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Maximiano-Barreto MA, Alves LCDS, Monteiro DQ, Matias M, Montayre J, Luchesi BM. Factors associated with low health literacy in unpaid caregivers of older people: a systematic review. Health Promot Int 2024; 39:daae118. [PMID: 39292532 DOI: 10.1093/heapro/daae118] [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] [Indexed: 09/20/2024] Open
Abstract
Health literacy is a public health issue. Unpaid caregivers of older people with low health literacy may have difficulties providing care, exerting a negative impact on the care process. The aim of the present study was to perform a systematic review of the literature on factors associated with low health literacy in unpaid caregivers of older people. Searches for relevant articles were conducted in the Cochrane Library, Embase, LILACS, PubMed and Web of Science databases. A total of 1440 articles were identified, nine of which met the eligibility criteria and were included in the systematic review, which was registered in PROSPERO (CRD42024522986). A total of 2209 unpaid caregivers participated in the studies selected for this review. Most were women (67.2%). The average frequency of inadequate health literacy was 27.1%. Sociodemographic characteristics (i.e. advanced age, low educational level, the female sex), factors related to the care process (i.e. low acculturation, low empowerment, poor ability to read medication package inserts, lower care capacity, greater disease severity, hospitalization of care recipients), cognitive factors and factors related to quality of life/well-being (i.e. less social support, poorer quality of life, greater cognitive impairment, higher levels of burden) were associated with low health literacy. In conclusion, low health literacy in unpaid caregivers of older people is associated with sociodemographic, care-related and cognitive factors as well as factors related to quality of life/well-being. Low health literacy may exert a negative impact on the health of caregivers and, consequently, the quality of care provided to older people.
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Affiliation(s)
- Madson Alan Maximiano-Barreto
- Department of Neuroscience and Behavioral Sciences, Research Group on Mental Health, Cognition and Ageing, University of São Paulo, Av. Tenente Catão Roxo, 2650, Ribeirão Preto, São Paulo, CEP: 14051-140, Brazil
| | - Ludmyla Caroline de Souza Alves
- Department of Nursing, Postgraduate Programme in Nursing, Federal University of São Carlos, Rodovia Washington Luís, km 235, São Carlos, São Paulo, CEP: 13565-905, Brazil
| | - Diana Quirino Monteiro
- Department of Gerontology, Federal University of São Carlos, Rodovia Washington Luís, km 235, São Carlos, São Paulo, CEP: 13565-905, Brazil
| | - Marisa Matias
- Centre for Psychology at University of Porto, R. Alfredo Allen, 4200-135, Porto, Portugal
| | - Jed Montayre
- School of Nursing, The Hong Kong Polytechnic University, 11 Yuk Choi Road, Hung Hom, Hong Kong, China
| | - Bruna Moretti Luchesi
- Department of Neuroscience and Behavioral Sciences, Research Group on Mental Health, Cognition and Ageing, University of São Paulo, Av. Tenente Catão Roxo, 2650, Ribeirão Preto, São Paulo, CEP: 14051-140, Brazil
- Três Lagoas Campus, Federal University of Mato Grosso do Sul, Av. Ranulpho Marques Leal, 3484, Três Lagoas, Mato Grosso do Sul, CEP: 79613-000, Brazil
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Mittal V, Hakes NA, Magnus D, Batten JN. Vagueness in Goals-of-Care Conferences for Critically Ill Patients: Types of Hedge Language Used by Physicians. Crit Care Med 2023; 51:1538-1546. [PMID: 37358354 DOI: 10.1097/ccm.0000000000005974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
OBJECTIVES Hedge language is a category of language that refers to words or phrases that make statements "fuzzier." We sought to understand how physicians use hedge language during goals-of-care conferences in the ICU. DESIGN Secondary analysis of transcripts of audio-recorded goals-of-care conferences in the ICU. SETTING Thirteen ICUs at six academic and community medical centers in the United States. PATIENTS Conferences were between clinicians and surrogates of incapacitated, critically ill adults. INTERVENTIONS Four investigators performed a qualitative content analysis of transcripts using deductive followed by inductive methods to identify types of hedge language used by physicians, then coded all instances of hedge language across 40 transcripts to characterize general patterns in usage. MEASUREMENTS AND MAIN RESULTS We identified 10 types of hedge language: numeric probabilistic statement ("there's an 80% chance"), qualitative probabilistic statement ("there's a good chance"), nonprobabilistic uncertainty statement ("hard to say for her"), plausibility shield ("we expect"), emotion-based statement ("we're concerned"), attribution shield ("according to Dr. X"), adaptor ("sort of"), metaphor ("the chips are stacking up against her"), time reference ("too soon to tell"), and contingency statement ("if we are lucky"). For most types of hedge language, we identified distinct subtypes. Physicians used hedge language frequently in every transcript (median: 74 hedges per transcript) to address diagnosis, prognosis, and treatment. We observed large variation in how frequently each type and subtype of hedge language was used. CONCLUSIONS Hedge language is ubiquitous in physician-surrogate communication during goals-of-care conferences in the ICU and can be used to introduce vagueness to statements in ways beyond expressing uncertainty. It is not known how hedge language impacts decision-making or clinician-surrogate interactions. This study prioritizes specific types of hedge language for future research based on their frequency and novelty.
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Affiliation(s)
- Vaishali Mittal
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Dermatology, Stanford University, Stanford, CA
| | - Nicholas A Hakes
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Medicine, Stanford University, Stanford, CA
- Department of Pediatrics, Stanford University, Stanford, CA
| | - Jason N Batten
- Center for Biomedical Ethics, Stanford University, Stanford, CA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA
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Marterre B. Surgeon-Patient Cross∼Talk: How It Happens, How to Fix It. Am Surg 2023; 89:3695-3701. [PMID: 37154267 DOI: 10.1177/00031348231175486] [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] [Indexed: 05/10/2023]
Abstract
Surgeon-patient communication is fraught with difficulties. Cross∼talk can be conceptualized as surgeons and patients speaking different languages, working out of different cerebral hemispheres. While as surgeons we principally function from our left brains, our patients are universally working from their right hemisphere, because the situation they find themselves in is new and overshadowed by extreme existential angst. Respecting patient autonomy is best done by shared decision-making, in which we attempt to bridge into the patient's right brain, openly exploring, and helping crystalize their values through a deliberative method that utilizes collaborative pushback. This approach is preferable to trying to drag them into our left-brained "fix it" mental model by informing them of the location in our well-worn surgical algorithm and asking them to choose between treatment options. Surrogates are under extreme psychosociospiritual duress, which can overwhelm and blunt their left-brained cognitive processing abilities (organizing information in working memory, evaluating options, and processing advice). However, this challenge can be overcome with empathy and by explaining the benefits and practice of substituted judgment during each family meeting. Whenever possible, the Palliative Triangle-surgeon, patient, family-should be established and executed preoperatively in high-stakes surgical scenarios to mitigate distress and prevent nonbeneficial value-incongruent over-treatment.
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Affiliation(s)
- Buddy Marterre
- Departments of Internal Medicine (Section on Palliative Care) and General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Lincoln TE, Buddadhumaruk P, Arnold RM, Scheunemann LP, Ernecoff NC, Chang CCH, Carson SS, Hough CL, Curtis JR, Anderson W, Steingrub J, Peterson MW, Lo B, Matthay MA, White DB. Association Between Shared Decision-Making During Family Meetings and Surrogates' Trust in Their ICU Physician. Chest 2023; 163:1214-1224. [PMID: 36336000 PMCID: PMC10258434 DOI: 10.1016/j.chest.2022.10.028] [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: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although trust is central to successful physician-family relationships in ICUs, little is known about how to promote surrogates' trust of ICU physicians in this setting. RESEARCH QUESTION Does the conduct of family conferences and physicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the physician? STUDY DESIGN AND METHODS A mixed-methods secondary analysis was done of a multicenter prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at six US medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range, 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine physicians' use of five SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by physicians during the family meeting impacted trust scores. RESULTS In adjusted models, conduct of a family meeting was associated with increased trust (average change, pre- to post family meeting: 0.91 point [95% CI, 0.4-1.4; P < .01]). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI, 0.08-0.67; P = .01). If all four elements were used, trust increased by 1.48 points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and was excluded from the final model. INTERPRETATION The conduct of family meetings and physicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating physician.
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Affiliation(s)
- Taylor E Lincoln
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA.
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Leslie P Scheunemann
- Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Chung-Chou H Chang
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Shannon S Carson
- Division of Pulmonary Disease and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Wendy Anderson
- Department of Medicine and Division of Hospital Medicine and Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Jay Steingrub
- Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, MA and Tufts University School of Medicine, Boston, MA
| | - Michael W Peterson
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Chan Medical School, Baystate, MA
| | - Douglas B White
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Baltazar AO, Popejoy L. Health Literacy of Surrogates and Communication Issues in Palliative Care Conversations in Critical Care: An Integrative Review. J Hosp Palliat Nurs 2023; 25:39-44. [PMID: 36622313 DOI: 10.1097/njh.0000000000000921] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Worldwide, 56.8 million persons are estimated to require palliative care. Critically ill patients benefit from palliative care by improving their quality of life through symptom management. Resistance to palliative care exists from surrogate decision-makers because of low health literacy and communication issues with providers. This research reviewed the literature to identify how health literacy and health care communication influenced palliative care conversations with decision-making surrogates and health outcomes of critically ill patients. The review included articles between 2011 and 2022 using the terms communication, health literacy, palliative care, critical care, intensive care, ICU, surrogate decision maker, family, and caregiver in PubMed, CINAHL, and Google Scholar. Fourteen articles were included. Quality was assessed through Joanna Briggs Institute appraisal tools. Health literacy of surrogates was not found to be significant for patient outcomes. However, there were significant differences between clinician and surrogate communication influenced by surrogates' previous health care experiences. Early communication about prognosis was important for surrogates. Structured communication approaches were preferred by surrogates. Limitations of the review included primarily White participants, small variability of research sites, and a few number of articles. Future research needs to study the effects of surrogate health literacy of critically ill patients on willingness to accept palliative care.
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Integrating Narrative Goals of Care in the Medical Intensive Care Unit: Impact on Educational and Clinical Outcomes. ATS Sch 2022; 3:449-459. [PMID: 36312808 PMCID: PMC9585691 DOI: 10.34197/ats-scholar.2022-0003in] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background High-quality goals of care (GOC) communication is fundamental to providing excellent critical care. Objective Educate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation. Methods Guided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19). Results All PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% (P < 0.05); for patients age ⩾80 years, 3.54% versus 29.41% (P < 0.05); and for patients with MICU length of stay ⩾7 days, 2.78% versus 24.44% (P < 0.05). Conclusion Combining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.
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Role Mismatch in Medical Decision-Making Participation Is Associated with Anxiety and Depression in Family Members of Patients in the Intensive Care Unit. J Trop Med 2022; 2022:8027422. [PMID: 35469334 PMCID: PMC9034962 DOI: 10.1155/2022/8027422] [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] [Received: 01/04/2022] [Accepted: 02/22/2022] [Indexed: 11/18/2022] Open
Abstract
This study aimed to investigate the mismatch between the preferred and actual roles in the medical decision-making of intensive care unit (ICU) patients' family members and the relationship between the role mismatch of family members' decisions and anxiety and depression syndromes. A total of 223 family members of ICU patients in the Affiliated Hospital of Jiangnan University in China were enrolled. The simple Chinese version of the Control Preference Scale was used to complete the surveys to assess the preferred and actual roles, and anxiety and depression syndromes were measured using the Generalized Anxiety Disorder-7 scale and Patient Health Questionnaire-9, respectively. For the preferred and actual roles, the active role rates were 16.1% and 8.1%, the cooperative role rates were 49.3% and 31.4%, and the passive role rates were 34.5% and 60.5%, respectively. The incidence of mismatch was 43.0% between the preferred and actual roles, and the consistency between their preferred and actual decision-making roles was poor (kappa = 0.309, P < 0.001). Family members with mismatched decision-making roles had significantly higher incidence rates of anxiety (90.6% vs. 57.5%, P < 0.001) and depression (86.5% vs. 63.0%, P < 0.001). Logistic regression analysis revealed that mismatches in decision-making roles remained independently associated with these outcomes after adjustment for family members' sociodemographic features. The results of the present study demonstrate that the preferred role of ICU patients' family members is mainly cooperative, and the actual role is mainly passive. The mismatch between the preferred and actual roles is associated with anxiety and depression among the ICU patients' family members.
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Barks MC, Schindler EA, Ubel PA, Jiao MG, Pollak KI, Huffstetler HE, Lemmon ME. Assessment of parent understanding in conferences for critically ill neonates. PATIENT EDUCATION AND COUNSELING 2022; 105:599-605. [PMID: 34130892 PMCID: PMC8664893 DOI: 10.1016/j.pec.2021.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 05/31/2023]
Abstract
OBJECTIVES This study aimed to characterize the use and impact of assessments of understanding in parent-clinician communication for critically ill infants. METHODS We enrolled parents and clinicians participating in family conferences for infants with neurologic conditions. Family conferences were audio recorded as they occurred. We used a directed content analysis approach to identify clinician assessments of understanding and parent responses to those assessments. Assessments were classified based on an adapted framework; responses were characterized as "absent," "yes/no," or "elaborated." RESULTS Fifty conferences involving the care of 25 infants were analyzed; these contained 374 distinct assessments of understanding. Most (n = 209/374, 56%) assessments were partial (i.e. okay?); a minority (n = 60/374, 16%) were open-ended. When clinicians asked open-ended questions, parents elaborated in their answers most of the time (n = 55/60, 92%). Approximately three-quarter of partial assessments yielded no verbal response from parents. No conferences included a teach-back. CONCLUSIONS Although common, most clinician assessments of understanding were partial or close-ended and rarely resulted in elaborated responses from parents. Open-ended assessments are an effective, underutilized strategy to increase parent engagement and clinician awareness of information needs. PRACTICE IMPLICATIONS Clinicians hoping to facilitate parent engagement and question-asking should rely on open-ended statements to assess understanding.
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Affiliation(s)
- Mary C Barks
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA.
| | - Emma A Schindler
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Peter A Ubel
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Megan G Jiao
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hanna E Huffstetler
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Monica E Lemmon
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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A Pilot Randomized Trial of an Interactive Web-based Tool to Support Surrogate Decision Makers in the Intensive Care Unit. Ann Am Thorac Soc 2021; 18:1191-1201. [PMID: 33326348 DOI: 10.1513/annalsats.202006-585oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Breakdowns in clinician-family communication in intensive care units (ICUs) are common, yet there are no easily scaled interventions to prevent this problem.Objectives: To assess the feasibility, usability, acceptability, and perceived effectiveness of a communication intervention that pairs proactive family meetings with an interactive, web-based tool to help surrogates prepare for clinician-family meetings.Methods: We conducted a two-arm, single-blind, patient-level randomized trial comparing the Family Support Tool with enhanced usual care in two ICUs in a tertiary-care hospital. Eligible participants included surrogates of incapacitated patients judged by their physicians to have ≥40% risk of death or severe long-term functional impairment. The intervention group received unlimited tool access, with prompts to complete specific content upon enrollment and before two scheduled family meetings. Before family meetings, research staff shared with clinicians a one-page summary of surrogates' main questions, prognostic expectations, beliefs about the patient's values, and attitudes about goals of care. The comparator group received usual care enhanced with scheduled family meetings. Feasibility outcomes included the proportion of participants who accessed the tool before the first family meeting, mean number of logins, and average tool engagement time. We assessed tool usability with the System Usability Scale, assessed tool acceptability and perceived effectiveness with internally developed questionnaires, and assessed quality of communication and shared decision-making using the Quality of Communication questionnaire.Results: Of 182 screened patients, 77 were eligible. We enrolled 52 (67.5%) patients and their primary surrogate. Ninety-six percent of intervention surrogates (24/25) accessed the tool before the first family meeting (mean engagement time, 62 min ± 27.7) and logged in 4.2 times (±2.1) on average throughout the hospitalization. Surrogates reported that the tool was highly usable (mean, 82.4/100), acceptable (mean, 4.5/5 ± 0.9), and effective (mean, 4.4/5 ± 0.2). Compared with the control group, surrogates who used the tool reported higher overall quality of communication (mean, 8.9/10 ± 1.6 vs. 8.0/10 ± 2.4) and higher quality in shared decision-making (mean, 8.7/10 ± 1.5 vs. 8.0/10 ± 2.4), but the difference did not reach statistical significance.Conclusions: It is feasible to deploy an interactive web-based tool to support communication and shared decision-making for surrogates in ICUs. Surrogates and clinicians rated the tool as highly usable, acceptable, and effective.
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Affiliation(s)
- Megan L McSherry
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sapna R Kudchadkar
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Abstract
OBJECTIVES Parents value clear communication with PICU clinicians about possible patient and family outcomes (prognostic conversations). We describe PICU parent and attending physician reports and agreement regarding the occurrence of prognostic conversations. We queried parents and physicians about prognostic conversation content, which healthcare providers had prognostic conversations, and whether parents wanted more prognostic information. DESIGN Prospective cross-sectional survey study. SETTING University-based 40-bed PICU. PARTICIPANTS Parents and attending physicians of PICU patients with multiple organ dysfunction within 24 hours of PICU admission. INTERVENTIONS Surveys administered to parents and attending PICU physicians 5-10 days after PICU admission. MEASUREMENTS AND MAIN RESULTS Surveys asked parents and physicians to report the occurrence of prognostic conversations related to PICU length of stay, risk of PICU mortality, and anticipated post-PICU physical, neurologic, and psychologic morbidities for patients and post-PICU psychologic morbidities for parents. Of 101 participants, 87 parents and 83 physicians reported having prognostic conversations. Overall concordance between parents and physicians was fair (Kappa = 0.22). Parents and physicians most commonly reported prognostic conversations about PICU length of stay (67.3% and 63.3%, respectively) and patient post-PICU physical morbidity (n = 48; 48.5% and n = 45; 44.5% respectively). Conversations reported less often by parents and physicians were about patient post-PICU psychologic morbidity (n = 13; 12.9% and n = 20; 19.8%, respectively). Per parent report, bedside nurses and physicians provided most prognostic information. Chaplains (n = 14; 50%) and social workers (n = 17; 60%) were more involved in conversations regarding parent psychologic morbidities. Most commonly, parents requested more information about length of stay and their child's physical morbidities. Parents less frequently wanted information about their own psychologic morbidities. CONCLUSIONS Most parents and physicians report having prognostic conversations, primarily about length of stay and post-ICU physical morbidities. Concordance between parents and physicians is suboptimal. Future studies should evaluate prognostic conversations at other timepoints, how information is delivered, and how these conversations impact the PICU experience.
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Impact of a Visual Support Dedicated to Prognosis on Symptoms of Stress of ICU Family Members: A Before-and-After Implementation Study. Crit Care Explor 2021; 3:e0483. [PMID: 34278313 PMCID: PMC8280076 DOI: 10.1097/cce.0000000000000483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Family members commonly have inaccurate expectations of patient's prognosis in ICU. Adding to classic oral information, a visual support, depicting day by day the evolution of the condition of the patient, improves the concordance in prognosis estimate between physicians and family members. The objective of this study was to evaluate the impact of this tool on symptoms of anxiety/depression of family members. DESIGN Bicenter prospective before-and-after study. SETTING A nonacademic and a university hospital. SUBJECTS Relatives of consecutive patients admitted in the two ICUs. INTERVENTIONS In the period "before," family members received classic oral information, and in the period "after," they could consult the visual support in the patient's room. The primary endpoint was the Hospital Anxiety and Depression Scale score of relatives at day 5. Secondary outcomes were the prevalence of symptoms of anxiety (Hospital Anxiety and Depression Scale anxiety subscale score > 7) and depression (Hospital Anxiety and Depression Scale depression subscale score > 7) at day 5 and Hospital Anxiety and Depression Scale score at day 90. MEASUREMENTS AND MAIN RESULTS A total of 140 patients and their referent family members were included (77 in period before and 63 after). Characteristics of patients of the two groups were similar regarding age, reason for admission, Simplified Acute Physiology Score II at admission, and Sequential Organ Failure Assessment score at day 5. At day 5, median Hospital Anxiety and Depression Scale score was 17 (9-25) before and 15 (10-22) after the implementation of the visual support (p = 0.43). The prevalence of symptoms of anxiety and depression was similar in the two groups (66.2% and 49.4% before and 68.3% and 36.5% after [not significant], respectively). At day 90, median Hospital Anxiety and Depression Scale score was 11 before (7-16) and 9 (5-16) after the implementation of the tool (p = 0.38). CONCLUSIONS In this study, the use of a visual support tool dedicated to prognosis did not modify the level of stress of family members.
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Tzuh S, Chang WC, Chou WC, Hsieh CH, Chen JS, Wen FH. Family Caregivers' Emotional Preparedness for Death is Distinct from Their Cognitive Prognostic Awareness for Cancer Patients. J Palliat Med 2021; 24:405-412. [PMID: 32790487 DOI: 10.1089/jpm.2020.0264] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Cognitive prognostic awareness (PA) and emotional preparedness for a loved one's death are distinct but related phenomena. However, the distinction between these two concepts has not been studied in family caregivers. Objective: To examine whether these two concepts are distinct by comparing their evolution and predictors over cancer patients' last year. Methods: Agreement between emotional preparedness for death and cognitive PA was longitudinally evaluated for 309 family caregivers by percentages and kappa coefficients. Predictors of the two outcomes were evaluated by multivariate logistic regression models with the generalized estimating equation. Results: Agreement between family caregivers' emotional preparedness for death and cognitive PA decreased slightly (54.73%-43.64%) from 181-365 to 1-30 days before the patient's death, with kappa values (95% confidence interval) from -0.060 (-0.123 to 0.003) to 0.050 (-0.074 to 0.174), indicating poor agreement. Participants were more likely to report adequate emotional preparedness for death if they had financial sufficiency, more contact/communication with the patient, lower caregiving burden, and stronger perceived social support. Family caregivers were more likely to have accurate PA if they were 56-65 years old, the patient's adult child, and had more contact/communication with the patient and greater subjective caregiving burden. Conclusions/Implications: Family caregivers' emotional preparedness for death and cognitive PA were distinct, as supported by their poor agreement, lack of reciprocal associations, and two different sets of predictors. Health care professionals should facilitate family caregivers' accurate PA and cultivate their emotional preparedness for death by enhancing patient-family contact/communication and easing their caregiving burden to improve quality of end-of-life care.
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Affiliation(s)
- Siew Tzuh
- School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan.,Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan.,Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan.,College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
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15
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Zheng M, Yin C, Cao Y, Zhang Y, Zhang K, Zhang X, Bian W, Wang L. Development and evaluation of a decision aid for family surrogate decision-makers for patients with acute kidney injury requiring renal replacement therapy (RRT) in ICUs: a study protocol. BMJ Open 2021; 11:e043385. [PMID: 33579767 PMCID: PMC7883861 DOI: 10.1136/bmjopen-2020-043385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Shared decision making is endorsed by guidelines for both acute kidney injury and critical care medicine. However, there is still a huge need for effective interventions, especially those focusing on decisions about renal replacement therapy for intensive care unit (ICU) patients with acute kidney injury. The decision aids provide evidence-based support for shared decision making, to achieve better decisions through enhanced knowledge of treatment options and treatment aligns with patients' preferences and values. Therefore, our objectives are to develop and evaluate a decision aid systematically and rigorously for family surrogate decision makers of ICU patients with acute kidney injury who need renal replacement therapy. METHODS AND ANALYSIS We will use a systematic development process that focuses on user-centred design to develop and evaluate the decision aid in three phases: (1) development of a draft prototype for the decision aid based on extensive literature reviews, interviews with key stakeholders and evidence synthesis; (2) alpha testing ('near live' usability) the decision aid during simulated clinical encounters to test its comprehensibility, acceptability and usability and (3) beta testing ('live' usability) to examine the aid's clinical feasibility. User testing will be conducted using mixed-methods approach to support iterative revision of the decision aid. The IPDASi (V.4.0) will be used for following qualitative assessment. All interviews will be analysed by Colaizzi's seven-step approach to qualitative analysis. The coding scheme will use to analyse user interactions. Questionnaire surveys will be analysed using paired sample t-tests when related to the before-and-after survey, otherwise using one-sample t-test. ETHICS AND DISSEMINATION Ethical approval for this research was obtained from the Ethics Committee of the First Affiliated Hospital of Army Medical University, PLA (Ref: KY2020104). All participants will sign a formal informed consent form. The findings will be published in peer-reviewed journals and reported in appropriate meetings. TRIAL REGISTRATION NUMBER ChiCTR2000031613.
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Affiliation(s)
- Miao Zheng
- Graduate School, Guizhou University of Traditional Chinese Medicine, Guiyang City, Guizhou Province, China
| | - Changlin Yin
- Department of Critical Care Medicine, Southwest Hospital of Third Military Medical University (Amy Medical University), Chongqing, China
| | - Ying Cao
- Department of Critical Care Medicine, Southwest Hospital of Third Military Medical University (Amy Medical University), Chongqing, China
| | - Yonghui Zhang
- Department of Critical Care Medicine, Southwest Hospital of Third Military Medical University (Amy Medical University), Chongqing, China
| | - Kuoliang Zhang
- Graduate School, Guizhou University of Traditional Chinese Medicine, Guiyang City, Guizhou Province, China
- Academic Research Office, Qiannan Medical College for Nationalities, Duyun City, Guizhou Province, China
| | - Xiaoqin Zhang
- Graduate School, Guizhou University of Traditional Chinese Medicine, Guiyang City, Guizhou Province, China
| | - Wei Bian
- Department of Ophthalmology, Southwest Hospital of Third Military Medical University (Amy Medical University), Chongqing, China
| | - Lihua Wang
- Addmin Office, Southwest Hospital of Third Military Medical University (Amy Medical University), Chongqing, China
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16
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O'Mara L, Palm K, Castillo-Angeles M, Bryant E, Moberg E, Armstrong K, Patel N, Tulebaev S, McDonald M, Tsitos D, Cooper Z. Frailty Interdisciplinary Pathway: Compliance and Sustainability in a Level I Trauma Center. J Trauma Nurs 2021; 28:59-66. [PMID: 33417405 DOI: 10.1097/jtn.0000000000000546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Frailty is a state of physiological vulnerability that predisposes many older adult trauma patients to poor health outcomes. Specialized care pathways for frail trauma patients have been shown to improve outcomes, but the compliance and sustainability of these pathways have not been reported (Bryant et al., 2019; Engelhardt et al., 2018). METHODS We retrospectively measured compliance and sustainability during the first 2 years of a frailty pathway for patients 65 years or older at an urban Level I trauma center. Compliance to 19 pathway elements was collected for 279 pathway patients between October 1, 2016, and September 30, 2018. Compliance was analyzed and reported as a percentage of the total possible times each element could have been completed per pathway guidelines. Benchmark compliance was 75% or more. RESULTS Retrospective 2-year mean overall compliance to all pathway elements was 68.2% and improved from Year 1 (65.0%) to Year 2 (71.4%). Seven elements achieved a mean 75% or more compliance over the 2-year period: frailty screening on admission (92.8%), consultation requests for physical therapy (97.9%), geriatrics (96.2%), and nutrition (92.3%), consultant care within 72 hr of admission (78.0%), delirium screening 3 times daily (76.3%), and daily senna administration (76.0%). Compliance to 10 elements significantly improved from Year 1 to Year 2 and significantly worsened in 2 elements. CONCLUSION Many standardized geriatric care processes for frail older adult trauma patients can be successfully integrated into routine daily inpatient practice and sustained over time. Multicenter studies are needed to demonstrate how to improve compliance and to understand better which pathway elements are most effective.
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Affiliation(s)
- Lynne O'Mara
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery (Mss O'Mara, Palm, Armstrong, Patel, and McDonald and Drs Castillo-Angeles and Cooper), Center for Surgery and Public Health (Ms Moberg and Dr Cooper), Division of Aging, Department of Medicine (Dr Tulebaev), and Department of Nursing (Ms Tsitos), Brigham and Women's Hospital, Boston, Massachusetts; and Rush Medical School, Chicago, Illinois (Ms Bryant)
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17
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Tang ST, Huang CC, Hu TH, Lo ML, Chou WC, Chuang LP, Chiang MC. End-of-Life-Care Quality in ICUs Is Associated With Family Surrogates' Severe Anxiety and Depressive Symptoms During Their First 6 Months of Bereavement. Crit Care Med 2021; 49:27-37. [PMID: 33116053 DOI: 10.1097/ccm.0000000000004703] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Evidence linking end-of-life-care quality in ICUs to bereaved family members' psychologic distress remains limited by methodological insufficiencies of the few studies on this topic. To examine comprehensively the associations of family surrogates' severe anxiety and depressive symptoms with end-of-life-care quality in ICUs over their first 6 months of bereavement. DESIGN Prospective, longitudinal, observational study. SETTING/PARTICIPANTS Family surrogates (n = 278) were consecutively recruited from seven medical ICUs at two academically affiliated medical centers in Taiwan. MEASUREMENTS AND STATISTICAL ANALYSIS Family surrogates' anxiety and depressive symptoms were assessed 1, 3, and 6 months postloss using the Hospital Anxiety and Depression Scale. Family satisfaction with end-of-life care in ICUs was assessed 1-month postloss by the Family Satisfaction in the ICU questionnaire. Patients' end-of-life care was documented over the patient's ICU stay. Associations of severe anxiety and depressive symptoms (scores ≥ 8 for each subscale) with end-of-life-care quality in ICUs (documented by patient care received and family satisfaction with end-of-life care in ICUs) were examined by multivariate logistic regression models with generalized estimating equation. MAIN RESULTS Prevalence of severe anxiety and depressive symptoms decreased significantly over time. Surrogates' lower likelihood of severe anxiety or depressive symptoms 3-6 month postloss was associated with death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and higher family satisfaction with end-of-life care in ICUs. Bereaved surrogates' higher likelihood of these symptoms was associated with physician-surrogate prognostic communication and conducting family meetings before patients died. CONCLUSIONS End-of-life-care quality in ICUs is associated with bereaved surrogates' psychologic well-being. Enhancing end-of-life-care quality in ICUs by improving the process of end-of-life care, for example, promoting death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and increasing family satisfaction with end-of-life care, can lighten bereaved family surrogates' severe anxiety symptoms and severe depressive symptoms.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, R.O.C
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
| | - Mei-Ling Lo
- School of Nursing, Medical College, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
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18
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Wycech J, Fokin AA, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation. J Palliat Med 2020; 24:705-711. [PMID: 32975481 DOI: 10.1089/jpm.2020.0218] [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: 11/12/2022] Open
Abstract
Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.
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Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | | | - Susan Koff
- TrustBridge Health, West Palm Beach, Florida, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida, USA
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19
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Abstract
PURPOSE OF REVIEW Children with medical or surgical critical illness or injury require skillful attention to physical, emotional, psychological, and spiritual needs, whereas their families need support and guidance in facing life-threatening or life-changing events and gut-wrenching decisions. This article reviews current evidence and best practices for integrating palliative care into the pediatric intensive care unit (PICU), with a focus on surgical patients. RECENT FINDINGS Palliative care is best integrated in a tiered approach, with primary palliative care provided by the PICU and surgical providers for all patients and families, including basic symptom management, high-quality communication, and end-of-life care. Secondary and tertiary levels of care involve unit or team-based 'champions' with additional expertise, and subspecialty palliative care teams, respectively. PICU and surgical providers should be able to provide primary palliative care, to identify patients and families for whom a palliative care consult would be helpful, and should be comfortable introducing the concept of palliative care to families. SUMMARY This review provides a framework and tools to enable PICU and surgical providers to integrate palliative care best practices into patient and family care.
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20
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Seidlein AH, Hannich A, Nowak A, Gründling M, Salloch S. Ethical aspects of time in intensive care decision making. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2019-105752. [PMID: 32332151 DOI: 10.1136/medethics-2019-105752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 03/06/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting.
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Affiliation(s)
- Anna-Henrikje Seidlein
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Arne Hannich
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Andre Nowak
- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle(Saale), Germany
| | - Matthias Gründling
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Sabine Salloch
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
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21
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Oppenheim IM, Lee EM, Vasher ST, Zaeh SE, Hart JL, Turnbull AE. Effect of Intensivist Communication in a Simulated Setting on Interpretation of Prognosis Among Family Members of Patients at High Risk of Intensive Care Unit Admission: A Randomized Trial. JAMA Netw Open 2020; 3:e201945. [PMID: 32236533 PMCID: PMC7113731 DOI: 10.1001/jamanetworkopen.2020.1945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Importance Discordance about prognosis between a patient's health care decision-making surrogate and the treating intensivist is common in the intensive care unit (ICU). Empowering families, friends, and caregivers of patients who are critically ill to make informed decisions about care is important, but it is unclear how best to communicate prognostic information to surrogates when a patient is expected to die. Objective To determine whether family members, who are often health care decision-making surrogates, interpret intensivists as being more optimistic when questions about prognosis in the ICU are answered indirectly. Design, Setting, and Participants This web-based randomized trial was conducted between September 27, 2019, and October 17, 2019, among a national sample of adult children, spouses, partners, or siblings of people with chronic obstructive pulmonary disease who were receiving long-term oxygen therapy. Participants were shown video vignettes depicting an intensivist answering a standardized question about the prognosis of a patient at high risk of death on day 3 of ICU admission. Participants were excluded if they had worked as a physician, nurse, or advanced health care practitioner. Data were analyzed from October 18, 2019, to November 12, 2019. Interventions Participants were randomized to view 1 of 4 intensivist communication styles in response to the question "What do you think is most likely to happen?": (1) a direct response (control), (2) an indirect response comparing the patient's condition with that of other patients, (3) an indirect response describing the patient's deteriorating physiological condition, or (4) redirection to a discussion of the patient's values and goals. Main Outcomes and Measures Participant responses to 2 questions: (1) "If you had to guess, what do you think the doctor thinks is the chance that your loved one will survive this hospitalization?" and (2) "What do you think are the chances that your loved one will survive this hospitalization?" answered using a 0% to 100% probability scale. Results Among 302 participants (median [interquartile range] age, 49 [38-59] years; 204 [68%] women) included in the trial, 165 (55%) were adult children of the individual with chronic obstructive pulmonary disease; 77 participants were randomized to view a direct response, 77 participants were randomized to view an indirect response referencing other patients, 68 participants were randomized to view an indirect response referencing physiological condition, and 80 participants were randomized to view a redirection response. Compared with participants who viewed a direct response, participants who viewed an indirect response referencing other patients (β = 10 [95% CI, 1-19]; P = .03), physiological condition (β = 10 [95% CI, 0-19]; P = .04), or redirection to a discussion of the patient's values and goals (β = 19 [95% CI, 10-28]; P < .001) perceived the intensivist to have a significantly more optimistic prognostic estimate. Conclusions and Relevance These findings suggest that family members interpret indirect or redirection responses to questions about prognosis in the ICU setting as more optimistic than direct responses. Trial Registration ClinicalTrials.gov Identifier: NCT04239209.
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Affiliation(s)
- Ian M Oppenheim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emma M Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott T Vasher
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandra E Zaeh
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joanna L Hart
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University School of Medicine, Baltimore, Maryland
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22
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Use of the Serious Illness Conversation Guide to Improve Communication with Surrogates of Critically Ill Patients. A Pilot Study. ATS Sch 2020; 1:119-133. [PMID: 33870276 PMCID: PMC8043290 DOI: 10.34197/ats-scholar.2019-0006oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: International family-centered critical care guidelines recommend formal, structured communication to ensure that clinical decision making is informed by a shared understanding of diagnosis and prognosis and patient goals and preferences. Tools to facilitate these recommendations are limited. Objective: To examine the feasibility, acceptability, and utility of a standardized serious illness conversation (SIC) to guide communication between nonpalliative care trained providers and surrogates of critically ill, mechanically ventilated patients. Methods: After providers received training, including simulation, we implemented SIC in October 2018. A total of 11 hospitalist providers were eligible to perform SICs over the study interval. Providers met in person with surrogates of adult, mechanically ventilated patients in the medical intensive care unit within 48 hours of intubation. To determine acceptability, surrogates were surveyed 2 months after SIC completion, and providers were surveyed between June and July 2018. To determine feasibility and utility, two independent investigators reviewed SIC documentation and coded responses into categories. Results: Of 72 eligible patients, advanced care planning documentation was completed in 50 patients, including 36 SICs, for an advance care planning completion rate of 69% and an SIC completion rate of 50%. The average SIC was completed in 30 minutes, 3 days after intubation. Of the 19 surrogates surveyed, 95% found the SIC to be mostly or extremely worthwhile. Nine of 11 hospitalist providers completed the follow-up survey. Each of the nine providers who completed the survey found the guide valuable to patient care and easy to administer. The conversation yielded valuable information in terms of goals, fears, and worries; sources of strength; abilities critical to the patient; and understanding how much the patient would be willing to go through for the possibility of gaining more time. Conclusion: We found that implementation of a structured communication tool in the intensive care unit was feasible and acceptable to surrogates and providers; yet, fidelity to the timing and completion was modest. The tool appeared to yield valuable information for understanding the goals, fears, and care preferences of mechanically ventilated patients. Steps to increase fidelity, in accordance with family-centered care guidelines, are warranted.
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Suen AO, Butler RA, Arnold R, Myers B, Witteman HO, Cox CE, Argenas A, Buddadhumaruk P, Bursic A, Ernecoff NC, Shields AM, Tran DK, White DB. Developing the family support tool: An interactive, web-based tool to help families navigate the complexities of surrogate decision making in ICUs. J Crit Care 2019; 56:132-139. [PMID: 31896447 DOI: 10.1016/j.jcrc.2019.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/24/2019] [Accepted: 12/05/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Although family members of incapacitated, critically ill patients often struggle in the role of surrogate decision maker, there are no low-cost, easily-scaled interventions to address this problem. AIM OF THE STUDY To develop and pilot-test the Family Support Tool, an interactive, web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs. MATERIAL AND METHODS We used a mixed methods, user-centered process to create the Family Support Tool, including: 1) creation of a preliminary design by an expert panel; 2) engagement of a key stakeholder panel to iteratively refine the preliminary design; 3) user testing of a low-fidelity prototype of the tool by 6 former ICU surrogates; 4) creation of a web-based prototype; and 5) user testing of the web-based prototype with 14 surrogates and ICU physicians, including semi-structured interviews and quantitative measurement of usability, acceptability, and perceived effectiveness. RESULTS The initial design contained a collection of videos and exercises designed to help individuals understand the surrogate's role and think through the patient's values and preferences. Based on family stakeholders' feedback about the emotional overwhelm they experience early in an ICU stay, we redesigned the tool to be viewed in sections, with the first section focused on decreasing surrogates' emotional distress, and later sections focused on helping surrogates prepare for family meetings. Surrogates actively making decisions in the ICU judged the final tool to be highly usable (mean summary score 83.5, correlating to 95th percentile when normalized to devices of its type), acceptable (mean 4.2 +/- 0.5 out of 5), and effective (mean 4.3 +/- 0.6 out of 5). All surrogates reported the tool helped them consider goals of care and all indicated they would recommend the tool to a friend. CONCLUSIONS We successfully developed a web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs that has high potential for scalability. Surrogates judged the tool to be usable, acceptable, and effective. These data support proceeding to test the tool in a pilot randomized clinical trial.
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Affiliation(s)
- Angela O Suen
- University of Pittsburgh, School of Medicine, Department of Medicine, Division of General Internal Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States of America
| | - Rachel A Butler
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Robert Arnold
- University of Pittsburgh, School of Medicine, Department of Medicine, Division of General Internal Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States of America; University of Pittsburgh Medical Center Palliative and Supportive Institute, Iroquois Building, Suite 308, 3600 Forbes Avenue at Meyran Avenue, Pittsburgh, PA 15213, United States of America
| | - Brad Myers
- Carnegie Mellon University, School of Computer Science, Human Computer Interaction Institute, 5000 Forbes Avenue, Pittsburgh, PA 15213, United States of America
| | - Holly O Witteman
- Université Laval, Department of Family & Emergency Medicine, Bureau 4617, Pavillon Ferdinand-Vandry, 1050 Avenue de la Médecine, Quebec, QC G1V 0A6, Canada
| | - Christopher E Cox
- Duke University, School of Medicine, Department of Medicine, Division of Pulmonary & Critical Care Medicine, 2301 Erwin Road, Durham, NC 27710, United States of America
| | - Amanda Argenas
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Praewpannanrai Buddadhumaruk
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Alexandra Bursic
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Natalie C Ernecoff
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Anne-Marie Shields
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Dang K Tran
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America
| | - Douglas B White
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, United States of America.
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Chen C, Michaels J, Meeker MA. Family Outcomes and Perceptions of End-of-Life Care in the Intensive Care Unit: A Mixed-Methods Review. J Palliat Care 2019; 35:143-153. [PMID: 31543062 DOI: 10.1177/0825859719874767] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this review was to evaluate end-of-life care (EOLC) in the intensive care unit (ICU) from the perspective of family members. Sandelowski's segregated approach from Joanna Briggs Institute (JBI) Mixed-Methods Systematic Reviews guided this review. A search was conducted in PubMed, CINAHL, PsycINFO, EMBASE, and ProQuest databases and identified 50 papers (33 quantitative, 15 qualitative, and 2 mixed-methodology studies). Five synthesized themes (distressing emotions, shared decision-making, proactive communication, personalized end-of- life care, and valuing of nursing care) were identified. For quantitative results, study methodologies and interventions were heterogeneous and did not always improve family members' perceived quality of care and family members' psychological distress. Configuration of qualitative and quantitative data revealed ICU end-of-life interventions were ineffective because they were not guided by family members' reported needs and perceptions. To fulfill the family members' needs for the patients' EOLC in the ICU, researchers should develop a theory to explicitly explain how the family members experience ICU EOLC and implement a theory-based intervention to improve family psychological outcomes.
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Affiliation(s)
- Chiahui Chen
- School of Nursing, University at Buffalo-The State University of New York, Buffalo, NY, USA
| | - Jacqueline Michaels
- School of Nursing, University at Buffalo-The State University of New York, Buffalo, NY, USA.,School of Nursing and Allied Health, SUNY Empire State College, Saratoga Springs, NY, USA
| | - Mary Ann Meeker
- School of Nursing, University at Buffalo-The State University of New York, Buffalo, NY, USA
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Numeracy and Interpretation of Prognostic Estimates in Intracerebral Hemorrhage Among Surrogate Decision Makers in the Neurologic ICU. Crit Care Med 2019; 46:264-271. [PMID: 29215368 DOI: 10.1097/ccm.0000000000002887] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Clinicians caring for patients with intracerebral hemorrhage must often discuss prognosis and goals of care with their patients' surrogate decision makers, and may make numeric estimates of likelihood of survival and functional independence, informed by validated prediction models. Surrogates' prognostic estimates are often discordant with physicians', suggesting that physicians' numeric statements may not be accurately interpreted. We sought to assess the relationship between numeracy and interpretation of prognostic estimates in intracerebral hemorrhage among surrogate decision makers. We also assessed surrogates' application of prognostic estimates to decisions regarding goals of care. DESIGN Single-center, survey-based, cross-sectional study. SETTING Twenty-two-bed neurologic ICU at an urban, academic hospital. SUBJECTS Surrogate decision makers for patients admitted to the neurologic ICU. INTERVENTIONS Participants completed a survey containing five clinical vignettes describing patients with nontraumatic intracerebral hemorrhage. For each patient, numerical estimates of survival and functional independence were explicitly provided, based on the validated outcome risk stratification scale (intracerebral hemorrhage score) and the Prediction of Functional Outcome in Patients with Primary Intracerebral Hemorrhage score. MEASUREMENTS AND MAIN RESULTS Participants were asked to make their own prognostic estimates, as well as to describe their preferred goals of care for each hypothetical patient. Respondent demographics were collected, and numeracy was assessed using a modified Lipkus 11-item scale. Poor numeracy was common (42 of 96 total subjects) in this relatively highly educated population. Most prognostic estimates (55%) made by surrogates were discordant with the provided estimates. High numeracy correlated with better concordance (odds ratio, 23.9 [5.57-97.64]; p < 0.001), independent of several factors, including level of education and religion. Numeracy also affected goals-of-care decisions made by surrogates. CONCLUSIONS Poor numeracy is common among surrogate decision makers in an intensive care setting and poses a barrier to communication between surrogates and clinicians regarding prognosis and goals of care.
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Midega TD, Oliveira HSBD, Fumis RRL. Satisfaction of family members of critically ill patients admitted to a public hospital intensive care unit and correlated factors. Rev Bras Ter Intensiva 2019; 31:147-155. [PMID: 31141080 PMCID: PMC6649209 DOI: 10.5935/0103-507x.20190024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/02/2019] [Indexed: 11/24/2022] Open
Abstract
Objective To analyze the satisfaction, medical situation understanding and symptoms of
anxiety and depression in family members of patients admitted to the
intensive care unit. Methods The family members of patients who were hospitalized for ≥ 72 hours
were invited to participate in the study, which was performed in a public
hospital. Questionnaires were answered to assess the understanding of the
diagnosis, treatment and prognosis, and the support received in the
intensive care unit. The family needs were also evaluated using a modified
version of the Critical Care Family Needs Inventory (CCFNI). The Hospital
Anxiety and Depression Scale (HADS) was used to assess the symptoms of
anxiety and depression. Results A total of 35 family members were interviewed within the patients' first week
of stay in the intensive care unit. Most patients (57.1%) were male, aged 54
± 19 years. Sepsis was the main reason for admission to the intensive
care unit (40%); the median of the Simplified Acute Physiology Score (SAPS)
3 was 68 (48 - 77), and 51.4% of the patients died in the intensive care
unit. The majority of the family members were female (74.3%) and were sons
or daughters of patients (54.3%), with a mean age of 43.2 ± 14 years.
Overall, 77.1% of the family members were satisfied with the intensive care
unit. A total of 37.1% of the family members did not understand the
prognosis. Receiving clear and complete information in the intensive care
unit and the doctor being accessible were factors that were significantly
correlated with the overall family satisfaction. The prevalence of symptoms
of anxiety (60%) and depression (54.3%) in the family members was high. Conclusion The emotional distress of family members is high during a patient's
hospitalization in the intensive care unit, although satisfaction is also
high. Clear and complete information provided by the intensivist and the
support received in the intensive care unit are significantly correlated
with the satisfaction of family members in a public hospital.
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Affiliation(s)
- Thais Dias Midega
- Unidade de Terapia Intensiva, Hospital Geral do Grajaú - São Paulo (SP), Brasil
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27
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Typologies of Decision-Makers in the ICU: A Qualitative Study of Patients With Acute Respiratory Distress Syndrome and Sepsis and Their Surrogates. Crit Care Explor 2019; 1:e0011. [PMID: 32166257 PMCID: PMC7063965 DOI: 10.1097/cce.0000000000000011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To develop hypotheses of patient and surrogate's rationale for decision-making. Design We pursued a qualitative study of patients with acute respiratory distress syndrome or sepsis and their surrogates. Fourteen patients and 28 surrogates were given semistructured interviews while in the ICU and again 30 days later. The interviews focused on goal outcomes for the ICU stay and why a patient or surrogate would want a specific intervention (e.g., intubation and cardiopulmonary resuscitation). Setting ICU of tertiary care academic hospital. Patients Fourteen acute respiratory distress syndrome or sepsis patients and 28 of their surrogates. Interventions None. Measurements and Main Results Interviews were analyzed using grounded theory and the constant comparative method on NVivo 10.0 (QSR International, Melbourne, Australia). We identified the following four typologies of decision-making rationale: 1) "Timers"-determined decisions based on the length of time on life support; 2) "Natural Livers"-rejected interventions using a "machine"; 3) "Deferrers"-relied on physician for decision-making and prognosis; and 4) "Believers"-relied on a higher power for guidance. Conclusions Our hypothesized typologies need validation in a prospective observational trial. If validated, they may allow for better clinician communication.
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Scheunemann LP, Ernecoff NC, Buddadhumaruk P, Carson SS, Hough CL, Curtis JR, Anderson WG, Steingrub J, Lo B, Matthay M, Arnold RM, White DB. Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units. JAMA Intern Med 2019; 179:676-684. [PMID: 30933293 PMCID: PMC6503570 DOI: 10.1001/jamainternmed.2019.0027] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Little is known about whether clinicians and surrogate decision makers follow recommended strategies for shared decision making by incorporating intensive care unit (ICU) patients' values and preferences into treatment decisions. OBJECTIVES To determine how often clinicians and surrogates exchange information about patients' previously expressed values and preferences and deliberate and plan treatment based on these factors during conferences about prognosis and goals of care for incapacitated ICU patients. DESIGN, SETTING, AND PARTICIPANTS A secondary analysis of a prospective, multicenter cohort study of audiorecorded clinician-family conferences between surrogates and clinicians of 249 incapacitated, critically ill adults was conducted. The study was performed between October 8, 2009, and October 23, 2012. Data analysis was performed between July 2, 2014, and April 20, 2015. Patient eligibility criteria included lack of decision-making capacity, a diagnosis of acute respiratory distress syndrome, and predicted in-hospital mortality of 50% or more. In addition to the patients, 451 surrogates and 144 clinicians at 13 ICUs at 6 US academic and community medical centers were included. MAIN OUTCOMES AND MEASURES Two coders analyzed transcripts of audiorecorded conversations for statements in which clinicians and surrogates exchanged information about patients' treatment preferences and health-related values and applied them in deliberation and treatment planning. RESULTS Of the 249 patients, 134 (54.9%) were men; mean (SD) age was 58.2 (16.5) years. Among the 244 conferences that addressed a decision about goals of care, 63 (25.8%; 95% CI, 20.3%-31.3%) contained no information exchange or deliberation about patients' values and preferences. Clinicians and surrogates exchanged information about patients' values and preferences in 167 (68.4%) (95% CI, 62.6%-74.3%) of the conferences and specifically deliberated about how the patients' values applied to the decision in 108 (44.3%; 95% CI, 38.0%-50.5%). Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 87 (35.7%) or less of the conferences; surrogates provided a substituted judgment in 33 (13.5%); and clinicians made treatment recommendations based on patients' values and preferences in 20 conferences (8.2%). CONCLUSIONS AND RELEVANCE Most clinician-family conferences about prognosis and goals of care for critically ill patients appear to lack important elements of communication about values and preferences, with robust deliberation being particularly deficient. Interventions may be needed to better prepare surrogates for these conversations and improve clinicians' communication skills for eliciting and incorporating patients' values and preferences into treatment decisions.
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Affiliation(s)
- Leslie P Scheunemann
- Division of Geriatric Medicine and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Natalie C Ernecoff
- Department of Health Policy and Management, University of North Carolina at Chapel Hill
| | - Praewpannarai Buddadhumaruk
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shannon S Carson
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill
| | - Catherine L Hough
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Wendy G Anderson
- Palliative Care Program, University of California, San Francisco Medical Center, San Francisco.,Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco.,Department of Physiological Nursing, University of California, San Francisco School of Nursing, San Francisco
| | - Jay Steingrub
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Bernard Lo
- The Greenwall Foundation, New York, New York
| | - Michael Matthay
- Departments of Medicine and Anesthesia and Perioperative Care, University of California, San Francisco
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania.,Palliative and Supportive Institute, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania
| | - Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Loizeau AJ, Shaffer ML, Habtemariam DA, Hanson LC, Volandes AE, Mitchell SL. Association of Prognostic Estimates With Burdensome Interventions in Nursing Home Residents With Advanced Dementia. JAMA Intern Med 2018; 178:922-929. [PMID: 29813159 PMCID: PMC6033677 DOI: 10.1001/jamainternmed.2018.1413] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Prognostication in advanced dementia is challenging but may influence care. OBJECTIVES To determine the accuracy of proxies' prognostic estimates for nursing home residents with advanced dementia, identify factors associated with those estimates, and examine the association between their estimates and use of burdensome interventions. DESIGN, SETTING, AND PARTICIPANTS Data were combined from 2 studies that prospectively followed 764 residents with advanced dementia and their proxies in Boston-area nursing homes for 12 months: (1) the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia, conducted from September 2009 to November 2012 (362 resident/proxy dyads; 35 facilities); and (2) the Educational Video to Improve nursing home Care in End-Stage Dementia, conducted from March 2013 to July 2017 (402 resident/proxy dyads; 62 facilities). Proxies were the residents' formally or informally designated medical decision makers. MAIN OUTCOMES AND MEASURES During quarterly telephone interviews, proxies stated whether they believed the resident would live less than 1 month, 1 to 6 months, 7 to 12 months, or more than 12 months. Prognostic estimates were compared with resident survival. Resident and proxy characteristics associated with proxy prognostic estimates were determined. The association between prognostic estimates and whether residents experienced any of the following was determined: hospital transfers, parenteral therapy, tube feeding, venipunctures, and bladder catheterizations. RESULTS The residents' mean (SD) age was 86.6 (7.3) years; 631 (82.6%) were women and 133 (17.4%) were men. Of the 764 residents, 310 (40.6%) died later than 12 months. Proxies estimated survival with moderate accuracy (C statistic, 0.67). When proxies perceived the resident would die within 6 months, they were more likely to report being asked (183 [7.2%] of 2526) vs not being asked (126 [5.0%] of 2526) about goals of care by nursing home clinicians (adjusted odds ratio [AOR], 1.94; 95% CI, 1.50-2.52). Residents were less likely to experience burdensome interventions when the proxy prognostic estimate was less than 6 months (89 [4.4%] of 2031) vs greater than 6 months (1008 [49.6%] of 2031) (AOR, 0.46; 95% CI, 0.34-0.62). CONCLUSIONS AND RELEVANCE Proxies estimated the prognosis of nursing home residents with advanced dementia with moderate accuracy. Having been asked about their opinion about the goal of care was associated with the proxies' perception that the resident had less than 6 months to live and that perception was associated with a lower likelihood the resident experienced burdensome interventions.
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Affiliation(s)
- Andrea J Loizeau
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts.,University Research Priority Program, Dynamics of Healthy Aging, University of Zurich, Zurich, Switzerland
| | | | | | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research and School of Medicine, Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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30
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Zahuranec DB, Anspach RR, Roney ME, Fuhrel-Forbis A, Connochie DM, Chen EP, Thompson BB, Varelas PN, Morgenstern LB, Fagerlin A. Surrogate Decision Makers' Perspectives on Family Members' Prognosis after Intracerebral Hemorrhage. J Palliat Med 2018; 21:956-962. [PMID: 29608394 DOI: 10.1089/jpm.2017.0604] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surrogate communication with providers about prognosis in the setting of acute critical illness can impact both patient treatment decisions and surrogate outcomes. OBJECTIVES To examine surrogate decision maker perspectives on provider prognostic communication after intracerebral hemorrhage (ICH). DESIGN Semistructured interviews were conducted and analyzed qualitatively for key themes. SETTING/SUBJECTS Surrogate decision makers for individuals admitted with ICH were enrolled from five acute care hospitals. RESULTS Fifty-two surrogates participated (mean age = 54, 60% women, 58% non-Hispanic white, 13% African American, 21% Hispanic). Patient status at interview was hospitalized (17%), in rehabilitation/nursing facility (37%), deceased (38%), hospice (4%), or home (6%). Nineteen percent of surrogates reported receiving discordant prognoses, leading to distress or frustration in eight cases (15%) and a change in decision for potentially life-saving brain surgery in three cases (6%). Surrogates were surprised or confused by providers' use of varied terminology for the diagnosis (17%) (e.g., "stroke" vs. "brain hemorrhage" or "brain bleed") and some interpreted "stroke" as having a more negative connotation. Surrogates reported that physicians expressed uncertainty in prognosis in 37%; with physician certainty in 56%. Surrogate reactions to uncertainty were mixed, with some surrogates expressing a negative emotional response (e.g., anxiety) and others reporting understanding or acceptance of uncertainty. CONCLUSIONS Current practice of prognostic communication in acute critical illness has many gaps, leading to distress for surrogates and variability in critical treatment decisions. Further work is needed to limit surrogate distress and improve the quality of treatment decisions.
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Affiliation(s)
- Darin B Zahuranec
- 1 Stroke Program, Department of Neurology, Michigan Medicine , Ann Arbor, Michigan.,2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Renee R Anspach
- 3 Department of Sociology, University of Michigan College of Literature, Science, and the Arts, Ann Arbor, Michigan
| | - Meghan E Roney
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Andrea Fuhrel-Forbis
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Daniel M Connochie
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Emily P Chen
- 1 Stroke Program, Department of Neurology, Michigan Medicine , Ann Arbor, Michigan.,2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan
| | - Bradford B Thompson
- 4 Department of Neurology, Alpert Medical School at Brown University , Providence, Rhode Island.,5 Department of Neurosurgery, Alpert Medical School at Brown University , Providence, Rhode Island
| | - Panayiotis N Varelas
- 6 Department of Neurology and Neurosurgery, Henry Ford Hospital , Detroit, Michigan
| | - Lewis B Morgenstern
- 1 Stroke Program, Department of Neurology, Michigan Medicine , Ann Arbor, Michigan.,7 Department of Epidemiology, University of Michigan School of Public Health , Ann Arbor, Michigan.,8 Department of Emergency Medicine, Michigan Medicine , Ann Arbor, Michigan
| | - Angela Fagerlin
- 2 Center for Bioethics and Social Sciences in Medicine , Michigan Medicine, Ann Arbor, Michigan.,9 Department of Population Health Sciences, University of Utah School of Medicine , Salt Lake City, Utah.,10 Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS) , Salt Lake City, Utah
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Yuen EYN, Knight T, Ricciardelli LA, Burney S. Health literacy of caregivers of adult care recipients: A systematic scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:e191-e206. [PMID: 27426731 DOI: 10.1111/hsc.12368] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/13/2016] [Indexed: 06/06/2023]
Abstract
Caregivers play a vital role in providing support to adults with a chronic condition, or cognitive or physical impairment. Low health literacy in caregivers has the potential to impact adequate care provision, and consequently, care recipient health outcomes. The aim of the study was to systematically review literature related to health literacy of caregivers of adult care recipients, and examine its relationship with care recipient, and caregiver, health outcomes. Electronic databases were searched for relevant English-language publications that assessed health literacy in caregivers. Included studies were abstracted into evidence tables and assessed using an eight-item quality scale. The search identified 2717 new titles and abstracts, with 67 shortlisted for full review. Twelve papers from 2003 to 2015 met the inclusion criteria. The prevalence of limited health literacy in caregivers ranged from 0% to 52.5% depending on the measure and cut-off criteria used. Associations were found between low caregiver health literacy and (i) poorer care recipient self-management behaviours; (ii) increased care recipient use of health services; and (iii) increased caregiver burden. The quality of the studies ranged from fair to excellent. Low health literacy in caregivers differed depending on the measures and scoring criteria used. Evidence to support the relationship between caregiver health literacy and care recipient, and caregiver health outcomes was limited to single studies. Recommendations for further research include: the development of caregiver health literacy measures across different populations; examination of associations between caregiver health literacy and care recipient outcomes; and the development of interventions designed to improve caregiver health literacy.
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Affiliation(s)
- Eva Y N Yuen
- School of Psychology, Deakin University, Burwood, Victoria, Australia
- College of Public Health, Temple University, Philadelphia, Pennsylvania, USA
| | - Tess Knight
- School of Psychology, Deakin University, Burwood, Victoria, Australia
| | | | - Susan Burney
- School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
- Szalmuk Family Psycho-oncology Unit, Cabrini Health, Malvern, Victoria, Australia
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Clinician Perspectives on an Electronic Portal to Improve Communication with Patients and Families in the Intensive Care Unit. Ann Am Thorac Soc 2018; 13:2197-2206. [PMID: 27700144 DOI: 10.1513/annalsats.201605-351oc] [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] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Communication in the intensive care unit (ICU) often falls short of patient and family needs, putting them at risk for significant physical and emotional harm. As electronic patient portals rapidly evolve, one designed specifically for the ICU might potentially enhance communication among patients, family members, and clinicians; however, the views of frontline ICU staff on such technology are unknown. OBJECTIVES To identify clinician perspectives on the current state of communication among patients, families, and clinicians in the ICU, and assess their views on whether and how an electronic portal may address existing communication deficits and improve care. METHODS Three focus groups comprised altogether of 26 clinicians from 6 ICUs, representing several disciplines in an academic medical center in Boston, Massachusetts. Transcripts were analyzed inductively for major themes using grounded theory. MEASUREMENTS AND MAIN RESULTS We identified seven themes reflecting clinician perspectives on communication challenges and desired portal functionality: (1) comprehension and literacy; (2) results and updates; (3) patient and family preferences; (4) interclinician communication; (5) family informational needs; (6) the ICU as an unfamiliar environment; and (7) enhancing humanism through technology. Each theme included current gaps in practice, potential benefits and concerns related to an ICU communication portal, and participant recommendations. Benefits included enhanced education, patient/family engagement, and clinician workflow. Challenges included the stress and uncertainty of ICU care, fear of technology replacing human connection, existing interclinician communication failures, and the tension between informing families without overwhelming them. CONCLUSIONS Overall, clinicians were cautiously supportive of an electronic portal to enhance communication in the ICU and made several specific recommendations for design and implementation. As new technologies expand opportunities for greater transparency and participation in care, clinician buy-in and positive impact will depend, in large part, on the extent to which the concerns of stakeholders are addressed. At the same time, clinicians anticipate several potential benefits that could help support provider workflow and engage patients and families through enhanced communication and humanism.
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Douglas SL, Daly BJ, Lipson AR. Differences in Predictions for Survival and Expectations for Goals of Care between Physicians and Family Surrogate Decision Makers of Chronically Critically Ill Adults. RESEARCH & REVIEWS. JOURNAL OF NURSING AND HEALTH SCIENCES 2017; 3:74-84. [PMID: 29911208 PMCID: PMC6003707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to determine the accuracy and concordance between physicians (MDs) and family surrogate decision makers (FSDMs) in predicting 3 month post-hospital patient mortality and concordance in identifying patient goals of care. A prospective cohort study was conducted in 3 intensive care units (ICUs). Two-hundred and sixty-four FSDMs and 54 attending MDs of patients who had resided in the ICU for >3 days were enrolled in the study. Expectation for mortality was measured dichotomously and goals of care were measured using a continuous visual analog scale. A value of 50 represented equal weight placed on goals of survival and QOL. Both MDs and FSDMs had mortality predictions that were lower than actual mortality. For MDs and FSDMs, their mortality predictions were most accurate at study enrollment. Discordance between MD and FSDM goals of care ranged from 36.4% at enrollment to 55.4% 15 days later (p=0.003). Our findings of optimistic prognosis for survival are consistent with the work of others. Our high rate of discordance regarding goals of care provided support for the need to establish standard processes to assure that values of patients and families are solicited and incorporated into treatment discussions for long-stay ICU patients.
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Affiliation(s)
| | | | - Amy R Lipson
- For Correspondence: Lipson AR, Senior Research Associate at the FPB School of Nursing, Case Western Reserve University, 10900 Euclid Ave Cleveland, Ohio 44106, United States, Tel: 216-368-3107;
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34
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Schuster M, Ferner M, Bodenstein M, Laufenberg-Feldmann R. [Palliative therapy concepts in intensive care medicine]. Anaesthesist 2017; 66:233-239. [PMID: 28378133 DOI: 10.1007/s00101-017-0294-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Involvement of palliative care is so far not common practice for critically ill patients on surgical intensive care units (ICUs) in Germany. The objectives of palliative care concepts are improvement of patient quality of life by relief of disease-related symptoms using an interdisciplinary approach and support of patients and their relatives considering their current physical, psychological, social and spiritual needs. The need for palliative care can be identified via defined screening criteria. Integration of palliative care can either be realized using a consultative model which focusses on involvement of palliative care consultants or an integrative model which embeds palliative care principles into the routine daily practice by the ICU team. Early integration of palliative care in terms of advance care planning (ACP) can lead to an increase in goals of care discussions and quality of life as well as a decrease of mortality and length of stay on the ICU. Moreover, stress reactions of relatives and ICU staff can be reduced and higher satisfaction with therapy can be achieved. The core of goal of care discussions is professional and well-structured communication between patients, relatives and staff. Consideration of palliative care principles by model-based integration into ICU practice can improve complex intensive care courses of disease in a productive but dignified way without neglecting curative attempts.
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Affiliation(s)
- M Schuster
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - M Ferner
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - M Bodenstein
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - R Laufenberg-Feldmann
- Klinik für Anästhesiologie, Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
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Turnbull AE, Chessare CM, Coffin RK, Needham DM. A brief intervention for preparing ICU families to be proxies: A phase I study. PLoS One 2017; 12:e0185483. [PMID: 28968409 PMCID: PMC5624606 DOI: 10.1371/journal.pone.0185483] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 09/13/2017] [Indexed: 11/19/2022] Open
Abstract
Background Family members of critically ill patients report high levels of conflict with clinicians, have poor understanding of prognosis, struggle to make decisions, and experience substantial symptoms of anxiety, depression, and post-traumatic stress regardless of patient survival status. Efficient interventions are needed to prepare these families to act as patient proxies. Objectives To assess a brief “patient activation” intervention designed to set expectations and prepare families of adult intensive care unit (ICU) patients to communicate effectively with the clinical team. Design Phase I study of acceptability and immediate side effects. Setting and participants 122 healthcare proxies of 111 consecutive patients with a stay of ≥24 hours in the Johns Hopkins Hospital Medical ICU (MICU), in Baltimore, Maryland. Intervention Reading aloud to proxies from a booklet (Flesch-Kincard reading grade level 3.8) designed with multidisciplinary input including from former MICU proxies. Results Enrolled proxies had a median age of 51 years old with 83 (68%) female, and 55 (45%) African-American. MICU mortality was 18%, and 37 patients (33%) died in hospital or were discharged to hospice. Among proxies 98% (95% CI: 94% - 100%) agreed or strongly agreed that the intervention was appropriate, 98% (95% CI: 92% - 99%) agreed or strongly agreed that it is important for families to know the information in the booklet, and 54 (44%, 95% CI 35%– 54%) agreed or strongly agreed that parts of the booklet are upsetting. Upset vs. non-upset proxies were not statistically or substantially different in terms of age, sex, education level, race, relation to the patient, or perceived decision-making authority. Conclusions This patient activation intervention was acceptable and important to nearly all proxies. Frequently, the intervention was simultaneously rated as both acceptable/important and upsetting. Proxies who rated the intervention as upsetting were not identifiable based on readily available proxy or patient characteristics.
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Affiliation(s)
- Alison E. Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Caroline M. Chessare
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Rachel K. Coffin
- Medical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
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Burelli G, Berthelier C, Vanacker H, Descaillot L, Philippon-Jouve B, Fabre X, Kaaki M, Chakarian JC, Domine A, Beuret P. Impact of a visual aid on discordance between physicians and family members about prognosis of critically ill patients. Anaesth Crit Care Pain Med 2017; 37:207-210. [PMID: 28790009 DOI: 10.1016/j.accpm.2017.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/04/2017] [Accepted: 05/26/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to evaluate the impact of a visual aid on the discordance about prognosis between physicians and family members. METHODS The study was performed in a general intensive care department with two 6-bed units. In the unit A, family members could consult a visual aid depicting day by day the evolution of global, hemodynamic, respiratory, renal and neurological conditions of the patient on a 10-point scale. In the unit B, they only received oral medical information. On day 7 of the ICU stay, the physician and family members estimated the prognosis of the patient among four proposals (life threatened; steady state but may worsen; steady state, should heal; will heal). Then we compared the rate of discordance about prognosis between physicians and family members in the two units. RESULTS Seventy-nine consecutive patients admitted in the intensive care department and still present at day 7, their family members and physicians, were enrolled. Patients in the two units were comparable in age, sex ratio, reason for admission, SAPS II at admission and SOFA score at day 7. In the unit A, physician-family members discordance about prognosis occurred for 12 out of 39 patients (31%) vs. 22 out of 40 patients (55%) in the unit B (P=0.04). CONCLUSION In our study, adding a visual aid depicting the evolution of the condition of critically ill patients day by day to classic oral information allowed the family to have an estimate of the prognosis less discordant with the estimate of the physician.
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Affiliation(s)
- Gabrielle Burelli
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | - Chloé Berthelier
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | - Hélène Vanacker
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | - Léonard Descaillot
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | | | - Xavier Fabre
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | - Mahmoud Kaaki
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | - Jean-Charles Chakarian
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | - Alexandre Domine
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
| | - Pascal Beuret
- Service de Réanimation, Centre Hospitalier Roanne, 28, rue de Charlieu, 42328 Roanne, France.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1917] [Impact Index Per Article: 273.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Turnbull AE, Hashem MD, Rabiee A, To A, Chessare CM, Needham DM. Evaluation of a strategy for enrolling the families of critically ill patients in research using limited human resources. PLoS One 2017; 12:e0177741. [PMID: 28542632 PMCID: PMC5444627 DOI: 10.1371/journal.pone.0177741] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/02/2017] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Clinical trials of interventions aimed at the families of intensive care unit (ICU) patients have proliferated but recruitment for these trials can be challenging. OBJECTIVES To evaluate a strategy for recruiting families of patients currently being treated in an ICU using limited human resources and time-varying daily screening over 7 consecutive days. METHODS We screened the Johns Hopkins Hospital medical ICU census 7 days per week to identify eligible family members. We then made daily, in-person attempts to enroll eligible families during a time-varying 2-hour enrollment period until families declined participation, consented, or were no longer eligible. MEASUREMENTS AND MAIN RESULTS The primary outcome was the proportion of eligible patients for whom ≥1 family member was enrolled. Secondary outcomes included enrollment of legal healthcare proxies, the consent rate among families approached for enrollment, and success rates for recruiting at different times during the day and week. Among 284 eligible patients, 108 (38%, 95% CI 32%-44%) had ≥1 family member enrolled, and 75 (26%, 95% CI 21%-32%) had their legal healthcare proxy enrolled. Among 117 family members asked to participate, 108 (92%, 95% CI 86%-96%) were enrolled. Patients with versus without an enrolled proxy were more likely to be white (44% vs. 30%, P = .02), live in a zip code with a median income of ≥$100,000 (15% vs. 5%, P = .01), be mechanically ventilated (63% vs. 47%, P = .01), die in the ICU (19% vs. 9%, P = .03), and to have longer ICU stays (median 5.0 vs. 1.8 days, P<.001). Day of the week and time of day were not associated with family presence in the ICU or consent rate. CONCLUSIONS Family members were recruited for more than one third of eligible patients, and >90% of approached consented to participate. There are important demographic differences between patients with vs without an enrolled family member.
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Affiliation(s)
- Alison E. Turnbull
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Mohamed D. Hashem
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Cleveland Clinic, Department of Medicine, Cleveland, Ohio, United States of America
| | - Anahita Rabiee
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - An To
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Caroline M. Chessare
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3758] [Impact Index Per Article: 536.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Preferences of Current and Potential Patients and Family Members Regarding Implementation of Electronic Communication Portals in Intensive Care Units. Ann Am Thorac Soc 2016; 13:391-400. [PMID: 26700656 DOI: 10.1513/annalsats.201509-638oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE The quality of communication with patients and family members in intensive care units (ICUs) is a focus of current interest for clinical care improvement. Electronic communication portals are commonly used in other healthcare settings to improve communication. We do not know whether patients and family members desire such portals in ICUs, and if so, what functionality they should provide. OBJECTIVES To define interest in and desired elements of an electronic communication portal among current and potential ICU patients and their family members. METHODS We surveyed, via an Internet panel, 1,050 English-speaking adults residing in the United States with a personal or family history of an ICU admission within 10 years (cohort A) and 1,050 individuals without a history of such admission (cohort B). We also administered a survey instrument in person to 105 family members of patients currently admitted to ICUs at an academic medical center in Boston (cohort C). MEASUREMENTS AND MAIN RESULTS Respondents, especially current ICU family members, supported an electronic communication portal, including access via an electronic tablet. They wanted at least daily updates, one-paragraph summaries of family meetings including a list of key decisions made, and knowledge of the role and experience of treating clinicians. Overall, they preferred detailed rather than "big picture" information. Respondents were generally comfortable sharing information with their family members. Preferences regarding a communication portal varied significantly by age, sex, ethnicity, and prior experience with ICU hospitalization. CONCLUSIONS Electronic communication portals appear welcome in contemporary ICUs. Frequent updates, knowledge about the professional qualifications of clinicians, detailed medical information, and documentation of family meetings are particularly desired.
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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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Prior Advance Care Planning Is Associated with Less Decisional Conflict among Surrogates for Critically Ill Patients. Ann Am Thorac Soc 2016; 12:1528-33. [PMID: 26240996 DOI: 10.1513/annalsats.201504-253oc] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Although numerous studies have documented that family members in intensive care units struggle with end-of-life decisions for incapacitated patients, there is little information about whether prior advance care planning lessens the burden of decision making. OBJECTIVES We sought to measure decisional conflict in surrogates of critically ill patients and to examine whether prior advance care planning is associated with less decisional conflict. METHODS We performed a secondary data analysis of a multicenter, prospective cohort study done at five U.S. academic medical centers that included 471 surrogates of 257 patients with acute respiratory distress syndrome. The main outcome was surrogates' burden of decision making as measured using the Decisional Conflict Scale. Surrogates completed a questionnaire item addressing whether they had had any prior advance care planning conversations with their loved ones. We used multilevel linear regression modeling to measure the association between decisional conflict and advance care planning. MEASUREMENTS AND MAIN RESULTS Moderate or high levels of decisional conflict (Decisional Conflict Scale score≥25) were present in 48% of surrogates. After adjusting for potential confounders, surrogates who had engaged in prior advance care planning conversations had significantly lower levels of decisional conflict than those who had not (mean score 3.3 points lower on the Decisional Conflict Scale; 95% confidence interval, -6.4 to -0.2; P=0.03). CONCLUSIONS Nearly half of surrogates for critically ill patients have moderate or high levels of decisional conflict. Prior advance care planning was associated with less decisional conflict. These results suggest that the scope of the benefit of advance care planning may extend beyond respecting patients' wishes to also ameliorating the burden on patients' loved ones who act as surrogates.
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Weinert C. Giving Doctors' Daily Progress Notes to Hospitalized Patients and Families to Improve Patient Experience. Am J Med Qual 2016; 32:58-65. [PMID: 26453323 DOI: 10.1177/1062860615610424] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hospital quality includes excellent physician-patient communication. The objective was to determine effects of distributing physicians' notes to patients. Hospitalized patients or family members on 6 wards at a university hospital received daily a printed copy of their medical team's progress note. Surveys were completed about the benefits and adverse effects of reading the physician notes. In all, 74% to 86% of patients or family members responded favorably that receiving doctors' notes improved understanding of their health condition or gave them more control over their hospital course. Patient concerns about privacy or offense were uncommon, although 16% thought notes were confusing or caused worry. Note distribution had minor effects on physician note writing practice. Having patients and family members read their physicians' progress notes is feasible and enhances patients' understanding of their diagnostic and treatment plan. Notes supplement traditional physician-patient verbal communication practice and have the potential to improve the hospitalized patient experience.
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Akahoshi T, Yasuda M, Momii K, Kubota K, Shono Y, Kaku N, Tokuda K, Nagata T, Yoshizumi T, Shirabe K, Hashizume M, Maehara Y. Sarcopenia is a predictive factor for prolonged intensive care unit stays in high-energy blunt trauma patients. Acute Med Surg 2016; 3:326-331. [PMID: 29123807 DOI: 10.1002/ams2.195] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 01/08/2016] [Indexed: 01/07/2023] Open
Abstract
Aim Sarcopenia has been increasingly reported as a prognostic factor for outcome in settings such as cirrhosis, liver transplantation, and emergent surgery. We aimed to elucidate the significance of sarcopenia in severe blunt trauma patients. Methods We retrospectively analyzed 84 patients emergently admitted to the intensive care unit at Kyushu University Hospital (Fukuoka, Japan) from May 2012 to April 2015. We assessed the amount of skeletal muscle present according to computed tomography and its relevance to ventilation-free days, patients' length of stay in the intensive care unit, and 28-day mortality. Results Twenty-five (29.7%) patients were defined as sarcopenic. Sixteen (19.7%) patients required 15 days or more in the intensive care unit. The major reason was a prolonged ventilation requirement due to flail chest (n = 7) or pneumonia (n = 3). Sarcopenic patients' stays in intensive care were significantly longer than those of non-sarcopenic patients (18.7 versus 6.4 days, respectively; P < 0.001). Univariate and multivariate analyses showed sarcopenia to be a significant risk factor for prolonged intensive care unit stay. Conclusion Sarcopenia is a risk factor that predicts prolonged intensive care unit stay in high-energy blunt trauma patients.
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Affiliation(s)
- Tomohiko Akahoshi
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan.,Disaster and Emergency Medicine Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Mitsuhiro Yasuda
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kenta Momii
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kensuke Kubota
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Yuji Shono
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Noriyuki Kaku
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kentaro Tokuda
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Takashi Nagata
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan.,Disaster and Emergency Medicine Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Tomoharu Yoshizumi
- Surgery and Science Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Ken Shirabe
- Surgery and Science Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Makoto Hashizume
- Disaster and Emergency Medicine Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
| | - Yoshihiko Maehara
- Emergency and Critical Care Center Graduate School of Medical Sciences, Kyushu University Fukuoka Japan.,Surgery and Science Graduate School of Medical Sciences, Kyushu University Fukuoka Japan
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Bjørshol CA, Sollid S, Flaatten H, Hetland I, Mathiesen WT, Søreide E. Great variation between ICU physicians in the approach to making end-of-life decisions. Acta Anaesthesiol Scand 2016; 60:476-84. [PMID: 26941116 DOI: 10.1111/aas.12640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/07/2015] [Accepted: 09/11/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting. METHODS The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities. RESULTS In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%. CONCLUSION There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training.
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Affiliation(s)
- C. A. Bjørshol
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - S. Sollid
- Department of Research and Development; Norwegian Air Ambulance Foundation; Drøbak Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
| | - H. Flaatten
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Anaesthesiology and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - I. Hetland
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
| | - W. T. Mathiesen
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
| | - E. Søreide
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
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Ernecoff NC, Witteman HO, Chon K, Chen YI, Buddadhumaruk P, Chiarchiaro J, Shotsberger KJ, Shields AM, Myers BA, Hough CL, Carson SS, Lo B, Matthay MA, Anderson WG, Peterson MW, Steingrub JS, Arnold RM, White DB. Key stakeholders' perceptions of the acceptability and usefulness of a tablet-based tool to improve communication and shared decision making in ICUs. J Crit Care 2016; 33:19-25. [PMID: 27037049 DOI: 10.1016/j.jcrc.2016.01.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 01/10/2016] [Accepted: 01/10/2016] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Natalie C Ernecoff
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Holly O Witteman
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada; Office of Education and Continuing Professional Development, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Research Centre of the CHU de Québec, Quebec City, Quebec, Canada
| | - Kristen Chon
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yanquan Iris Chen
- Human-Computer Interaction Institute, Carnegie Mellon University, Pittsburgh, PA
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jared Chiarchiaro
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Anne-Marie Shields
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Brad A Myers
- Human-Computer Interaction Institute, Carnegie Mellon University, Pittsburgh, PA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA
| | - Shannon S Carson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Wendy G Anderson
- Department of Medicine and Division of Hosiptal Medicine and Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Michael W Peterson
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Jay S Steingrub
- Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, Massachusetts and Tufts University School of Medicine, Boston, MA
| | - Robert M Arnold
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Douglas B White
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Cai X, Robinson J, Muehlschlegel S, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units. Neurocrit Care 2015; 23:131-41. [PMID: 25990137 PMCID: PMC4816524 DOI: 10.1007/s12028-015-0149-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.
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Affiliation(s)
- Xuemei Cai
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
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Bakitas M, Dionne-Odom JN, Kamal A, Maguire JM. Priorities for Evaluating Palliative Care Outcomes in Intensive Care Units. Crit Care Nurs Clin North Am 2015; 27:395-411. [PMID: 26333759 DOI: 10.1016/j.cnc.2015.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Defining the quality of intensive care unit (ICU) care when patients are dying is challenging. Palliative care has been recommended to improve outcomes of dying ICU patients; however, traditional ICU quality indicators do not always align with palliative care. Evidence suggests that some aspects of ICU care improve when palliative care is integrated; however, consensus is lacking concerning the outcomes that should be measured. Overcoming challenges to measuring palliative care will require consensus development and rigorous research on the best way to evaluate ICU palliative care services.
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Affiliation(s)
- Marie Bakitas
- School of Nursing, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, NB 2M019C, 1701 University Boulevard, Birmingham, AL 35233, USA.
| | - J Nicholas Dionne-Odom
- School of Nursing, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, NB 2M019C, 1701 University Boulevard, Birmingham, AL 35233, USA
| | - Arif Kamal
- Division of Medical Oncology, Duke Palliative Care, Duke Clinical Research Institute, Duke University, 2400 Pratt Street, #8043, Durham, NC 27710, USA
| | - Jennifer M Maguire
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina - Chapel Hill, Bioinformatics Building, Suite 4124, Campus Box 7020, Chapel Hill, NC 27599, USA
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Measuring "quality": what do patient- and surrogate-perceived assessments of communication actually mean? Crit Care Med 2015; 43:700-1. [PMID: 25700054 DOI: 10.1097/ccm.0000000000000760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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