care consults is recommended and probably cost-effective. Projects that promote direct contact of care team members with patients/families may be more likely to improve care than educational interventions for caregivers only. The family's response to critical illness includes adverse psychological outcome ('postintensive care syndrome-family'). Information brochures and structured communication protocols are likely to improve engagement of family members in surrogate decision-making; however, validation of outcome effects of their use is needed.

SUMMARY

Optimizing palliative care and communication skills is the current challenge in ICU end-of-life care. Intervention strategies should be interdisciplinary, multiprofessional and family-centred in order to quickly reach these goals.

Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness

BACKGROUND

Problems persist with surrogate decision making in intensive care units, leading to distress for surrogates and treatment that may not reflect patients' values.

OBJECTIVES

To assess the feasibility, acceptability, and perceived effectiveness of a multifaceted, nurse-led intervention to improve surrogate decision making in intensive care units.

STUDY DESIGN

A single-center, single-arm, interventional study in which 35 surrogates and 15 physicians received the Four Supports Intervention, which involved incorporating a family support specialist into the intensive care team. That specialist maintained a longitudinal relationship with surrogates and provided emotional support, communication support, decision support, and anticipatory grief support. A mixed-methods approach was used to evaluate the intervention.

RESULTS

The intervention was implemented successfully in all 15 patients, with a high level of completion of each component of the intervention. The family support specialist devoted a mean of 48 (SD 36) minutes per day to each clinician-patient-family triad. All participants reported that they would recommend the intervention to others. At least 90% of physicians and surrogates reported that the intervention (1) improved the quality and timeliness of communication, (2) facilitated discussion of the patient's values and treatment preferences, and (3) improved the patient-centeredness of care.

CONCLUSIONS

The Four Supports Intervention is feasible, acceptable, and was perceived by physicians and surrogates to improve the quality of decision making and the patient-centeredness of care. A randomized trial is warranted to determine whether the intervention improves patient, family, and health system outcomes.

Family engagement regarding the critically ill patient

The Institute of Medicine strongly recommends a health care system that supports family members. Nowhere is the need for family-centered care greater than with critically ill patients. Simplistically, family-centered care is primarily about communication. Unfortunately, family perception of communication in the intensive care unit (ICU) is quite poor. This article reviews some strategies to improve communication, including family meetings and family presence at resuscitation. It also highlights some of the areas within the realm of ICU care in which family engagement is particularly important, including advance directives, end-of-life care, brain death, and organ donation.

Action research studies in the intensive care setting: a systematic review

OBJECTIVES

To review published studies using action research in the intensive care unit (ICU) in order to provide an intervention framework to improve clinical outcomes.

DESIGN

Systematic review.

METHODS

Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Scopus, Medline, Embase, PsycINFO, and the World Wide Web were undertaken using MeSH key words including: 'action research'; 'health care research', 'health services evaluation'; 'intensive care unit'. Reference lists of retrieved articles was also undertaken to identify further articles. All studies were reviewed by two authors using a critical appraisal tool.

RESULTS

The search strategy generated 195 articles. Only 21 studies projects were identified using action research in the ICU. The majority of studies were conducted in the United Kingdom. The participants in the action research studies ranged from 6 to 253. Predominately studies using action research involved nurses in collaboration with patients and family and other health care practitioners to address identified problems in the ICU.

CONCLUSIONS

Based on this review it appears that action research is a promising methodological approach to address clinical practice improvement in the ICU. Studies retrieved focussed primarily on process and formative evaluation but not on clinical outcomes. There is a need to incorporate outcome assessment in action research in the ICU to increase the framework of action research to improve clinical outcomes.

Instrument development measuring critical care nurses' attitudes and behaviors with end-of-life care

BACKGROUND

Although critical care nurses are expected to focus on providing life-sustaining measures, many intensive care patients actually receive end-of-life care.

OBJECTIVES

The aim of this study was to develop an instrument to measure nursing attitudes and behaviors regarding end-of-life care.

METHOD

Phase 1 was focused on item development from a content analysis of the literature and qualitative interviews of critical care nurses. Phase 2 consisted of content validity assessment and pilot testing. Phase 3 included field testing, factor analysis, and reliability estimation.

RESULTS

The Values of Intensive Care Nurses for End-of-Life (n = 695) was found to have four factors: Self-appraisal, Appraisal of Others, Emotional Strain, and Moral Distress. Reliability estimates ([alpha]) were acceptable at .59-.78, but the interitem range (.12-.78) was wider than desirable. Test-retest reliability was deemed adequate based on Pearson's correlations (.68-.81) and intraclass correlation coefficients (.65-.79) but less so when considering [kappa] (.05-.30). The Behaviors of Intensive Care Nurses for End-of-Life (n = 682) was found to have two factors: Communication and Nursing Tasks. Reliability estimates were adequate when considering internal consistency ([alpha] = .67 and .78, respectively), item total correlations (.30-.61), and test-retest as judged by Pearson's and intraclass correlations (.77-.81) but not when [kappa] was considered (.02-.40). The interitem correlations (.20-.35) were also lower than desirable.

DISCUSSION

Both the Values of Intensive Care Nurses for End-of-Life and the Behaviors of Intensive Care Nurses for End-of-Life were found to have conceptually linked factors and acceptable internal consistency estimates ([alpha]). However, test-retest estimates were inconsistent, suggesting that further work needs to be done on the stability of these instruments.

Mandatory ethics consultation policy

OBJECTIVE

To describe ethics consultations at a single institution that has a mandatory ethics consultation policy.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of all adult patients who were admitted to the intensive care unit at Columbia University Medical Center and had an ethics consultation between August 1, 2006, and July 31, 2007. All mandatory and nonmandatory ethics consultations were reviewed. Patient diagnosis, prognosis, presence of do-not-resuscitate order, presence of written advance directives, reason for the ethics consultation, and survival data were collected. The number of ethics consultations hospital-wide from January 1, 2000, to December 31, 2007, was collected.

RESULTS

The total number of mandatory and nonmandatory ethics consultations requested was 168. Of these consultations, 108 (64%) were considered mandatory, and 60 (36%) were considered nonmandatory. Between January 1, 2000, and December 31, 2007, the total number of ethics consultations increased 84%.

CONCLUSION

The increase in the total number of ethics consultations is interpreted as a positive outcome of the mandatory policy. The mandatory ethics consultation policy has possibly increased exposure to ethics consultant-physician interactions, increased learning for physicians, and raised awareness among physicians and nurses of potential ethics assistance.

Terminal withdrawal of mechanical ventilation at a long-term acute care hospital: comparison with a medical ICU

BACKGROUND

Failure to wean from prolonged mechanical ventilation (MV) is common in long-term acute care hospitals (LTACHs), but the process of terminal withdrawal of MV in LTACHs is not well described. We compared terminal withdrawal of MV at an LTACH with that in a medical ICU (MICU).

METHODS

A retrospective medical chart review was done of all patients undergoing terminal withdrawal of MV in an LTACH (n = 30) and in a MICU (n = 74) over a 2-year period.

RESULTS

The decision to withdraw MV was more likely initiated by patient or family in the LTACH and by medical staff in the MICU (p < 0.0001). Social workers, pastoral care, and hospital administration were more likely to participate in the withdrawal process at the LTACH compared with the MICU (p < 0.05). Time from initiation of MV to orders for do not resuscitate, comfort measures only, or withdrawal of MV was significantly greater in the LTACH (weeks) compared with the MICU (days) (p < 0.05). The dose of benzodiazepines given during the final 24 h of life was greater in the MICU as compared with the LTACH (p < 0.05). Narcotic and benzodiazepine use in the hour before or after withdrawal of MV did not differ between the two groups. COPD and pneumonia were the most common causes of death among patients undergoing withdrawal of MV at the LTACH, as opposed to septic shock in the MICU (p < 0.05).

CONCLUSIONS

Terminal withdrawal of MV in the LTACH differs from that in the MICU with regard to decision making, benzodiazepine use, and cause of death.

Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine

BACKGROUND

These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence.

PRINCIPAL FINDINGS

Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula.

CONCLUSIONS

End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.

Treatment at the end of life

End-of-life care has gained recognition as an important interdisciplinary clinical domain during the past three decades largely because scientific and medical advances have changed the nature of dying in the US. Advances in the treatment of life-limiting ilness have typically focused on medical issues and on treating the physical symptoms that accompany the final stage of a terminal illness. However, because the lengthening life span has made more choices available at the end of life, there is also greater need for evidence-based psychosocial treatment to diminish some of the prolonged emotional, psychological treatment to diminish some of the prolonged emotional, psychological, social, and spiritual distress that accompanies dying. Both terminally ill older adults and their caregivers can be helped by interventions that address the need for information, education, preparation, communication, emotional support, and advocacy. This paper preents a review of evidence-based psychosocial treatments at the end of life for both older adults and their caregivers.

Good nursing care to ICU patients on the edge of life

Critically ill patients are admitted to intensive care units (ICUs) to receive advanced technological and medical treatment. Some patients seem not to benefit from the treatment, and sometimes questions are raised as to whether treatment should be withheld or withdrawn. This study was conducted using ICU nurses' experiences with the aim of acquiring a deepened understanding of what good nursing care is for these patients. The study was performed at an adult ICU in Norway, where 14 ICU female nurses were included as participants. The research design was based on interpretative phenomenology and data was collected by group interviews inspired by focus-group methodology. The participants were divided into two groups and each group was interviewed four times. Colaizzi's model was used in the process of analysis. The results show that good nursing care depended on several basic conditions: continuity, knowledge, competence and cooperation, and included clear goals to give appropriate life-saving -- or end-of-life treatment and care. Cornerstones in good nursing care were nurses' verbal communication and nurses' use of their hands. The study emphasises several consequences for future ICU nursing practice and education to enhance good nursing care to patients on the edge of life.

End-of-Life Nursing Education Consortium (ELNEC) Training Program

The integration of palliative care in critical care settings is essential to improve care of the dying, and critical care nurses are leaders in these efforts. However, lack of education in providing end-of-life (EOL) care is an obstacle to nurses and other healthcare professionals as they strive to deliver palliative care. Education regarding pain and symptom management, communication strategies, care at the end of life, ethics, and other aspects of palliative care are urgently needed. Efforts to increase EOL care education in most undergraduate and graduate nursing curricula are beginning; yet, most critical care nurses have not received formal training in palliative care. Moreover, educational resources such as critical care nursing textbooks often contain inadequate information on palliative care. The ELNEC-Critical Care program provides a comprehensive curriculum that concentrates on the requirements of those nurses who are working in areas of critical care. Extensive support materials include CD-ROM, binder, Web sites, newsletters, textbooks, and other supplemental items. The ultimate goal is to improve EOL care for patients in all critical care settings and enhance the experience of family members witnessing the dying process of their loved ones.

Understanding and changing attitudes toward withdrawal and withholding of life support in the intensive care unit

A careful examination of our attitudes toward end-of-life care is critical to our understanding of where change is needed to improve patient outcomes. The objectives of our narrative review are 1) to review why the intensive care unit setting presents particular challenges for the delivery of optimal end-of-life care, 2) to outline how four different research methods can provide insights into our understanding of attitudes about withdrawal of life support, and 3) to suggest seven different approaches to changing prevailing attitudes toward withdrawal of life support in the intensive care unit. To better understand attitudes about end-of-life care in general and withdrawal of life support in particular, we reviewed four different sources of data: 1) decision support tools, 2) qualitative research, 3) surveys, and 4) observational studies. Understanding these attitudes offers valuable insights about strategies that may help to improve the care of dying patients and their families. There are several ways to change attitudes; the approaches we reviewed are 1) promoting social change professionally, 2) legitimizing end-of-life research, 3) determining what families of dying patients need, 4) initiating quality improvement locally, 5) evaluating the benefits and harms of new initiatives, 6) modeling quality end-of-life care for future clinicians, and 7) using narratives. Attitudes toward end-of-life care are influenced by many factors and change slowly. Our attitudes have social and personal origins; they are grounded in values that are collective and community based. Different research methods provide insights into attitudes toward death in the intensive care unit and withdrawal of life support in particular. Understanding these attitudes may offer valuable insights about strategies that should help improve the care for dying patients and their families.

Improving palliative care in intensive care units: identifying strategies and interventions that work

The disciplines of critical care and palliative care may initially seem to be polar opposites, yet they share fundamental features. Both focus on the sickest patients in the healthcare system. Each discipline's primary goal-extending life for critical care and comfort and quality of life for palliative care-represents an important secondary goal for the other. A tremendous body of work in the last decade has laid the foundation for improving palliative care in intensive care units of the future. Pioneering projects have demonstrated the feasibility and acceptance of integrating palliative aspects of care within critical care settings and practice. This article introduces this special supplement of Critical Care Medicine, which describes the developments that have occurred moving us toward integration of palliative and critical care, and lays the foundation for the articles published in this supplement.

Toward interventions to improve end-of-life care in the pediatric intensive care unit

Although children account for only about 3% of all deaths that occur in the United States each year, these patients and their families have needs that are uniquely different from those of adult patients. To date, however, no research on interventions to improve end-of-life care in the pediatric intensive care unit (PICU) has been performed. This review seeks to facilitate and inform future interventional studies by summarizing existing descriptive data about end-of-life care in this setting. These data are organized around six domains that have been identified as critical to high-quality, family-centered care: 1) support of the family unit; 2) communication with the child and family about treatment goals and plans; 3) ethics and shared decision making; 4) relief of pain and other symptoms; 5) continuity of care; and 6) grief and bereavement support. These data are integrated and used to develop evidence-based suggestions for a variety of interventions that could be implemented and then evaluated for their potential contribution to improving the care of children dying in the PICU.

One-day quantitative cross-sectional study of family information time in 90 intensive care units in France

RATIONALE

Providing family members with clear, honest, and timely information is a major task for intensive care unit physicians. Time spent informing families has been associated with effectiveness of information but has not been measured in specifically designed studies.

OBJECTIVES

To measure time spent informing families of intensive care unit patients.

METHODS

One-day cross-sectional study in 90 intensive care units in France.

MEASUREMENTS

Clocked time spent by physicians informing the families of each of 951 patients hospitalized in the intensive care unit during a 24-hr period.

MAIN RESULTS

Median family information time was 16 (interquartile range, 8-30) mins per patient, with 20% of the time spent explaining the diagnosis, 20% on explaining treatments, and 60% on explaining the prognosis. One third of the time was spent listening to family members. Multivariable analysis identified one factor associated with less information time (room with more than one bed) and seven factors associated with more information time, including five patient-related factors (surgery on the study day, higher Logistic Organ Dysfunction score, coma, mechanical ventilation, and worsening clinical status) and two family-related factors (first contact with family and interview with the spouse). Median information time was 20 (interquartile range, 10-39) mins when three factors were present and 106.5 (interquartile range, 103-110) mins when five were present.

CONCLUSION

This study identifies factors associated with information time provided by critical care physicians to family members of critically ill patients. Whether information time correlates with communication difficulties or communication skills needs to be evaluated. Information time provided by residents and nurses should be studied.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Peer-professional workgroups in palliative care: a strategy for advancing professional discourse and practice

BACKGROUND

As part of a comprehensive national effort to improve care at the end of life, the Promoting Excellence in End-of-Life Care program of The Robert Wood Johnson Foundation convened "national peer-professional workgroups" of recognized authorities or leaders to advance palliative aspects of practice in their respective specialties or fields.

OBJECTIVE

The conveners' goals were to establish research and practice agendas to integrate palliative care within selected fields and health care settings, and to expand delivery of palliative care to special patient populations that have been underserved by palliative care. We hypothesized that leading professionals within specific fields, chartered to achieve clear goals, and then provided with sufficient administrative and logistical support, could develop recommendations for expanding access to, quality of and financing for palliative care within their disciplines.

DESIGN

Staff at the national program office of Promoting Excellence in End-of-Life Care convened eight disease-based, specialty-based or issue-based workgroups (the selected workgroup topics were amyotrophic lateral sclerosis, cost accounting, critical care, end-stage renal disease, human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] disease, Huntington's disease, pediatric care, and surgical palliative care). The national program office implemented a small group process design in convening the groups, and provided coordination, oversight and administrative support, along with funds to support meetings (telephone and in-person). A workgroup "charter" guided groups in determining the scope of efforts and set specific, time-limited goals. From the outset, the workgroups developed plans for dissemination of workgroup recommendations to defined stakeholder audiences, including health care providers, policy-makers, payers, researchers, funders, educators, professional organizations and patient advocacy groups.

SETTING AND SUBJECTS

Groups averaged 25 members and met for an average of 24 months. Promoting Excellence leadership chose workgroup topic areas that addressed patient populations underserved for palliative care, and corresponding professional specialties with demonstrated interest and readiness to improve education, evidence base, and professional expertise in palliative aspects of care.

RESULTS

Each workgroup was highly productive and advanced changes in respective fields through developing and disseminating recommendations to their respective fields regarding practice, education, clinical and health service research and policy. Beyond their chartered responsibilities, workgroups also developed educational programs and curricula and a wide array of resources. The workgroups also authored articles for publication, intended to stimulate professional discourse and influence clinical norms and culture.

CONCLUSIONS

The national peer-professional workgroup model exceeded original expectations and produced well-considered Recommendations to the Field as well as a body of resources for professionals in expanding access to and quality of palliative care. Results of this experimental venture in professional change suggest that the workgroup model may be a useful, cost-effective, rapid-change strategy for quality improvement in other areas of professional practice and service delivery.

Prognosis in critical care

Prognostic risk prediction models have been employed in the intensive care unit (ICU) setting since the 1980s and provide health care providers with important information to help inform decisions related to treatment and prognosis, as well as to compare outcomes across institutions. Prognostic models for critical care are among the most widely utilized and tested predictive models in healthcare. In this article, we review and compare mortality prediction models, including the APACHE (1981), SAPS (1984), APACHE-II (1985), MPM (1987), APACHE-III (1991), SAPS-II (1993), and MPM-II (1993). We emphasize the importance of model calibration in this domain. In addition, we present a brief review of the statistical methodology, multiple logistic regression, which underlies most of the models currently used in critical care.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Decision tools for life support: a review and policy analysis

OBJECTIVE

To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care.

DESIGN

Review article. SETTING AND SOURCES: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search.

MEASUREMENTS AND MAIN RESULTS

Forty-nine documents were included and coded for authorship, source, development methodology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n=21, 43%), professional organizations (n=19, 44%), and provider organizations. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a literature review, and 2 (4%) were based upon the author's professional experience. Tools differed in format and focus; we characterize three types as decision schemas (involving clinical practice algorithms; n=7, 14%), decision guides (reviewing legal or professional positions; n=29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n=13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and pregnant patients (10%). Positions on these key life-support issues varied.

CONCLUSIONS

Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and practicality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes.

Death in the pediatric ICU: caring for children and families at the end of life

The need to improve care for children and families at the end of life is acknowledged widely. This article reviews current research concerning end-of-life care in the pediatric ICU. How children die, how decisions are made, management of the dying process, and parent and caregiver experiences are major themes. Gaps in current knowledge are identified, and suggestions are made for future research.

Death rounds: end-of-life discussions among medical residents in the intensive care unit

PURPOSE

We introduced "Death Rounds," a monthly discussion of the issues and emotions surrounding the care of dying patients, into the intensive care unit (ICU) rotations for medical house staff. We surveyed participating residents to evaluate their satisfaction with these discussions.

SUBJECTS AND METHODS

Death Rounds occurred at university-based teaching hospitals in Seattle, Washington and Salt Lake City, Utah, between October 2000 and March 2002. Residents who had attended Death Rounds were surveyed in April 2002.

RESULTS

A 10-item survey was distributed by e-mail to 116 residents in Utah and Washington. Of 116 residents, 97 (84%) responded to the survey; 50 of these 97 had attended at least one Death Rounds. Of these 50, the majority reported that Death Rounds were worthwhile (76%) and that sessions should be incorporated into all ICU rotations (76%).

CONCLUSIONS

Death Rounds provide a unique opportunity for residents to discuss the issues raised in caring for dying patients. This conference can be easily incorporated into the ICU curriculum. Most residents who participated in the survey indicated that they valued Death Rounds and believed that it should be included in all ICU rotations.

Understanding end-of-life caring practices in the emergency department: developing Merleau-Ponty's notions of intentional arc and maximum grip through praxis and phronesis

The emergency department (ED) is a fast-paced, highly stressful environment where clinicians function with little or suboptimal information and where time is measured in minutes and hours. In addition, death and dying are phenomena that are often experienced in the ED. Current end-of-life care models, based on chronic illness trajectories, may be difficult to apply in the ED. A philosophical approach examining end-of-life care may help us understand how core medical and nursing values are embodied as care practices and as ethical comportment. The integration of Aristotle's notions of phronesis and praxis with Merleau-Ponty's ontological notions of intentional arc and maximum grip in the context of the culture and practices of the ED offers a unique view of clinical and ethical practice at the end-of-life in the emergency setting. Caring for people at the end-of-life calls us to act virtuously based on previous experience, meanings and local practices. The maximum grip of the ultimate particulars of the situation combined with one's experiential and theoretical knowledge opens up situated possibilities for the expert clinician.

Agreement among family members in their assessment of the Quality of Dying and Death

Improving end-of-life care requires accurate indicators of the quality of dying. The purpose of this study was to measure the agreement among family members who rate a loved one's dying experience. We administered the Quality of Dying and Death instrument to 94 family members of 38 patients who died in the intensive care unit. We measured a quality of dying score of 60 out of 100 points and found moderate agreement among family members as measured by an intraclass correlation coefficient (ICC) of 0.44. Variability on individual items ranged from an ICC of 0.15 to 1.0. Families demonstrated more agreement on frequencies of events (ICC 0.54) than on determinations of quality (ICC 0.32). These findings reveal important variability among family raters and suggest that until the variability is understood, multiple raters may generate more comprehensive end-of-life data and may more accurately reflect the quality of dying and death.

Palliative care in the intensive care unit: barriers, advances, and unmet needs

The concept that critical illness and terminal illness are necessarily distinct entities has given way to the understanding that they often exist on the same spectrum. Consequently, there is growing consensus that palliative treatment must coexist with attempts at restorative treatment in the intensive care unit (ICU). Palliative care in the ICU has evolved from a relatively one-dimensional construct of terminal sedation in dying patients to a multidisciplinary field addressing symptom control, physician-patient-family communication,spiritual needs, and the needs of health care providers. As ongoing research efforts yield new insights, our ability to practice evidence-based palliative care in the ICU will grow, and new avenues for improvement will become evident.

Factors associated with nurse assessment of the quality of dying and death in the intensive care unit*

OBJECTIVE

To determine the feasibility of using nurse ratings of quality of dying and death to assess quality of end-of-life care in the intensive care unit and to determine factors associated with nurse assessment of the quality of dying and death for patients dying in the intensive care unit.

DESIGN

Prospective cohort study.

SETTING

Hospital intensive care unit.

PATIENTS

178 patients who died in an intensive care unit during a 10-month period at one hospital.

INTERVENTIONS

Nurses completed a 14-item questionnaire measuring the quality of dying and death in the intensive care unit (QODD); standardized chart reviews were also completed.

MEASUREMENTS AND MAIN RESULTS

Five variables were found to be associated with QODD scores. Higher (better) scores were significantly associated with having someone present at the time of death (p <.001), having life support withdrawn (p =.006), having an acute diagnosis such as intracranial hemorrhage or trauma (p =.007), not having cardiopulmonary resuscitation in the last 8 hrs of life (p <.001), and being cared for by the neurosurgery or neurology services (p =.002). Patient age, chronic disease, and Glasgow Coma Scale scores were not associated with the 14-item QODD. Using multivariate analyses, we identified three variables as independent predictors of the QODD score: a) not having cardiopulmonary resuscitation performed in the last 8 hrs of life; b) having someone present at the moment of death; and c) being cared for by neurosurgery or neurology services.

CONCLUSIONS

Intensive care unit nurse assessment of quality of dying and death is a feasible method for obtaining quality ratings. Based on nurse assessments, this study provides evidence of some potential targets for interventions to improve the quality of dying for some patients: having someone present at the moment of death and not having cardiopulmonary resuscitation in the last 8 hrs of life. If nurse-assessed quality of dying is to be a useful tool for measuring and improving quality of end-of-life care, it is important to understand the factors associated with nurse ratings.

Narcotic and benzodiazepine use after withdrawal of life support: association with time to death?

OBJECTIVE

To determine whether the dose of narcotics and benzodiazepines is associated with length of time from mechanical ventilation withdrawal to death in the setting of withdrawal of life-sustaining treatment in the ICU.

DESIGN

Retrospective chart review.

SETTING

University-affiliated, level I trauma center.

PATIENTS

Consecutive critically ill patients who had mechanical ventilation withdrawn and subsequently died in the ICU during two study time periods.

RESULTS

There were 75 eligible patients with a mean age of 59 years. The primary ICU admission diagnoses included intracranial hemorrhage (37%), trauma (27%), acute respiratory failure (27%), and acute renal failure (20%). Patients died during a median of 35 min (range, 1 to 890 min) after ventilator withdrawal. On average, 16.2 mg/h opiates in morphine equivalents and 7.5 mg/h benzodiazepine in lorazepam equivalents were administered during the time period starting 1 h before ventilator withdrawal and ending at death. There was no statistically significant relationship between the average hourly narcotic and benzodiazepine use during the 1-h period prior to ventilator withdrawal until death, and the time from ventilator withdrawal to death. The restriction of medication assessment in the last 2 h of life showed an inverse association between the use of benzodiazepines and time to death. For every 1 mg/h increase in benzodiazepine use, time to death was increased by 13 min (p = 0.015). There was no relationship between narcotic dose and time to death during the last 2 h of life (p = 0.11).

CONCLUSIONS

We found no evidence that the use of narcotics or benzodiazepines to treat discomfort after the withdrawal of life support hastens death in critically ill patients at our center. Clinicians should strive to control patient symptoms in this setting and should document the rationale for escalating drug doses.

Clinician discomfort with life support plans for mechanically ventilated patients

OBJECTIVE

To examine the incidence and predictors of clinician discomfort with life support plans for ICU patients.

DESIGN AND SETTING

Prospective cohort in 13 medical-surgical ICUs in four countries.

PATIENTS

657 mechanically ventilated adults expected to stay in ICU at least 72 h.

MEASUREMENTS AND RESULTS

Daily we documented the life support plan for mechanical ventilation, inotropes and dialysis, and clinician comfort with these plans. If uncomfortable, clinicians stated whether the plan was too technologically intense (the provision of too many life support modalities or the provision of any modality for too long) or not intense enough, and why. At least one clinician was uncomfortable at least once for 283 (43.1%) patients, primarily because plans were too technologically intense rather than not intense enough (93.9% vs. 6.1%). Predictors of discomfort because plans were too intense were: patient age, medical admission, APACHE II score, poor prior functional status, organ dysfunction, dialysis in ICU, plan to withhold dialysis, plan to withhold mechanical ventilation, first week in the ICU, clinician, and city.

CONCLUSIONS

Clinician discomfort with life support perceived as too technologically intense is common, experienced mostly by nurses, variable across centers, and is more likely for older, severely ill medical patients, those with acute renal failure, and patients lacking plans to forgo reintubation and ventilation. Acknowledging the sources of discomfort could improve communication and decision making.

Dying in the ICU: strategies that may improve end-of-life care

PURPOSE

Since 10 to 20% of adult patients admitted to the intensive care unit (ICU) in Canada die, addressing the needs of dying critically ill patients is of paramount importance. The purpose of this article is to suggest some strategies to consider to improve the care of patients dying in the ICU.

SOURCE

Data sources were randomized clinical trials, observational studies and surveys. We purposively selected key articles on end-of-life care to highlight eight initiatives that have the potential to improve care for dying critically ill patients. These initiatives were presented at the International Consensus Conference on End-of-Life Care in the ICU on April 24-25, 2003 in Brussels, Belgium.

PRINCIPAL FINDINGS

We describe eight strategies that, if adopted, may positively impact on the end-of-life care of critically ill patients: 1) promote social change through professional initiatives; 2) legitimize research in end-of-life care; 3) determine what dying patients need; 4) determine what families of dying patients need; 5) initiate quality improvement locally; 6) use quality tools with care; 7) educate future clinicians; and 8) personally engage in end-of-life care. Most of these strategies have not been subjected to rigorous evaluation.

CONCLUSION

Adoption of some of these strategies we describe may lead to improved end-of-life care in the ICU. Future studies should include more formal evaluation of the efficacy of end-of-life interventions to help us ensure high quality, clinically relevant, culturally adapted care for all dying critically ill patients.

Decision making and satisfaction with care in the pediatric intensive care unit: findings from a controlled clinical trial

OBJECTIVE

To facilitate critical decision making and improve satisfaction with care among families of patients in a pediatric intensive care unit.

DESIGN

Prospective observational study followed by a nonrandomized controlled trial of a clinical intervention to identify conflicts and facilitate communication between families and the clinical team.

SETTING

The pediatric intensive care unit of a Boston teaching hospital.

PATIENTS

A total of 127 patients receiving care in the pediatric intensive care unit in 1998-1999 and their families.

INTERVENTIONS

Interviews were conducted with surrogates and decisionally capable older children concerning the adequacy of information provided, understanding, communication, and perceived decisional conflicts. Findings were relayed to the clinical team, who then developed tailored follow-up recommendations.

MEASUREMENTS AND MAIN RESULTS

A survey administered to surrogates at baseline and day 7 or intensive care unit discharge measured satisfaction with care. Information on patient acuity and hospital stay were extracted from medical records and hospital databases. Wilcoxon rank-sum tests and incidence rate comparisons were used to assess the impact of the intervention on satisfaction and sentinel decision making, respectively. Incidence rates of care plan decision making, including decisions to adopt a comfort-care-only plan and decisions to forego resuscitation, were lower among families who received the intervention. The intervention did not significantly affect satisfaction with care.

CONCLUSIONS

Prospectively screening for and intervening to mitigate potential conflict did not increase decision making or parental satisfaction with the care provided in this pediatric intensive care unit.