Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study

Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review

BACKGROUND

Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them.

AIM

The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies.

DESIGN

Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies.

METHODS

Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions.

RESULTS

Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity.

CONCLUSION

Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.

Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study

BACKGROUND

Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values.

AIM

To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI.

METHODS

A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality.

RESULTS

1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001).

CONCLUSION

The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.

Interprofessional interventions and factors that improve end-of-life care in intensive care units: An integratory review

INTRODUCTION

The changes in health dynamics, caused by the SARS-COVD-2 pandemic and its consequences, generated a greater need to integrate palliative care in the ICU to promote a dignified death.

OBJECTIVE

Identify interprofessional interventions and factors that improve the care of patients at the end of life.

METHODOLOGY

Integrative review, including experimental, quasi-experimental, observational, analytical, and descriptive studies with correlation of variables, published from 2010 to 2021, identified in COCHRANE, CINAHL, CUIDEN, LILACS, SCIELO, Dialnet, PsychInfo, PubMed, PROQUES, PSYCHOLOGY, JOURNALS, SCIENCEDIRECT, with MeSH/DECS terms: "Critical Care", "IntensiveCare" "Life support care", "Palliative care", "Life Quality", "Right to die". 36,271 were identified, after excluding duplicate title, abstract, year of publication, design, theme, methodological quality, objectives, and content, 31 studies were found.

RESULTS

It included 31 articles, 16.7% experimental, 3.3% quasi-experimental, 80% observational, analytical, and descriptive with correlation of variables, 38% published in the United States, 38%, and 19% in Brazil. The pooled sample was 24,779 participants. 32.2% of the studies had level of evidence 1 recommendation (c), and 25.8% level of evidence 2 recommendation (c). This paper synthesises evidence to promote Interprofessional Collaborative Practice in the ICU, improve end-of-life care, and interventions to achieve established therapeutic goals, implement effective care policies, plans, and programmes for critically ill patients and their families; factors that affect palliative care and improve with training and continuing education for health personnel.

CONCLUSION

There are interventions to manage physical and emotional symptoms, training strategies and emotional support aimed at health personnel and family members to improve the quality of death and reduce stays in the ICU. The interdisciplinary team requires training on palliative and end-of-life care to improve care.

Prevalence and long-term outcomes of patients with life-limiting illness admitted to intensive care units in Australia and New Zealand

Objective

Determine the prevalence and outcomes of patients with life-limiting illness (LLI) admitted to Australian and New Zealand Intensive Care Units (ICUs).

Design setting participants

Retrospective registry-linked observational cohort study of all adults admitted to Australian and New Zealand ICUs from 1st January 2018 until 31st December 2020 (New Zealand) and 31st March 2022 (Australia), recorded in the Australian and New Zealand Intensive Care Society Adult Patient Database.

Main outcome measures

The primary outcome was 1-year mortality. Secondary outcomes included ICU and hospital mortality, ICU and hospital length of stay, and 4-year survival.

Results

A total of 566,260 patients were included, of whom 129,613 (22.9%) had one or more LLI. Mortality at one year was 28.1% in those with LLI and 10.4% in those without LLI (p < 0.001). Mortality in intensive care (6.8% v 3.4%, p < 0.001), hospital (11.8% v 5.0%, p < 0.001), and at two (36.6% v 14.1%, p < 0.001), three (43.7% v 17.7%, p < 0.001) and four (55.6% v 24.5%, p < 0.001) years were all higher in the cohort of patients with LLI. Patients with LLI had a longer ICU (1.9 [0.9, 3.7] v 1.6 [0.9, 2.9] days, p < 0.001) and hospital length of stay (8.8 [49,16.0] v 7.2 [3.9, 12.9] days, p < 0.001), and were more commonly readmitted to ICU during the same hospitalisation than patients without LLI (5.2% v 3.7%, p < 0.001). After multivariate analysis the LLI with the strongest adverse effect on survival was frailty (HR 2.08, 95% CI 2.03 to 2.12, p < 0.001), followed by the presence of metastatic cancer (HR 1.97, 95% CI 1.92 to 2.02, p < 0.001), and chronic liver disease (HR 1.65, 95% CI 1.65 to 1.71, p < 0.001).

Conclusion

Patients with LLI account for almost a quarter of ICU admissions in Australia and New Zealand, require prolonged ICU and hospital care, and have high mortality in subsequent years. This knowledge should be used to identify this vulnerable cohort of patients, and to ensure that treatment is aligned to each patient's values and realistic goals.

Interprofessional Interventions to Improve Serious Illness Communication in the Intensive Care Unit: A Scoping Review

Serious illness communication is fundamental to the provision of quality care for patients in the intensive care unit (ICU). Evidence suggests that including interprofessional team members in such communication is beneficial. This scoping review--conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines-maps existing evidence regarding interprofessional interventions to improve serious illness communication in the ICU. The review yielded 14 studies for inclusion, which were organized by 3 thematic categories of strategies implemented: training curriculum, scheduled meetings, and liaison role. Most used a combination of intervention strategies. Outcome measures varied across the studies but could be broadly categorized as patient/family-focused, provider-focused, or systems-focused. Great heterogeneity between studies exists. More research is needed.

iValidate: a communication-based clinical intervention in life-limiting illness

OBJECTIVES

Report the implementation, user evaluation and key outcome measures of an educational intervention-the iValidate educational programme-designed to improve engagement in shared decision-making by health professionals caring for patients with life-limiting illness (LLI).

DESIGN

Prospective, descriptive, cohort study.

PARTICIPANTS

Health professionals working in acute care settings caring for patients with an LLI.

MAIN OUTCOMES MEASURED

Participant evaluation of learning outcomes for communication skills and shared decision-making; demographic data of participants attending education workshops; and documentation of patients with LLI goals of management, including patient values and care decision based on area in acute care and seniority of doctor.

RESULTS

The programme was well accepted by participants. Participant evaluations demonstrated self-reported improved confidence in the areas of patient identification, information gathering to ascertain patient values and shared decision-making. There was strong agreement with the course-enhanced knowledge of core communication skills and advanced skills such as discussing mismatched agendas.

CONCLUSIONS

We described the educational pedagogy, implementation and key outcome measures of the iValidate education programme, an intervention designed to improve person-centred care for patients with an LLI. A targeted education programme could produce cultural and institutional change for vulnerable populations within a healthcare institution. A concurrent research programme suggests effectiveness within the current service and the potential for transferability.

The false dichotomy of surgical futility in the emergency laparotomy setting: scoping review

BACKGROUND

Futile is defined as 'the fact of having no effect or of achieving nothing'. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This scoping review aimed to identify key concepts around surgical futility as it relates to emergency laparotomy.

METHODS

Using the Arksey and O'Malley framework, a scoping review was conducted. A search of the Cochrane Library, Google Scholar, MEDLINE, and Embase was performed up until 1 November 2021 to identify literature relevant to the topic of futility in emergency laparotomy.

RESULTS

Three cohort studies were included in the analysis. A total of 105 157 patients were included, with 1114 patients reported as futile. All studies were recent (2019 to 2020) and focused on the principle of quantitative futility (assessment of the probability of death after surgery) within a timeline after surgery: two defining futility as death within 48 hours of surgery and one as death within 72 hours. In all cases this was derived from a survival histogram. Predictors of defined futile procedures included age, level of independence prior to admission, surgical pathology, serum creatinine, arterial lactate, and pH.

CONCLUSION

There remains a paucity of research defining, exploring, and analysing futile surgery in patients undergoing emergency laparotomy. With limited published work focusing on quantitative futility and the binary outcome of death, research is urgently needed to explore all principles of futility, including the wishes of patients and their families.

Values, preferences and goals identified during shared decision making between critically ill patients and their doctors

Objective: Examine values, preferences and goals elicited by doctors following goals-of-care (GOC) discussions with critically ill patients who had life-limiting illnesses. Design: Descriptive qualitative study using four-stage latent content analysis. Setting: Tertiary intensive care unit (ICU) in South Western Victoria. Participants: Adults who had life-limiting illnesses and were admitted to the ICU with documented GOC, between October 2016 and July 2018. Intervention: The iValidate program, a shared decision-making clinical communication education and clinical support program, for all ICU registrars in August 2015. Main outcome measures: Matrix of themes and subthemes categorised into values, preferences and goals. Results: A total of 354 GOC forms were analysed from 218 patients who had life-limiting illnesses and were admitted to the ICU. In the categories of values, preferences and goals, four themes were identified: connectedness and relational autonomy, autonomy of decision maker, balancing quality and quantity of life, and physical comfort. The subthemes - relationships, sense of place, enjoyment of activities, independence, dignity, cognitive function, quality of life, longevity and physical comfort - provided a matrix of issues identified as important to patients. Relationship, place, independence and physical comfort statements were most frequently identified; longevity was least frequently identified. Conclusion: Our analysis of GOC discussions between medical staff and patients who had life-limiting illnesses and were admitted to the ICU, using a shared decision-making training and support program, revealed a framework of values, preferences and goals that could provide a structure to assist clinicians to engage in shared decision making.

Don't forget shared decision-making in the COVID-19 crisis

Mechanical ventilation as a resource is limited and may lead to poor outcomes in at‐risk populations. Critical care supports may not be preferred by those at risk of deterioration in the COVID‐19 setting. Patient‐centred communication and shared decision‐making should continue to remain central to clinical practice.

Challenges for nurses when communicating with people who have life-limiting illness and their families: A focus group study

AIMS AND OBJECTIVES

The proposed study aimed to answer the following question: What communication issues do nurses find challenging when caring for people with life-limiting illness?

BACKGROUND

Evidence suggests that attitudes, skills and knowledge about how nurses communicate effectively with patients and their families could be improved. However, the literature predominantly focuses on nurses working in oncology and the medical profession.

DESIGN

A qualitative descriptive design was used.

METHODS

Focus groups were conducted with 39 nurses from three wards within a regional healthcare organisation in Victoria, Australia. Data were analysed using thematic content analysis. The COREQ checklist was used to document reporting of the study.

RESULTS

In their view, nurses have the potential to develop a strong bond with patients and their families. Three key themes were identified: (a) feeling unskilled to have difficult conversations with patients who have life-limiting illness; (b) interacting with family members adds complexity to care of patients who have life-limiting illness; and (c) organisational factors impede nurses' capacity to have meaningful conversations with patients and their families.

CONCLUSIONS

Caring for individuals with life-limiting illness is complex and often occurs in an emotionally charged environment. However, nurses report being hampered by time restraints and lack of information about the patient's condition and goals of care. Limitations in conversation structure and a comprehensive range of core communication skills affect their ability to confidently engage in conversations, particularly when they are responding to prognostic questions.

RELEVANCE TO CLINICAL PRACTICE

Whilst nurses are responsible for performing technical skills, they can maximise care by developing a trusting relationship with patients and their relatives. Increased acuity limits the time nurses have to talk with patients. In addition, they lack confidence to deal with difficult questions. Specific training may increase nurses' confidence and efficiency when communicating with patients and their families.

Patients with life-limiting illness presenting to the emergency department

OBJECTIVE

To examine characteristics, outcomes and flow for patients over the age of 45 years with a life-limiting illness (LLI) presenting to a regional ED.

METHODS

Retrospective, observational cohort study of patients with LLI in an Australian regional ED over a 15-day period. Eligible patients were 45 years of age or older who fulfilled criteria for having an LLI. Data included demographics, diagnosis for current presentation, presence of advance care documentation, LLI category, admission and discharge destination from ED, ED and hospital length of stay and outcome for patients admitted to the acute hospital.

RESULTS

A total of 152 (12%) patients had an LLI. The LLI group were older, had a significantly longer median length of stay in the ED (5.9 [interquartile range 4.0-8.4] vs 3.9 h [interquartile range 2.5-6.3], P < 0.0001) and were less likely to leave the ED within 4 h (26% vs 51.5%, P < 0.0001). Forty-six percent of patients with an LLI had some form of advanced care documentation. Patients with an LLI were more likely to require hospital admission. In relation to illness trajectory, the frailty/dementia trajectory group had comparatively the longest ED length of stay with less than 10% leaving the ED within 4 h. This group were more likely to be discharged to a residential care facility.

CONCLUSION

A significant proportion of patients 45 years or older had an LLI which had implications for their length of ED stay and discharge destination.

The "sphere of care": A qualitative study of colorectal cancer patient and caregiver experiences of support within the cancer treatment setting

Introduction

Colorectal cancer is associated with considerable physical and psychosocial burden. Whilst social support is known to facilitate psychological adjustment to cancer, patients’ and caregivers’ experiences of social support within a treatment setting and their perceptions of the role of the treating team in providing this support is unknown. Specifically, there is a gap in the research that explores in detail who people affected by colorectal cancer consider to be supportive, and the function, timing and nature of this support, whilst receiving treatment. This study explored both patients’ and caregivers’ a) experiences of social support and how this relates to their experience of treatment; and b) what facilitates support in the treatment setting.

Methods

Individual interviews (N = 20) were conducted with patients diagnosed with colorectal cancer and caregivers of such patients. Audiotaped interviews were transcribed verbatim and analysed using the framework method.

Results

Three major themes emerged from the data: a) treating team as a source of support, highlighting the importance of connection with the treating team; b) changes in existing social supports, encompassing issues regarding distance in interpersonal relationships as a consequence of cancer; and c) differing dimensions of support, exploring the significance of shared experience, practical, financial, and emotional support.

Conclusions

Patients and caregivers perceived the treating team as a major source of support. Support from the treating team was particularly important in the context of the changes that occur as a result of a diagnosis of colorectal cancer and the effects of subsequent treatment. Incidental support from others encountered in the treatment setting was also experienced and was equally important to both patients and caregivers. This has implications for the way health care professionals respond to both patients and caregivers in the treatment setting in terms of communication, interventions and environment.

Progressive respiratory disease: the importance of prognostic conversations and advance care planning

The “curative medical model” dominates medical decision-making, but in patients with advanced lung disease it can be redundant and even harmful. Clinicians are reluctant to abandon the traditional approach. However, a steady sea-change is under way not just for potentially life-limiting respiratory disease but also for other long-term conditions, such as heart failure. The sea-change is welcome, but it has been slow in coming for reasons that are complex and entrenched.

Prognostic conversations and advance care planning facilitate improved care in life-limiting respiratory conditionshttp://ow.ly/MOtp30fqPOw