1
|
Lee JJ, Mathur S, Gerhart J, Glover CM, Ritz E, Basapur S, Greenberg JA. Written communication and the ICU team experience (WRITE): A pre-post intervention study. Intensive Crit Care Nurs 2024; 84:103753. [PMID: 38924848 DOI: 10.1016/j.iccn.2024.103753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/05/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Families of critically ill patients may benefit from receiving a written update of patient care each day. Our objective was to develop a system to facilitate care provider creation of written updates and to determine the effect of implementing this process on the care provider experience. DESIGN The experiences of ICU care providers (nurses, advanced practice providers, and physicians) were measured monthly during a 3-month pre-intervention and a 3-month intervention period. During the intervention period, written updates were sent to families each day and posted in the electronic medical record. Study investigators assisted by editing and distributing the written communication to families. SETTING An urban academic medical center in the United States. MAIN OUTCOME MEASURES Nurse-Physician Collaboration Scale (NPCS) and Maslach Burnout Inventory (MBI). RESULTS Over the 3-month intervention period, care providers created written communication for families of 152 patients (average 5 ICU days per family). NPCS scores among the 65 participating care providers were significantly lower, indicating greater collaboration during the intervention vs. pre-intervention period: 49.9 (95 % CI 46.4-53.6) vs. 55.4 (95 % CI 51.5-59.3), p = 0.002. MBI scores were similar during the intervention vs. pre-intervention periods. A subset of care providers participated in individual interviews. Care providers reported that the process of creating written communication was acceptable and had clear benefits for both families and the medical team. CONCLUSIONS Use of written communication as a supplement to verbal communication improves collaboration among ICU care providers without affecting symptoms of burnout. IMPLICATIONS FOR PRACTICE We created a system to facilitate written communication with ICU families that was acceptable to care providers and improved aspects of their experience. In the future, use of written communication can be enhanced with refinements to the process that reduce the time spent creating written updates while highlighting the benefits to families and care providers.
Collapse
Affiliation(s)
| | - Shubha Mathur
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - James Gerhart
- Department of Psychology, Central Michigan University, Mt. Pleasant, MI, USA
| | - Crystal M Glover
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA; Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Ethan Ritz
- Bioinformatics and Biostatistics Core, Rush University Medical Center, Chicago, IL, USA
| | - Santosh Basapur
- Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jared A Greenberg
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| |
Collapse
|
2
|
Jennerich AL. An Approach to Caring for Patients and Family of Patients Dying in the ICU. Chest 2024; 166:127-135. [PMID: 38354905 DOI: 10.1016/j.chest.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
TOPIC IMPORTANCE Death is common in the ICU and often occurs after a decision to withhold or withdraw life-sustaining therapies. Care of the dying is a core skill for ICU clinicians, requiring expert communication, primarily with family of critically ill patients. REVIEW FINDINGS Limited high-quality evidence supports specific practices related to the care of dying patients in the ICU; thus, many of the recommendations that exist are based on expert opinion. Value exists in sharing a practical approach to caring for patients during the dying process, including topics to be addressed with family members, rationales for recommended care, and strategies for implementing comfort measures only. Through dedicated preparation and planning, clinicians can help family members navigate this intense experience. SUMMARY After a decision had been made to discontinue life-sustaining therapies, family members need to be given a clear description of comfort measures only and provided with additional detail about what it entails, including therapies or interventions to be discontinued, monitoring during the dying process, and common features of the dying process. Order sets can be a valuable resource for ensuring that adequate analgesia and sedation are available and the care plan is enacted properly. To achieve a good death for patients, a collaborative effort among members of the care team is essential.
Collapse
Affiliation(s)
- Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
| |
Collapse
|
3
|
Bryan AF, Reich AJ, Norton AC, Campbell ML, Schwartzstein RM, Cooper Z, White DB, Mitchell SL, Fehnel CR. Process of Withdrawal of Mechanical Ventilation at End of Life in the ICU: Clinician Perceptions. CHEST CRITICAL CARE 2024; 2:100051. [PMID: 38957855 PMCID: PMC11218830 DOI: 10.1016/j.chstcc.2024.100051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
BACKGROUND Nearly one-quarter of all Americans die in the ICU. Many of their deaths are anticipated and occur following the withdrawal of mechanical ventilation (WMV). However, there are few data on which to base best practices for interdisciplinary ICU teams to conduct WMV. RESEARCH QUESTION What are the perceptions of current WMV practices among ICU clinicians, and what are their opinions of processes that might improve the practice of WMV at end of life in the ICU? STUDY DESIGN AND METHODS This prospective two-center observational study conducted in Boston, Massachusetts, the Observational Study of the Withdrawal of Mechanical Ventilation (OBSERVE-WMV) was designed to better understand the perspectives of clinicians and experience of patients undergoing WMV. This report focuses on analyses of qualitative data obtained from in-person surveys administered to the ICU clinicians (nurses, respiratory therapists, and physicians) caring for these patients. Surveys assessed a broad range of clinician perspectives on planning, as well as the key processes required for WMV. This analysis used independent open, inductive coding of responses to open-ended questions. Initial codes were reconciled iteratively and then organized and interpreted using a thematic analysis approach. Opinions were assessed on how WMV could be improved for individual patients and the ICU as a whole. RESULTS Among 456 eligible clinicians, 312 in-person surveys were completed by clinicians caring for 152 patients who underwent WMV. Qualitative analyses identified two main themes characterizing high-quality WMV processes: (1) good communication (eg, mutual understanding of family preferences) between the ICU team and family; and (2) medical management (eg, planning, availability of ICU team) that minimizes patient distress. Team member support was identified as an essential process component in both themes. INTERPRETATION Clinician perceptions of the appropriateness or success of WMV prioritize the quality of team and family communication and patient symptom management. Both are modifiable targets of interventions aimed at optimizing overall WMV.
Collapse
Affiliation(s)
- Ava Ferguson Bryan
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Amanda J Reich
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Andrea C Norton
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Margaret L Campbell
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Richard M Schwartzstein
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Zara Cooper
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Douglas B White
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Susan L Mitchell
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Corey R Fehnel
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| |
Collapse
|
4
|
Ramirez P, Mueller A, Shelton K, Dudzinski DM, Colbert A, Jacobsen J, Greenwald JL, Ludmir J. Family Perceptions of Virtual Family-Centered Rounds in a Quaternary Cardiac Intensive Care Unit. J Intensive Care Med 2024; 39:499-504. [PMID: 38374623 DOI: 10.1177/08850666241233495] [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: 02/21/2024]
Abstract
Background: Family-centered rounds (FCR) reduce the risk of psychological comorbidities of family members and improve the quality of communication between providers and families. Materials and methods: We conducted a pilot quality improvement study analyzing family perceptions of virtual FCR. Family members of previously admitted cardiac ICU patients who participated in at least one session of virtual FCR between April 2020 and June 2021 at Massachusetts General Hospital were surveyed post-ICU discharge. Results: During the study, 82 family members enrolled and participated in virtual FCR with 29 completing the post-admission telephone survey. Many cardiac ICU patients were male (n = 53), and a majority were discharged home (43%) with the patient's wives being the most common respondents to the questionnaire (n = 18). Across all questions in the survey, more than 75% of the respondents perceived the highest level of care in trust, communication, relationship, and compassion with their provider. Participants perceived the highest level of care in trust (96%), explanation (88%), as well as care and understanding (89%). Conclusions: Family members of cardiac ICU patients positively rated the quality of communication and perceived a high level of trust and communication between their providers on the virtual format.
Collapse
Affiliation(s)
- Paolo Ramirez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Cardiology Division, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ken Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David M Dudzinski
- Cardiology Division, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Annie Colbert
- Cardiology Division, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Juliet Jacobsen
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Jonathan Ludmir
- Cardiology Division, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
5
|
Mooney S, Devagiri S, Puuri A, Naylor M, Bear K, Akpan US. Improving Parental Knowledge of Medically Complex Neonates Through Scheduled Conferences. Am J Med Qual 2024; 39:105-114. [PMID: 38683697 DOI: 10.1097/jmq.0000000000000180] [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: 05/02/2024]
Abstract
Reports of parental dissatisfaction from incomplete or inconsistent information led to a quality improvement (QI) project to establish planned family conferences at 10 days and 1 month of life, for 50% of the medically complex neonates admitted to a neonatal intensive care unit within 1 year. A QI team instituted a system in which social workers scheduled family conferences and a neonatologist conducted the conferences. Team members tracked measures using statistical process control charts over 21 months. The QI team scheduled conferences for greater than 80% of eligible families, with an 86% completion rate on days 10 and 30, exceeding project goals of 50%. The majority of the families surveyed were satisfied with the meetings. Only 2% of parents surveyed found meetings burdensome, compared to 14% of physicians. A sustainable method for scheduling meetings and preparation for conferences, including the use of a template led to success.
Collapse
Affiliation(s)
- Serena Mooney
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Sailaja Devagiri
- Department of Neonatology, East Carolina University Health Medical Center, Greenville, NC
| | - Angela Puuri
- Department of Neonatology, East Carolina University Health Medical Center, Greenville, NC
| | - Martha Naylor
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Kelly Bear
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Uduak S Akpan
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC
| |
Collapse
|
6
|
Van Scoy LJ, Scott AM, Higgins J, Wasserman E, Heyland D, Chinchilli V, Green MJ. Feasibility and Acceptability of a Novel Intensive Care Unit Communication Intervention ("Let's Talk") and Initial Assessment Using the Multiple Goals Theory of Communication. Am J Hosp Palliat Care 2024; 41:373-382. [PMID: 37173285 PMCID: PMC10885768 DOI: 10.1177/10499091231176296] [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: 05/15/2023] Open
Abstract
Background: Family members of intensive care unit (ICU) patients often report poor communication, feeling unprepared for ICU family meetings, and poor psychological outcomes after decision-making. The objective of this study was to create a tool to prepare families for ICU family meetings and assess feasibility of using Communication Quality Analysis (CQA) to measure communication quality of family meetings. Methods: This observational study was conducted at an academic tertiary care center in Hershey, PA from March 2019 to 2020. Phase 1a involved conceptual design. Phase 1b entailed acceptability testing of 2 versions of the tool (text-only, comic) with 9 family members of non-capacitated ICU patients; thematic analysis of semi-strucutred interviews was conducted. Phase 1c assessed feasibility of applying CQA to audio-recorded ICU family meetings (n = 17); 3 analysts used CQA to assess 6 domains of communication quality. Wilcoxon Signed Rank tests were used to interpret CQA scores. Results: Four themes emerged from Phase 1b interviews: participants 1) found the tool useful for meeting preparation and organizing thoughts, 2) appreciated emotional content, 3) preferred the comic form (67%), and 4) had indifferent or negative perceptions about specific elements. In Phase 1c, clinicians scored higher on the CQA content and engagement domains; family members scored higher on the emotion domain. CQA scores in the relationship and face domains had the lowest quality ratings. Conclusions: Let's Talk may help families become better prepared for ICU family meetings. CQA provides a feasible approach to assessing communication quality that identifies specific areas of strengths and weaknesses in communication.
Collapse
Affiliation(s)
- Lauren J Van Scoy
- Departments of Medicine, Humanities and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Allison M Scott
- Department of Communication, University of Kentucky, Lexington, KY, USA
| | - Jacob Higgins
- Department of Nursing Professional Practice and Development, University of Kentucky College of Nursing and UK Healthcare, Lexington, KY, USA
| | - Emily Wasserman
- Departments of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Daren Heyland
- Department of Critical Care Medicine, Queens University, Kingston, ON, Canada
| | - Vernon Chinchilli
- Departments of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Michael J Green
- Departments of Medicine and Humanities, Penn State College of Medicine, Hershey, PA, USA
| |
Collapse
|
7
|
Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, Divatia JV, Kumar A, Iyer SK, Deodhar J, Bhat RS, Salins N, Thota RS, Mathur R, Iyer RK, Gupta S, Kulkarni P, Murugan S, Nasa P, Myatra SN. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024; 28:200-250. [PMID: 38477011 PMCID: PMC10926026 DOI: 10.5005/jp-journals-10071-24661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs. How to cite this article Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.
Collapse
Affiliation(s)
- Raj K Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Kaushambi, Uttar Pradesh, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Butola
- Department of Palliative Care, Border Security Force Sector Hospital, Panisagar, Tripura, India
| | - Roop Gursahani
- Department of Neurology, P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Dhvani Mehta
- Division of Health, Vidhi Centre for Legal Policy, New Delhi, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care, and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd, Mohali, Punjab, India
| | - Shiva K Iyer
- Department of Critical Care, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Jayita Deodhar
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajani S Bhat
- Department of Interventional Pulmonology and Palliative Medicine, SPARSH Hospitals, Bengaluru, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Raghu S Thota
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Roli Mathur
- Department of Bioethics, Indian Council of Medical Research, Bengaluru, Karnataka, India
| | - Rajam K Iyer
- Department of Palliative Care, Bhatia Hospital; P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Sangeetha Murugan
- Department of Education and Research, Karunashraya, Bengaluru, Karnataka, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| |
Collapse
|
8
|
Tanaka Y, Masukawa K, Sakuramoto H, Kato A, Ishigami Y, Tatsuno J, Ito K, Kizawa Y, Miyashita M. Development of quality indicators for palliative care in intensive care units and pilot testing them via electronic medical record review. J Intensive Care 2024; 12:1. [PMID: 38195590 PMCID: PMC10775577 DOI: 10.1186/s40560-023-00713-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/27/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Patients in intensive care units (ICUs) often require quality palliative care for relief from various types of suffering. To achieve quality palliative care, specific goals need to be identified, measured, and reported. The present study aimed to develop quality indicators (QIs) for palliative care in ICUs, based on a systematic review and modified Delphi method, and test their feasibility by reviewing electronic medical record (EMR) data. METHODS The current study was performed in two phases: the development of QIs using the modified Delphi method, and pilot-testing the quality of palliative care in ICUs based on EMR review. The pilot test included 262 patients admitted to the general or emergency ICU at a university hospital from January 1, 2019, to June 30, 2019. RESULTS A 28-item QI set for palliative care in ICUs was developed based on the consensus of 16 experts. The Delphi process resulted in low measurability ratings for two items: "Assessment of the patient's psychological distress" and "Assessment of the patient's spiritual and cultural practices." However, these items were determined to be important for quality care from the perspective of holistic assessment of distress and were adopted in the final version of the QI set. While the pilot test results indicated the feasibility of the developed QIs, they suggested that the frequency of care performance varied, and certain aspects of palliative care in ICUs needed to be improved, namely (1) regular pain assessment, (2) identification of the patient's advance directive and advance care planning for treatment, (3) conducting an interdisciplinary family conference on palliative care, and (4) assessment of psychological distress of family members. CONCLUSIONS The QI set, developed using the modified Delphi method and tested using EMR data, provided a tool for assessing the quality of palliative care in ICUs. In the two ICUs considered in this study, aspects of the palliative care process with a low performance frequency were identified, and further national surveys were recommended. It is necessary to conduct ongoing surveys at more facilities to improve the quality of palliative care in ICUs.
Collapse
Affiliation(s)
- Yuta Tanaka
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
| | - Kento Masukawa
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Hideaki Sakuramoto
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, Fukuoka, Japan
| | - Akane Kato
- Department of Adult and Geriatric Nursing, School of Health Science, Shinshu University, Matsumoto, Nagano, Japan
| | - Yuichiro Ishigami
- Department of Transitional and Palliative Care, Aso Iizuka Hospital, Fukuoka, Japan
| | - Junko Tatsuno
- Nursing Department, Kokura Memorial Hospital, Fukuoka, Japan
| | - Kaori Ito
- Department of Surgery, Division of Acute Care Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative and Supportive Care, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| |
Collapse
|
9
|
Cox CE, Ashana DC, Riley IL, Olsen MK, Casarett D, Haines KL, O’Keefe YA, Al-Hegelan M, Harrison RW, Naglee C, Katz JN, Yang H, Pratt EH, Gu J, Dempsey K, Docherty SL, Johnson KS. Mobile Application-Based Communication Facilitation Platform for Family Members of Critically Ill Patients: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2349666. [PMID: 38175648 PMCID: PMC10767607 DOI: 10.1001/jamanetworkopen.2023.49666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024] Open
Abstract
Importance Unmet and racially disparate palliative care needs are common in intensive care unit (ICU) settings. Objective To test the effect of a primary palliative care intervention vs usual care control both overall and by family member race. Design, Setting, and Participants This cluster randomized clinical trial was conducted at 6 adult medical and surgical ICUs in 2 academic and community hospitals in North Carolina between April 2019 and May 2022 with physician-level randomization and sequential clusters of 2 Black patient-family member dyads and 2 White patient-family member dyads enrolled under each physician. Eligible participants included consecutive patients receiving mechanical ventilation, their family members, and their attending ICU physicians. Data analysis was conducted from June 2022 to May 2023. Intervention A mobile application (ICUconnect) that displayed family-reported needs over time and provided ICU attending physicians with automated timeline-driven communication advice on how to address individual needs. Main Outcomes and Measures The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST; range 0-130, with higher scores reflecting greater need) score between study days 1 and 3. Secondary outcomes included family-reported quality of communication and symptoms of depression, anxiety, and posttraumatic stress disorder at 3 months. Results A total of 111 (51% of those approached) family members (mean [SD] age, 51 [15] years; 96 women [86%]; 15 men [14%]; 47 Black family members [42%]; 64 White family members [58%]) and 111 patients (mean [SD] age, 55 [16] years; 66 male patients [59%]; 45 Black patients [41%]; 65 White patients [59%]; 1 American Indian or Alaska Native patient [1%]) were enrolled under 37 physicians randomized to intervention (19 physicians and 55 patient-family member dyads) or control (18 physicians and 56 patient-family member dyads). Compared with control, there was greater improvement in NEST scores among intervention recipients between baseline and both day 3 (estimated mean difference, -6.6 points; 95% CI, -11.9 to -1.3 points; P = .01) and day 7 (estimated mean difference, -5.4 points; 95% CI, -10.7 to 0.0 points; P = .05). There were no treatment group differences at 3 months in psychological distress symptoms. White family members experienced a greater reduction in NEST scores compared with Black family members at day 3 (estimated mean difference, -12.5 points; 95% CI, -18.9 to -6.1 points; P < .001 vs estimated mean difference, -0.3 points; 95% CI, -9.3 to 8.8 points; P = .96) and day 7 (estimated mean difference, -9.5 points; 95% CI, -16.1 to -3.0 points; P = .005 vs estimated mean difference, -1.4 points; 95% CI, -10.7 to 7.8; P = .76). Conclusions and Relevance In this study of ICU patients and family members, a primary palliative care intervention using a mobile application reduced unmet palliative care needs compared with usual care without an effect on psychological distress symptoms at 3 months; there was a greater intervention effect among White family members compared with Black family members. These findings suggest that a mobile application-based intervention is a promising primary palliative care intervention for ICU clinicians that directly addresses the limited supply of palliative care specialists. Trial Registration ClinicalTrials.gov Identifier: NCT03506438.
Collapse
Affiliation(s)
- Christopher E. Cox
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Deepshikha C. Ashana
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Isaretta L. Riley
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Maren K. Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - David Casarett
- Department of Medicine, Section of Palliative Care and Hospice Medicine, Duke University, Durham, North Carolina
| | - Krista L. Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, North Carolina
| | | | - Mashael Al-Hegelan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Robert W. Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jason N. Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Hongqiu Yang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Elias H. Pratt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Jessie Gu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Katelyn Dempsey
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | | | - Kimberly S. Johnson
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Health Care System, Durham, North Carolina
| |
Collapse
|
10
|
Georgakis S, Dragioti E, Gouva M, Papathanakos G, Koulouras V. The Complex Dynamics of Decision-Making at the End of Life in the Intensive Care Unit: A Systematic Review of Stakeholders' Views and Influential Factors. Cureus 2024; 16:e52912. [PMID: 38406151 PMCID: PMC10893775 DOI: 10.7759/cureus.52912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
A lack of consensus resulting in severe conflicts is often observed between the stakeholders regarding their respective roles in end-of-life (EOL) decision-making in the ICU. Since the burden of these decisions lies upon the individuals, their opinions must be known by medical, judicial, legislative, and governmental authorities. Part of the solution to the issues that arise would be to examine and understand the views of the people in different societies. Hence, in this systematic review, we assessed the attitudes of the physicians, nurses, families, and the general public toward who should be involved in decision-making and influencing factors. Toward this, we searched three electronic databases, i.e., PubMed, CINAHL (Cumulative Index to Nursing & Allied Health), and Embase. A matrix was developed, discussed, accepted, and used for data extraction by two independent investigators. Study quality was evaluated using the Newcastle-Ottawa Scale. Data were extracted by one researcher and double-checked by a second one, and any discrepancies were discussed with a third researcher. The data were analyzed descriptively and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-three studies met our inclusion criteria. Most involved healthcare professionals and reported geographic variations in different timeframes. While paternalistic features have been observed, physicians overall showed an inclination toward collaborative decision-making. Correspondingly, the nursing staff, families, and the public are aligned toward patient and relatives' participation, with nurses expressing their own involvement as well. Six categories of influencing factors were identified, with high-impact factors, including demographics, fear of litigation, and regulation-related ones. Findings delineate three key points. Firstly, overall stakeholders' perspectives toward EOL decision-making in the ICU seem to be leaning toward a more collaborative decision-making direction. Secondly, to reduce conflicts and reach a consensus, multifaceted efforts are needed by both healthcare professionals and governmental/regulatory authorities. Finally, due to the multifactorial complexity of the subject, directly related to demographic and regulatory factors, these efforts should be more extensively sought at a regional level.
Collapse
Affiliation(s)
- Spiros Georgakis
- Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, GRC
| | - Elena Dragioti
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
| | - Mary Gouva
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
| | | | | |
Collapse
|
11
|
Jöbges S, Dutzmann J, Barndt I, Burchardi H, Duttge G, Grautoff S, Gretenkort P, Hartog C, Knochel K, Nauck F, Neitzke G, Meier S, Michalsen A, Rogge A, Salomon F, Seidlein AH, Schumacher R, Riegel R, Stopfkuchen H, Janssens U. Ethisch begründet entscheiden in der Intensivmedizin. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:52-57. [PMID: 38190826 DOI: 10.1055/a-2211-9608] [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: 01/10/2024]
Abstract
The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis.
Collapse
|
12
|
Sunga P, Knighten ML, Tarver C, Brant JM. Implementation of an Educational Toolkit to Increase Nurse Competence in Spirituality and Spiritual Care of Oncology Patients. J Holist Nurs 2023; 41:394-402. [PMID: 36348633 DOI: 10.1177/08980101221137238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Affiliation(s)
- Pamela Sunga
- Hematology and Hematopoietic Cell Transplant Nurse Coordinator, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Christine Tarver
- Executive Director of Professional Practice and Nursing Excellence, City of Hope National Medical Center, Duarte, CA, USA
| | - Jeannine M Brant
- Executive Director of Clinical Science & Innovation, City of Hope National Medical Center, Duarte, CA, USA
| |
Collapse
|
13
|
Hendershot KA, Elias MN, Taylor BL, Wahlster S, Creutzfeldt CJ. An Update on Palliative Care in Neurocritical Care: Providing Goal‑Concordant Care in the Face of Prognostic Uncertainty. Curr Treat Options Neurol 2023; 25:517-529. [PMID: 39055121 PMCID: PMC11271663 DOI: 10.1007/s11940-023-00778-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 07/27/2024]
Abstract
Purpose of review We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU). Recent findings Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient's prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve.
Collapse
Affiliation(s)
- Kristopher A. Hendershot
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Maya N. Elias
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Breana L. Taylor
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Claire J. Creutzfeldt
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, 325 9th Avenue, Box 359775, Seattle, WA 98104‑2499, USA
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Goss A, Ge C, Crawford S, Goostrey K, Buddadhumaruk P, Hough CL, Lo B, Carson S, Steingrub J, White DB, Muehlschlegel S. Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study. Neurology 2023; 101:e558-e569. [PMID: 37290972 PMCID: PMC10401677 DOI: 10.1212/wnl.0000000000207462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/13/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). METHODS We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. RESULTS We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). DISCUSSION Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.
Collapse
Affiliation(s)
- Adeline Goss
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Connie Ge
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
| | - Sybil Crawford
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Kelsey Goostrey
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Praewpannanrai Buddadhumaruk
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Catherine L Hough
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Bernard Lo
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Shannon Carson
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Jay Steingrub
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Douglas B White
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Susanne Muehlschlegel
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
| |
Collapse
|
16
|
You H, Ma JE, Haverfield MC, Oyesanya TO, Docherty SL, Johnson KS, Cox CE, Ashana DC. Racial Differences in Physicians' Shared Decision-Making Behaviors during Intensive Care Unit Family Meetings. Ann Am Thorac Soc 2023; 20:759-762. [PMID: 36790912 PMCID: PMC10174123 DOI: 10.1513/annalsats.202212-997rl] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Affiliation(s)
| | - Jessica E. Ma
- Durham Veterans Affairs Health SystemDurham, North Carolina
| | | | | | | | | | | | | |
Collapse
|
17
|
Reifarth E, Garcia Borrega J, Kochanek M. How to communicate with family members of the critically ill in the intensive care unit: A scoping review. Intensive Crit Care Nurs 2023; 74:103328. [PMID: 36180318 DOI: 10.1016/j.iccn.2022.103328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To map the existing approaches to communication with family members of the critically ill in the intensive care unit and the corresponding implementation requirements and benefits. METHODS We conducted a scoping review in February 2022 by searching PubMed, CINAHL, APA PsycINFO, and Cochrane Library for articles published between 2000 and 2022. We included records of all designs that met our inclusion criteria and applied frequency counts and qualitative coding. RESULTS The search yielded 3749 records, 63 met inclusion criteria. The included records were of an interventional (43 %) or observational (14 %) study design or review articles (43 %), and provided information in three categories: communication platforms, strategies, and tools. For implementation in the intensive care unit, the approaches required investing time and resources. Their reported benefits were an increased quality of communication and satisfaction among all parties involved, improved psychological outcome among family members, and reduced intensive care unit length of stay and costs. CONCLUSION The current approaches to communication with patients' family members offer insights for the development and implementation of communication pathways in the intensive care unit of which the benefits seem to outweigh the efforts. Structured interprofessional frameworks with standardised tools based on empathic communication strategies are encouraged.
Collapse
Affiliation(s)
- Eyleen Reifarth
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Jorge Garcia Borrega
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| | - Matthias Kochanek
- Department I of Internal Medicine, University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO), Faculty of Medicine, University of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany.
| |
Collapse
|
18
|
Nygaard AM, Haugdahl HS, Brinchmann BS, Lind R. Interprofessional care for the ICU patient's family: solitary teamwork. J Interprof Care 2023; 37:11-20. [PMID: 35285396 DOI: 10.1080/13561820.2022.2038548] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The aim of this study was to explore how interprofessional family care by ICU teams was reflected in their daily work. Data were collected from four ICUs in Norway. Fieldwork and focus groups with ICU nurses and physicians were conducted in addition to dyadic and individual interviews of surgeons and internists. In line with a constructivist grounded theory approach, the core category "solitary teamworking" was constructed. Together with three sub-categories, proximity and distance, silent interprofessional work and a connecting link, this core category conceptualizes interprofessional family care as a form of contradictory cooperation where physicians and nurses alternate between working alone and as a team. The sub-categories reveal three notable characteristics of interprofessional family care: (1) it is emotionally challenging, affected by proximity and distance to the families and between the clinicians, (2) it is silent, at a strategic and organizational level, and (3) nurses and family members have an essential role as a connecting link in the ICU team. Interprofessional family care needs strong involvement by an organization that supports and prioritizes family care, includes family members as an active part of the ICU team and emphasizes interprofessional dialogue.
Collapse
Affiliation(s)
- Anne Mette Nygaard
- Department of Health and Care Sciences, UiT, the Arctic University of Norway, Tromso, Norway
| | - Hege Selnes Haugdahl
- Department of Public Health and Nursing, Levanger Hospital, Nord-Trøndelag Hospital Trust and NTNU Norwegian University of Science and Technology, Norway
| | | | - Ranveig Lind
- Department of Health and Care Sciences, UiT the Arctic University of Norway and Research Nurse at Intensive Care Unit, University Hospital of North Norway, Tromso, Norway
| |
Collapse
|
19
|
Drewelow E, Ritzke M, Altiner A, Icks A, Montalbo J, Kalitzkus V, Löscher S, Pashutina Y, Fleischer S, Abraham J, Thürmann P, Mann NK, Wiese B, Wilm S, Wollny A, Feldmeier G, Buuck T, Mortsiefer A. Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home. PEC INNOVATION 2022; 1:100032. [PMID: 37213749 PMCID: PMC10194292 DOI: 10.1016/j.pecinn.2022.100032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/03/2022] [Accepted: 03/19/2022] [Indexed: 05/23/2023]
Abstract
Objectives For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home. Methods Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting. Results A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study. Conclusion The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT. Innovation Adapting family conferences to primary care for frail patients with polypharmacy.
Collapse
Affiliation(s)
- E. Drewelow
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
- Corresponding author at: Institut für Allgemeinmedizin, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, DE, Germany.
| | - M. Ritzke
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Altiner
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Icks
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - J. Montalbo
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - V. Kalitzkus
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - S. Löscher
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Y. Pashutina
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - S. Fleischer
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112 Halle, Germany
| | - J. Abraham
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112 Halle, Germany
| | - P. Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstraße 40, 42283 Wuppertal, Germany
| | - NK. Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstraße 40, 42283 Wuppertal, Germany
| | - B. Wiese
- WG Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - S. Wilm
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - A. Wollny
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - G. Feldmeier
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - T. Buuck
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Mortsiefer
- Institute of General Practice and Primary Care, Faculty of Health, Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | | |
Collapse
|
20
|
Kalitzkus V, Steinhoff P, Wilm S, Mortsiefer A. [Recommendations for the Use of Family Conferences in Family Medicine - a Scoping Review]. ZFA. ZEITSCHRIFT FUR ALLGEMEINMEDIZIN 2022; 98:377-385. [PMID: 37123509 PMCID: PMC10125253 DOI: 10.53180/zfa.2022.0377-0385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/23/2022] [Indexed: 05/02/2023]
Abstract
Background Family conferences are pre-planned meetings between the treatment team, patient, family members and representatives of other involved disciplines on an agreed topic. There is no review of family conferences in family medicine. The aim of the scoping review is to compile the available recommendations on the use, implementation and documentation of family conferences in family medicine and other medical fields that can be transferred to the family practice setting. Methods Systematic literature search in the databases PubMed, Scopus, Google Scholar and Cochrane Library. Articles published in German or English up to 31.12.2021 were included. The fields of family therapy, paediatrics and neonatology were excluded. Results The search yielded 1,557 hits; after deducting duplicates and reviewing the abstracts, 108 hits were used for the full-text review. Of these, 53 hits were included in the review. Many recommendations on the use, preparation and implementation of family conferences can be transferred to the FM setting. For successful family conferences, a structured procedure is recommended, which includes good preparation of all participants, a multi-stage procedure during the family conference itself, as well as good documentation and follow-up of the agreements. The use of proven patient-centred communication models is recommended. Conclusions Although there are no validated concepts for the procedure of family conferences in the FM setting, practice recommendations can be derived that should be empirically tested in practice and in studies.
Collapse
Affiliation(s)
- Vera Kalitzkus
- Institut für Allgemeinmedizin (ifam), Forschungsschwerpunkt Familienmedizin, Centre for Health and Society, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | - Paula Steinhoff
- Institut für Soziologie und Sozialpsychologie, Universität zu Köln, Deutschland
| | - Stefan Wilm
- Institut für Allgemeinmedizin (ifam), Forschungsschwerpunkt Familienmedizin, Centre for Health and Society, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | - Achim Mortsiefer
- Institut für Allgemeinmedizin und Ambulante Gesundheitsversorgung (IAMAG), Lehrstuhl für Allgemeinmedizin II und Patientenorientierung in der Primärversorgung, Fakultät für Gesundheit/Department für Humanmedizin, Universität Witten/Herdecke, Witten, Deutschland
| |
Collapse
|
21
|
Jöbges S, Denke C, Seidlein AH. Optimierung der Zugehörigenbetreuung – angehörigenzentrierte Intensivmedizin. Med Klin Intensivmed Notfmed 2022; 117:575-583. [DOI: 10.1007/s00063-022-00964-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/29/2022] [Accepted: 08/18/2022] [Indexed: 12/01/2022]
|
22
|
Walter JK, Hill D, Drust WA, Lisanti A, DeWitt A, Seelhorst A, Hasiuk ML, Arnold R, Feudtner C. Intervention Codesign in the Pediatric Cardiac Intensive Care Unit to Improve Family Meetings. J Pain Symptom Manage 2022; 64:8-16. [PMID: 35339610 PMCID: PMC9189043 DOI: 10.1016/j.jpainsymman.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Family meetings are encouraged in the pediatric cardiac intensive care unit (CICU) with the expectation of supporting parental shared decision-making (SDM). However, they often fall short of this goal. Additionally, interprofessional team and family meetings are dominated by input from physicians, under-utilizing the skillset of the full clinical team. OBJECTIVES 1) To determine feasibility of a codesign process to optimize the preparation of the interprofessional team and parents for conducting SDM-oriented family meetings in the CICU, and 2) to describe the resulting elements of the intervention including new support documents for the team and family to prepare for the meeting, team member roles in the meeting, and optimization of communication skills. METHODS Experience-based codesign was used with CICU clinicians and parents of children hospitalized in the CICU to develop an intervention at a single institution. Sessions were audio recorded and transcribed and analyzed using modified grounded theory. Participants were surveyed about their engagement in the codesign process to assess feasibility. RESULTS Fifteen professionals and six parents enrolled in the codesign and endorsed engagement in the process and importance of the intervention elements. Participants identified the benefit of complementary parent and team preparation for family meetings noting five distinct types of meetings that occurred frequently. Documents, processes, and skills training were developed to improve interprofessional teamwork regarding shared decision making and support of parents in family meetings. CONCLUSION A codesign of an intervention with clinicians and parents in the CICU is a feasible and resulted in an intervention with broad support among clinicians in the CICU.
Collapse
Affiliation(s)
- Jennifer K Walter
- Pediatric Advanced Care Team (J.K.W., C.F.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia Research Institute (J.K.W., D.H., W.A.D., A.L., C.F.), Philadelphia, Pennsylvania, USA.
| | - Douglas Hill
- Children's Hospital of Philadelphia Research Institute (J.K.W., D.H., W.A.D., A.L., C.F.), Philadelphia, Pennsylvania, USA
| | - William A Drust
- Children's Hospital of Philadelphia Research Institute (J.K.W., D.H., W.A.D., A.L., C.F.), Philadelphia, Pennsylvania, USA
| | - Amy Lisanti
- Children's Hospital of Philadelphia Research Institute (J.K.W., D.H., W.A.D., A.L., C.F.), Philadelphia, Pennsylvania, USA; Department of Family and Community Health (A.L.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Aaron DeWitt
- Division of Cardiac Critical Care Medicine (A.D., A.S.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amanda Seelhorst
- Division of Cardiac Critical Care Medicine (A.D., A.S.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ma Luisa Hasiuk
- Department of Patient and Family Services (M.L.H.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert Arnold
- Section of Palliative Care (R.A.), University of Pittsburgh School of Medicine, Palliative and Supportive Institute UMPC Health System, Pittsburgh, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team (J.K.W., C.F.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia Research Institute (J.K.W., D.H., W.A.D., A.L., C.F.), Philadelphia, Pennsylvania, USA
| |
Collapse
|
23
|
Langer T, Depalo FC, Forlini C, Landini S, Mezzetti A, Previtali P, Monti G, de Toma C, Biscardi D, Giannini A, Fumagalli R, Mistraletti G. Communication and visiting policies in Italian intensive care units during the first COVID-19 pandemic wave and lockdown: a nationwide survey. BMC Anesthesiol 2022; 22:187. [PMID: 35710331 PMCID: PMC9203262 DOI: 10.1186/s12871-022-01726-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/09/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND During the first coronavirus disease 2019 (COVID-19) pandemic wave, an unprecedented number of patients with respiratory failure due to a new, highly contagious virus needed hospitalization and intensive care unit (ICU) admission. The aim of the present study was to describe the communication and visiting policies of Italian intensive care units (ICUs) during the first COVID-19 pandemic wave and national lockdown and compare these data with prepandemic conditions. METHODS A national web-based survey was conducted among 290 Italian hospitals. Each ICU (active between February 24 and May 31, 2020) was encouraged to complete an individual questionnaire inquiring the hospital/ICU structure/organization, communication/visiting habits and the role of clinical psychology prior to, and during the first COVID-19 pandemic wave. RESULTS Two hundred and nine ICUs from 154 hospitals (53% of the contacted hospitals) completed the survey (202 adult and 7 pediatric ICUs). Among adult ICUs, 60% were dedicated to COVID-19 patients, 21% were dedicated to patients without COVID-19 and 19% were dedicated to both categories (Mixed). A total of 11,102 adult patients were admitted to the participating ICUs during the study period and only approximately 6% of patients received at least one visit. Communication with family members was guaranteed daily through an increased use of electronic devices and was preferentially addressed to the same family member. Compared to the prepandemic period, clinical psychologists supported physicians more often regarding communication with family members. Fewer patients received at least one visit from family members in COVID and mixed-ICUs than in non-COVID ICUs, l (0 [0-6]%, 0 [0-4]% and 11 [2-25]%, respectively, p < 0.001). Habits of pediatric ICUs were less affected by the pandemic. CONCLUSIONS Visiting policies of Italian ICUs dedicated to adult patients were markedly altered during the first COVID-19 wave. Remote communication was widely adopted as a surrogate for family meetings. New strategies to favor a family-centered approach during the current and future pandemics are warranted.
Collapse
Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Francesca Carmela Depalo
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Clarissa Forlini
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Silvia Landini
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | | | - Paola Previtali
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Gianpaola Monti
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Carolina de Toma
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Davide Biscardi
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Children's Hospital, ASST Spedali Civili, Brescia, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy.
| | - Giovanni Mistraletti
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
24
|
Gray TF, Kwok A, Do KM, Zeng S, Moseley ET, Dbeis YM, Umeton R, Tulsky JA, El-Jawahri A, Lindvall C. Associations Between Family Member Involvement and Outcomes of Patients Admitted to the Intensive Care Unit: Retrospective Cohort Study. JMIR Med Inform 2022; 10:e33921. [PMID: 35704362 PMCID: PMC9244649 DOI: 10.2196/33921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/01/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Little is known about family member involvement, by relationship status, for patients treated in the intensive care unit (ICU). OBJECTIVE Using documentation of family interactions in clinical notes, we examined associations between child and spousal involvement and ICU patient outcomes, including goals of care conversations (GOCCs), limitations in life-sustaining therapy (LLST), and 3-month mortality. METHODS Using a retrospective cohort design, the study included a total of 858 adult patients treated between 2008 and 2012 in the medical ICU at a tertiary care center in northeastern United States. Clinical notes generated within the first 48 hours of admission to the ICU were used with standard machine learning methods to predict patient outcomes. We used natural language processing methods to identify family-related documentation and abstracted sociodemographic and clinical characteristics of the patients from the medical record. RESULTS Most of the 858 patients were White (n=650, 75.8%); 437 (50.9%) were male, 479 (55.8%) were married, and the median age was 68.4 (IQR 56.5-79.4) years. Most patients had documented GOCC (n=651, 75.9%). In adjusted regression analyses, child involvement (odds ratio [OR] 0.81; 95% CI 0.49-1.34; P=.41) and child plus spouse involvement (OR 1.28; 95% CI 0.8-2.03; P=.3) were not associated with GOCCs compared to spouse involvement. Child involvement was not associated with LLST when compared to spouse involvement (OR 1.49; 95% CI 0.89-2.52; P=.13). However, child plus spouse involvement was associated with LLST (OR 1.6; 95% CI 1.02-2.52; P=.04). Compared to spouse involvement, there were no significant differences in the 3-month mortality by family member type, including child plus spouse involvement (OR 1.38; 95% CI 0.91-2.09; P=.13) and child involvement (OR 1.47; 95% CI 0.9-2.41; P=.12). CONCLUSIONS Our findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Early child plus spouse involvement was associated with LLST, suggesting that decisions about LLST were more likely to occur when the child and spouse were both involved compared to the involvement of only the spouse. More research is needed to further understand the involvement of different family members in ICU care and its association with patient outcomes.
Collapse
Affiliation(s)
- Tamryn F Gray
- Department of Medicine, Harvard Medical School, Boston, MA, United States.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Anne Kwok
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Khuyen M Do
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Sandra Zeng
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Yasser M Dbeis
- Department of Informatics & Analytics, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Renato Umeton
- Department of Informatics & Analytics, Dana-Farber Cancer Institute, Boston, MA, United States.,Department of Biological Engineering and Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States.,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| | - James A Tulsky
- Department of Medicine, Harvard Medical School, Boston, MA, United States.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Areej El-Jawahri
- Department of Medicine, Harvard Medical School, Boston, MA, United States.,Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, United States
| | - Charlotta Lindvall
- Department of Medicine, Harvard Medical School, Boston, MA, United States.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States
| |
Collapse
|
25
|
Kentish-Barnes N, Jensen HI, Curtis JR. The legacy of the interprofessional family meeting. Intensive Care Med 2022; 48:933-935. [PMID: 35513708 DOI: 10.1007/s00134-022-06718-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Nancy Kentish-Barnes
- Famiréa Research Group, Medical Intensive Care Unit, AP-HP, Saint Louis University Hospital, 1 Avenue Claude Vellefaux, 75010, Paris, France.
| | - Hanne Irene Jensen
- Department of Anaesthesiology and Intensive Care, Lillebaelt Hospital, University Hospital of Southern Denmark, Odense, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
26
|
Yu WC, Huang CT, Sheng WH. Application of a pre-emptive question and answer platform to improve the level of satisfaction during family meetings in general medical wards. BMC Health Serv Res 2022; 22:499. [PMID: 35422016 PMCID: PMC9008296 DOI: 10.1186/s12913-022-07929-z] [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: 09/06/2021] [Accepted: 03/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background A successful family meeting is key to family-centered care and may foster communication and improve the level of satisfaction of the family in terms of communication. In this study, we evaluated whether a proactive communication channel could improve the level of satisfaction of family members following a family meeting in a general medical ward setting. Methods We conducted a pre- and post-study to compare the level of satisfaction of a family with a family meeting before (N = 39) and after (N = 29) intervention in two general medical wards of a tertiary-care referral center. The intervention included a pre-emptive question and answer platform and a written response to family-raised queries in addition to a regular setting. Following each family meeting, family members were requested to fill a 10-item survey assessing their levels of satisfaction. Results The characteristics of the family members in terms of demographics, education levels, and previous experiences with family meetings in the pre- and post-intervention groups were similar. The scores in all the items that indicated the level of satisfaction significantly improved after intervention. The overall score for satisfaction increased from 85 (interquartile range, 80–95) to 98 (interquartile range, 93–100; P < 0.001). Conclusions Compared with conventional practice, the inclusion of a proactive communication platform along with a written response to raised queries as a part of family meetings improved the satisfaction levels of the family in terms of the content and process of the meeting in the general ward setting. Further studies are needed to delineate the optimal timing and use of such a communication modality. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07929-z.
Collapse
|
27
|
Seaman JB, Rak KJ, Carpenter AK, Arnold RM, White DB. Intensive Care Unit Clinicians' Perspectives on Achieving Proactive Interprofessional Family Meetings. Am J Crit Care 2022; 31:129-136. [PMID: 35229153 DOI: 10.4037/ajcc2022719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although proactive interprofessional family meetings are widely recommended as a best practice for patient- and family-centered care in intensive care units (ICUs), adherence to this recommendation is low. OBJECTIVES To enhance understanding of practices, barriers, and facilitators related to the conduct of family meetings from the perspective of ICU clinicians and to elicit clinicians' ideas and opinions about strategies to achieve proactive interprofessional family meetings. METHODS Semistructured telephone interviews were conducted with ICU clinicians who were purposively selected from among a national sample. Constant comparative analysis was used to generate a matrix of themes; enrollment ceased when no new ideas emerged. RESULTS Interviews were conducted with 14 participants (10 nurses, 3 physicians, and 1 care manager). Rather than having a protocol for proactive family meetings, participants primarily held family meetings when physicians thought that it was time to discuss a transition to comfort-focused care. Other barriers included clinicians' discomfort with end-of-life conversations, physicians' time constraints, and nurses' competing clinical responsibilities. Facilitators included physicians' skill and comfort with difficult conversations, advocacy for family meetings from care managers/ social workers, and having full-time intensivists. Participants offered/endorsed multiple intervention ideas, including scheduling preemptively, monitoring unit performance, and adding discussion of a family meeting to daily rounds. CONCLUSIONS A key barrier to proactive family meetings is the mindset that family meetings need occur only when a clinical decision must be made, rather than proactively to support and engage families. Clinicians suggested ways to make proactive family meetings routine.
Collapse
Affiliation(s)
- Jennifer B. Seaman
- Jennifer B. Seaman is an assistant professor of nursing, Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Kimberly J. Rak
- Kimberly J. Rak is a medical anthropologist, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amanda K. Carpenter
- Amanda K. Carpenter, former research coordinator in the Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, is currently the operations manager for North Jersey Community Research Initiative, Newark, New Jersey
| | - Robert M. Arnold
- Robert M. Arnold is a distinguished service professor of medicine, Department of General Internal Medicine; chief, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, and medical director, UPMC Palliative and Supportive Institute, Pittsburgh, Pennsylvania
| | - Douglas B. White
- Douglas B. White is a vice chair and professor of critical care medicine, and director, Program on Ethics and Decision Making in Critical Illness, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine
| |
Collapse
|
28
|
Schwartz AC, Dunn SE, Simon HFM, Velasquez A, Garner D, Tran DQ, Kaslow NJ. Making Family-Centered Care for Adults in the ICU a Reality. Front Psychiatry 2022; 13:837708. [PMID: 35401268 PMCID: PMC8987300 DOI: 10.3389/fpsyt.2022.837708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/25/2022] [Indexed: 12/29/2022] Open
Abstract
Despite the value of family-centered care (FCC) in intensive care units (ICUs), this approach is rarely a reality in this context. This article aims to increase the likelihood that ICU-based care incorporates best practices for FCC. Consistent with this goal, this article begins by overviewing FCC and its merits and challenges in ICUs. It then offers a systemic framework for conceptualizing FCC in this challenging environment, as such a model can help guide the implementation of this invaluable approach. This systemic framework combined with previous guidelines for FCC in the ICU are used to inform the series of recommended best practices for FCC in the ICU that balance the needs and realities of patients, families, and the interprofessional healthcare team. These best practices reflect an integration of the existing literature and previously published guidelines as well as our experiences as healthcare providers, family members, and patients. We encourage healthcare leaders and interprofessional ICU healthcare teams to adopt these best practices and modify them for the specific healthcare needs of the patients they serve and their families.
Collapse
Affiliation(s)
- Ann C Schwartz
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Sarah E Dunn
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Hannah F M Simon
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Alvaro Velasquez
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - David Garner
- Department of Nursing, Grady Health System, Atlanta, GA, United States
| | - Duc Quang Tran
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Nadine J Kaslow
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| |
Collapse
|
29
|
Hartog CS, Maia PA, Ricou B, Danbury C, Galarza L, Schefold JC, Soreide E, Bocci MG, Pohrt A, Sprung CL, Avidan A. Changes in communication of end-of-life decisions in European ICUs from 1999 to 2016 (Ethicus-2) - a prospective observational study. J Crit Care 2021; 68:83-88. [PMID: 34952475 DOI: 10.1016/j.jcrc.2021.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE We investigated changes in communication practice about end-of-life decisions in European ICUs over 16 years. MATERIALS AND METHODS This prospectively planned secondary analysis of two observational studies in 22 European ICUs in 1999-2000 (Ethicus-1) and 2015-16 (Ethicus-2) included consecutive patients who died or with limitation of life-sustaining therapy. ICUs were grouped into North, Central and South European regions. RESULTS A total 4592 patients were included in 1999-2000 (n = 2807) and 2015-16 (n = 1785). Information about patient wishes increased overall (from 25.4% [570] to 51.1% [840]) and in all regions (42% to 61% [North], 22% to 56% [Central] and 20% to 32% [South], all p < 0.001). Discussions of treatment limitations with patients or families increased overall (66.0% to 76.1%) and in Northern and Central Europe (87% to 94% and 75% to 82.2%, respectively, all p < 0.001) but not in the South. Strongest predictor for discussions was the region (North>Central>South) followed by patient decision-making capacity. CONCLUSION End-of-life decisions are increasingly discussed but communication practices vary by region and follow a North-South gradient. Despite increased availability of information, patient preferences still remain unknown in every second patient. This calls for increased efforts to assess patient preference in advance and make them known to ICU clinicians.
Collapse
Affiliation(s)
- Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany; Klinik Bavaria, Kreischa, Germany.
| | - Paulo A Maia
- Intensive Care Medicine, Centro Hospitalar e Universitário do Porto, ICBAP, Porto, Portugal
| | - Bara Ricou
- Department of Acute Care Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Chris Danbury
- Intensive Care, Royal Berkshire Hospital, Reading, United Kingdom
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitario de Castellon, Castellon de la Plana, Spain
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, University of Bern, Switzerland
| | - Eldar Soreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Norway and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Maria G Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anne Pohrt
- Institute of Biometry and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Charles L Sprung
- Division of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Alexander Avidan
- Division of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| |
Collapse
|
30
|
Putting Prognosis First: Impact of an Intensive Care Unit Team Premeeting Curriculum. ATS Sch 2021; 2:386-396. [PMID: 34667988 PMCID: PMC8519315 DOI: 10.34197/ats-scholar.2020-0063oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background: The paradigm of care has shifted in the pediatric intensive care unit (ICU) such that patients are frequently cared for by teams of specialists rather than the ICU attending physician solely managing care. An unintended consequence of care managed by multiple specialists is that families often receive conflicting messages from different team members, with little focus on disclosing prognosis. Objective: To address this gap, we developed and pilot-tested a team communication skills training (CST) program focused on the healthcare team premeeting in which roles, purpose, and prognosis are clarified before meeting with the family. Our aim was to assess whether the team CST program was associated with increased discussion of prognosis during the team premeeting. Methods: We conducted a single-center, observational pilot study to develop and test a team CST program using a before/after design. Pediatric ICU physicians and specialists from pediatric neurology and pediatric oncology who co-led family conferences in the pediatric ICU participated in a 1-day team CST program. Team premeetings were audio-recorded and transcribed. Results: We analyzed seven pre- and 10 post-CST program audio-recorded team premeetings, which each compromised a median of eight healthcare team members. Prognosis was more likely to be discussed in post-CST team premeetings (10/10 vs. 3/7; P = 0.0147). Agreement on prognosis was achieved more frequently in post-CST teams compared with pre-CST teams, although the percentage of agreement did not reach significance (9/10 vs. 3/7; P = 0.1007). Conclusions: A CST program with a structured approach to conducting a team premeeting was associated with an increased discussion of prognosis among team members before convening with the family in the pediatric ICU.
Collapse
|
31
|
Chou TJ, Wu YR, Tsai JS, Cheng SY, Yao CA, Peng JK, Chiu TY, Huang HL. Telehealth-Based Family Conferences with Implementation of Shared Decision Making Concepts and Humanistic Communication Approach: A Mixed-Methods Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010801. [PMID: 34682545 PMCID: PMC8535301 DOI: 10.3390/ijerph182010801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/10/2021] [Accepted: 10/12/2021] [Indexed: 01/14/2023]
Abstract
Smartphone-enabled, telehealth-based family conferences represent an attractive and safe alternative to deliver communication during the COVID-19 pandemic. However, some may fear that the therapeutic relationship might be filtered due to a lack of direct human contact. The study aims to explore whether shared decision-making model combining VALUE (Value family statements, Acknowledge emotions, Listen, Understand the patient as a person, Elicit questions) and PLACE (Prepare with intention, Listen intently and completely, Agree on what matters most, Connect with the patient’s story, Explore emotional cues) framework can help physicians respond empathetically to emotional cues and foster human connectedness in a virtual context. Twenty-five virtual family conferences were conducted in a national medical center in Taiwan. The expression of verbal emotional distress was noted in 20% of patients and 20% of family members, while nonverbal distress was observed in 24% and 28%, respectively. On 10-point Likert scale, the satisfaction score was 8.7 ± 1.5 toward overall communication and 9.0 ± 1.1 on meeting the family’s needs. Adopting SDM concepts with VALUE and PLACE approaches helps physicians foster connectedness in telehealth family conferences. The model has high participant satisfaction scores and may improve healthcare quality among the pandemic.
Collapse
Affiliation(s)
- Tzu-Jung Chou
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
| | - Yu-Rui Wu
- Department of Family Medicine, Taitung Christian Hospital, Taitung 950, Taiwan;
| | - Jaw-Shiun Tsai
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Chien-An Yao
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
| | - Jen-Kuei Peng
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Hsien-Liang Huang
- Department of Family Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (T.-J.C.); (J.-S.T.); (S.-Y.C.); (C.-A.Y.); (J.-K.P.); (T.-Y.C.)
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei 100, Taiwan
- New Southbound Health Center, National Taiwan University Hospital, Taipei 100, Taiwan
- Correspondence: ; Tel.: +886-2-2312-3456 (ext. 66832)
| |
Collapse
|
32
|
Abstract
The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.
Collapse
Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, San Francisco, California
| | | |
Collapse
|
33
|
Creutzfeldt CJ. Palliative Care and Shared Decision Making in the Neurocritical Care Unit. ACTA ACUST UNITED AC 2021; 27:1430-1443. [PMID: 34618767 DOI: 10.1212/con.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the evidence on integrating palliative care into the care of patients with various types of serious neurologic illness, emphasizes the importance of palliative care in the neurocritical care unit, and suggests tools for clinicians to improve their communication skills and decision making. RECENT FINDINGS Palliative care is a holistic approach to medical care that aims to relieve physical, psychological, social, and spiritual suffering. It is both a medical specialty as young as neurocritical care itself and an approach to patient care by all clinicians who manage patients with serious illness. Patients presenting to the neurocritical care unit and their families have unique palliative care needs that challenge communication and shared decision making. SUMMARY Palliative care, effective communication, and shared decision making require a set of core skills that all neurology clinicians should master.
Collapse
|
34
|
Ahmed N, Davids R. COVID 19: are South African junior doctors prepared for critical care management outside the intensive care unit? Pan Afr Med J 2021; 40:41. [PMID: 34795822 PMCID: PMC8571942 DOI: 10.11604/pamj.2021.40.41.30134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/01/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION the coronavirus disease 2019 (COVID-19) pandemic has negatively impacted countries across the globe. Infected individuals will seek aid at various health care facilities. Many patients will recover without requiring specialised treatment. A significant percentage of infected individuals will need critical care management, which will begin in the emergency department, generally staffed by junior doctors. Junior doctors will need to stabilize, triage and manage these patients prior to referral to specialized units. Above and beyond the usual occupational demands that accompany junior doctors in state facilities, this pandemic will thrust further responsibility on them. The objectives were to describe crisis preparedness of junior doctors in the areas of triage decision-making and critical care management, outside the intensive care unit. METHODS this is a descriptive, cross-sectional study, utilizing a web-based survey. Junior doctors in South Africa, being doctors in year one or year two of internship and community service, were invited to participate anonymously via various social media platforms. Results: a total of 210 junior doctors across South Africa answered the survey. Junior doctors expressed confidence with knowledge of intubation drugs, to perform intubation and cardiopulmonary arrest resuscitation without supervision. Only 13.3% of respondents expressed comfort with setting and adjusting ventilator settings independently. 57% of participants expressed discomfort with making critical care triage decisions. Ninety-three percent (93%) of participants expressed benefit from a telemedicine intervention. CONCLUSION junior doctors in South Africa indicate that they are prepared to initiate management of the critically ill patient outside the intensive care unit but remain uncertain in their ability to provide ongoing critical care management. The COVID-19 pandemic has highlighted the need to prepare junior doctors with the ability to manage critical care triage and management in emergency rooms. Leveraging of the workforce in South Africa may be potentiated by telemedicine interventions.
Collapse
Affiliation(s)
- Nadiya Ahmed
- Department of Surgical Sciences, Department Anaesthesiology and Critical Care, Tygerberg Hospital, Stellenbosch University, Western Cape, South Africa
| | - Ryan Davids
- Department of Surgical Sciences, Department Anaesthesiology and Critical Care, Tygerberg Hospital, Stellenbosch University, Western Cape, South Africa
| |
Collapse
|
35
|
Frivold G, Ågård AS, Jensen HI, Åkerman E, Fossum M, Alfheim HB, Rasi M, Lind R. Family involvement in the intensive care unit in four Nordic countries. Nurs Crit Care 2021; 27:450-459. [PMID: 34405494 DOI: 10.1111/nicc.12702] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/20/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Relevance to clinical practice The findings from the study highlighting family involvement, high-quality communication and flexible visiting policy as central aspects of family care may inspire clinicians to identify aspects of everyday family care in their ICUs calling for further improvement. AIMS AND OBJECTIVES To describe family involvement, communication practices and visiting policies in adult ICUs. DESIGN A cross-sectional survey. METHOD A questionnaire consisting of 11 sections was developed, pilot tested and e-mailed to 196 ICUs. The participants were intensive care nurses in adult ICUs in four Nordic countries. RESULTS The survey was conducted in October to December 2019. The response rate was 81% (158/196) of the invited ICUs. Most of the units had fewer than 11 beds. Family participation in patient care, including involvement in ward rounds and presence during cardiopulmonary resuscitation, varied between the countries, whereas most families in all countries were involved in decision-making. Family conferences were generally initiated by staff or family members. Children under 18 did not always receive information directly from the staff, and parents were not advised about how to inform their children. Although most respondents described open visiting, restrictions were also mentioned in free-text comments. CONCLUSIONS The level of family care in ICUs in the four Nordic countries is generally based on nurses' discretion. Although most Nordic ICUs report having an open or flexible visiting policy, a wide range of potential restrictions still exists. Children and young relatives are not routinely followed up. Family members are included in communication and decision-making, whereas family involvement in daily care, ward rounds and family-witnessed resuscitation seem to be areas with a potential for improvement.
Collapse
Affiliation(s)
- Gro Frivold
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
| | - Anne Sophie Ågård
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Science in Nursing, Aarhus University, Aarhus, Denmark
| | - Hanne Irene Jensen
- Departments of Anaesthesiology and Intensive Care, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Eva Åkerman
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Mariann Fossum
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
| | - Hanne Birgit Alfheim
- Faculty of Health, VID Specialized University, Oslo, Norway.,Postoperative and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Matias Rasi
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ranveig Lind
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,Intensive Care Unit, University Hospital of North Norway, Tromsø, Norway
| |
Collapse
|
36
|
Lamiani G, Mistraletti G, Moreschi C, Andrighi E, Vegni E. Cultivating Empathy and Soft Skills Among Intensive Care Residents: Effects of a Mandatory, Simulation-Based, Experiential Training. Ann Transplant 2021; 26:e931147. [PMID: 34385409 PMCID: PMC8369950 DOI: 10.12659/aot.931147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Communication with families is crucial in ICU care. However, only a few residency programs include communication and relationship training in their curricula. This study aimed to assess the impact of a communication-skill course on residents’ empathy and self-reported skills. Material/Methods A single-center, observational study was conducted. Since 2017, the 4th-year residents of the Anaesthesia and Intensive Care School, University of Milan attended the mandatory “Program to Enhance Relational and Communication Skills in ICU (PERCS-ICU)”. PERCS-ICU lasted 10 hours and involved small groups of residents. The course was articulated around the simulation and debriefing of 3 difficult conversations with trained actors. Before and after the course, residents completed the Jefferson Scale of Empathy and a questionnaire measuring self-assessed preparation, communication skills, relational skills, confidence, anxiety, emotional awareness, management of emotions, and self-reflection when conducting difficult conversations. The quality and usefulness of the course and the case scenario were assessed on a 5-point Likert scales. Results Between 2017 and 2019, 6 PERCS-ICU courses were offered to 71 residents, 69 of whom completed the questionnaires. After the course, residents reported improvements in empathy (p<.05), preparation (p<.001), communication skills (p<.005), confidence (p<.001), self-reflection (p<.001), and emotional awareness (p<.001). Residents perceived the course as very useful (mean=4.79) and high-quality (mean=4.58). The case scenario appeared very realistic (mean=4.83) and extremely useful (mean=4.91). All residents recommended the course to other colleagues. Conclusions PERCS-ICU proved to be a well-received and effective course to improve residents’ empathy and some self-reported skills. The long-term effects remain to be investigated.
Collapse
Affiliation(s)
- Giulia Lamiani
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Giovanni Mistraletti
- Unit of Anesthesia and Intensive Care, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Elisa Andrighi
- Unit of Clinical Psychology, ASST Santi Paolo e Carlo, Milan, Italy
| | - Elena Vegni
- Department of Health Sciences, University of Milan, Milan, Italy.,Unit of Clinical Psychology, ASST Santi Paolo e Carlo, Milan, Italy
| |
Collapse
|
37
|
Abstract
OBJECTIVES To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care. DATA SOURCES Semistructured narrative literature review and quantitative survey assessments. STUDY SELECTION English language publications that examined critical care practices in relation to reducing cost or waste. DATA EXTRACTION Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking. DATA SYNTHESIS Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices. CONCLUSIONS Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.
Collapse
|
38
|
Ahmad MH, Teo SP. Post-intensive Care Syndrome. Ann Geriatr Med Res 2021; 25:72-78. [PMID: 34120434 PMCID: PMC8272999 DOI: 10.4235/agmr.21.0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022] Open
Abstract
The increasing survival rate after discharge from the intensive care unit (ICU) has revealed long-term impairments in the cognitive, psychiatric, and physical domains among survivors. However, clinicians often fail to recognize this post-ICU syndrome (PICS) and its debilitating effects on family members (PICS-F). This study describes two cases of PICS to illustrate the different impairments that may occur in ICU survivors. The PICS risk factors for each domain and the interactions among risk factors are also described. In terms of diagnostic evaluation, limited evidence-based or validated tools are available to assist with screening for PICS. Clinicians should be aware to monitor for its symptoms on the basis of cognitive, psychiatric, and physical domains. The Montreal Cognitive Assessment is recommended to screen for cognition, as it has a high sensitivity and can evaluate executive function. Mood disorders should also be screened. For mobile patients, a 6-minute walk test should be performed. PICS can be prevented by applying the ABCDEF bundle ABCDEF bundle in ICU described in this paper. Finally, the family members of patients in the ICU should be involved in patient care and a tactful communication approach is required to reduce the risk of PICS-F.
Collapse
Affiliation(s)
- Muhammad Hanif Ahmad
- Geriatrics and Palliative Unit, Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam
| | - Shyh Poh Teo
- Geriatrics and Palliative Unit, Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam
| |
Collapse
|
39
|
Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France. Contemp Clin Trials 2021; 107:106465. [PMID: 34091062 DOI: 10.1016/j.cct.2021.106465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help. DESIGN AND INTERVENTION We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months. PARTICIPANTS We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less. OUTCOMES We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries. CONCLUSIONS We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.
Collapse
|
40
|
Chang DW, Neville TH, Parrish J, Ewing L, Rico C, Jara L, Sim D, Tseng CH, van Zyl C, Storms AD, Kamangar N, Liebler JM, Lee MM, Yee HF. Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments. JAMA Intern Med 2021; 181:786-794. [PMID: 33843946 PMCID: PMC8042568 DOI: 10.1001/jamainternmed.2021.1000] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 02/19/2021] [Indexed: 11/14/2022]
Abstract
Importance For critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit. Objective To examine whether use of time-limited trials (TLTs) as the default care-planning approach for critically ill patients with advanced medical illnesses was associated with decreased duration and intensity of nonbeneficial ICU care. Design, Setting, and Participants This prospective quality improvement study was conducted from June 1, 2017, to December 31, 2019, at the medical ICUs of 3 academic public hospitals in California. Patients at risk for nonbeneficial ICU treatments due to advanced medical illnesses were identified using categories from the Society of Critical Care Medicine guidelines for admission and triage. Interventions Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers. Main Outcomes and Measures Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure). Results A total of 209 patients were included (mean [SD] age, 63.6 [16.3] years; 127 men [60.8%]; 101 Hispanic patients [48.3%]), with 113 patients (54.1%) in the preintervention period and 96 patients (45.9%) in the postintervention period. Formal family meetings increased from 68 of 113 (60.2%) to 92 of 96 (95.8%) patients between the preintervention and postintervention periods (P < .01). Key components of family meetings, such as discussions of risks and benefits of ICU treatments (preintervention, 15 [34.9%] vs postintervention, 56 [94.9%]; P < .01), eliciting values and preferences of patients (20 [46.5%] vs 58 [98.3%]; P < .01), and identifying clinical markers of improvement (9 [20.9%] vs 52 [88.1%]; P < .01), were discussed more frequently after intervention. Median ICU length of stay was significantly reduced between preintervention and postintervention periods (8.7 [interquartile range (IQR), 5.7-18.3] days vs 7.4 [IQR, 5.2-11.5] days; P = .02). Hospital mortality was similar between the preintervention and postintervention periods (66 of 113 [58.4%] vs 56 of 96 [58.3%], respectively; P = .99). Invasive ICU procedures were used less frequently in the postintervention period (eg, mechanical ventilation preintervention, 97 [85.8%] vs postintervention, 70 [72.9%]; P = .02). Conclusions and Relevance In this study, a quality improvement intervention that trained physicians to communicate and plan ICU care with family members of critically ill patients in the ICU using TLTs was associated with improved quality of family meetings and a reduced intensity and duration of ICU treatments. This study highlights a patient-centered approach for treating critically ill patients that may reduce nonbeneficial ICU care. Trial Registration ClinicalTrials.gov Identifier: NCT04181294.
Collapse
Affiliation(s)
- Dong W. Chang
- Division of Pulmonary and Critical Care Medicine, Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care Medicine, Ronald Reagan University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer Parrish
- Division of Pulmonary and Critical Care Medicine, Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
| | - Lian Ewing
- Los Angeles County Department of Health Services, Los Angeles, California
- Division of Pulmonary and Critical Care Medicine, Olive View Medical Center, David Geffen School of Medicine at UCLA, Sylmar, California
| | - Christy Rico
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Liliacna Jara
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Danielle Sim
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Chi-hong Tseng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Carin van Zyl
- Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Aaron D. Storms
- Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Nader Kamangar
- Los Angeles County Department of Health Services, Los Angeles, California
- Division of Pulmonary and Critical Care Medicine, Olive View Medical Center, David Geffen School of Medicine at UCLA, Sylmar, California
| | - Janice M. Liebler
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - May M. Lee
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Hal F. Yee
- Los Angeles County Department of Health Services, Los Angeles, California
| |
Collapse
|
41
|
Mistraletti G, Giannini A. When the Words Serve As Drugs. Chest 2021; 159:2137-2138. [PMID: 34099119 DOI: 10.1016/j.chest.2021.02.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Giovanni Mistraletti
- Department of Pathophysiology and Transplantation, University of Milan, and SC Anesthesia and Intensive Care, San Paolo Hospital - Polo Universitario, ASST dei Santi Paolo e Carlo, Milan, Italy.
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Children's Hospital, ASST Spedali Civili, Brescia, Italy
| |
Collapse
|
42
|
Kawashima T, Kawakami A, Ashida K, Tanaka M. Development of the nursing practice scale for end-of-life family conferences in critical care. Intensive Crit Care Nurs 2021; 66:103076. [PMID: 34059417 DOI: 10.1016/j.iccn.2021.103076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to develop the Nursing Practice Scale for End-of-life Family conferences in critical care and to clarify the current status of nursing practice regarding family conferences. RESEARCH METHODOLOGY/DESIGN We conducted a cross-sectional, self-administered questionnaire survey with 955 critical care unit nurses in 97 hospitals. Content validity, factor validity and criterion-related validity, known-group validity, internal consistency and test-retest reliability were evaluated. Data were then analysed statistically. SETTING Adult intensive care units or high dependency units in Japan. RESULTS Three factors with 39 items were extracted through item analysis and confirmatory factor analysis as hypothesised (Factor 1: Preparation, Factor 2: Discussion and Factor 3: Follow-up), and the mean score per item for each factor was 3.57, 3.73 and 3.75, respectively. Nurses who had any certification or had worked in critical care unit for >5 years had a significantly greater score than the others. The Cronbach's α were 0.86-0.96 and the intraclass correlation coefficients were 0.79-0.87. CONCLUSION The Nursing Practice Scale for End-of-life Family conferences in critical care is a valid and reliable scale. This study could effectively facilitate communication among patients, their families and healthcare providers.
Collapse
Affiliation(s)
- Tetsuharu Kawashima
- Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Aki Kawakami
- Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Kaoru Ashida
- Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Makoto Tanaka
- Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| |
Collapse
|
43
|
Carroll E, Nelson A, Kurzweil A, Zabar S, Lewis A. Using Objective Structured Clinical Exams (OSCE) to Teach Neurology Residents to Disclose Prognosis after Hypoxic Ischemic Brain Injury. J Stroke Cerebrovasc Dis 2021; 30:105846. [PMID: 33984743 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Neurologists need to be adept at disclosing prognosis and breaking bad news. Objective structured clinical examinations (OSCE) allow trainees to practice these skills. METHODS In 2017, in conjunction with the NYU School of Medicine Simulation Center, neurology faculty designed an OSCE case in which a resident had to inform a standardized patient (SP) her father had severe global hypoxic ischemic injury. The residents were surveyed on the experience using a Likert scale from 1 (worst) to 5 (best). The SP completed a behavioral anchored checklist and marked items as "not done," "partly done," or "well done". RESULTS 57 third and fourth year neurology residents completed the case from 2018 to 2020, 54 (95%) of whom completed the post-OSCE survey. Residents reported feeling moderately prepared for the simulation (mean Likert score 3.7/5), and thought their performance was average (3.4/5). Overall, they found the case to be very helpful (4.6/5). The residents performed well in the realms of maintaining professionalism (64% rated "well done"), developing a relationship (62% rated "well done"), and information gathering (61% rated "well done"). There was room for improvement in the realms of providing education and presenting the bad news (39% and 37% rated "partly/not done," respectively). CONCLUSIONS OSCE cases can be used to teach neurology trainees how to discuss prognosis and break bad news. Feedback about this simulation was positive, though its efficacy has yet to be evaluated and could be a future direction of study.
Collapse
Affiliation(s)
- Elizabeth Carroll
- Department of Neurology, NYU Langone Medical Center, 530 1st Ave, HCC-5A, New York 10016, NY, United States.
| | - Aaron Nelson
- Department of Neurology, NYU Langone Medical Center, New York, NY, United States.
| | - Arielle Kurzweil
- Department of Neurology, NYU Langone Medical Center, New York, NY, United States.
| | - Sondra Zabar
- Department of Medicine, NYU Langone Medical Center, New York, NY, United States.
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, United States; Department of Neurosurgery, NYU Langone Medical Center, New York, NY, United States.
| |
Collapse
|
44
|
Shead DC, Ahmed N, Davids RA. Let's Talk About It: What COVID-19 Has Taught a South African Intensive Care Unit About Communication. Dimens Crit Care Nurs 2021; 40:135-138. [PMID: 33792270 PMCID: PMC8030875 DOI: 10.1097/dcc.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
45
|
Amaya Vanegas SV, Gomezese Ribero ÓF. Palliative extubation: obstacles, challenges and solutions. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Life support withdrawal can be a challenging decision, but it should be considered as an option when death is inevitable or recovery to an acceptable quality of life is not possible. The process is beset by obstacles that must be overcome to finally offer patients comfort and a peaceful death.In this article, we offer a series of tools that seek to solve the challenges of palliative extubation, as well as a protocol that could facilitate the decision to withdraw life support, making palliative extubation an alternative to consider instead of artificially prolonging life at the expense of unacceptable human and economic costs.
Collapse
|
46
|
Gambhir HS, Goodrick S, Dhamoon A, Kaul V. Impact of Structured and Scheduled Family Meetings on Satisfaction in Patients Admitted to Hospitalist Service. J Patient Exp 2021; 8:23743735211002748. [PMID: 34179412 PMCID: PMC8205387 DOI: 10.1177/23743735211002748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Effective communication is key to patient satisfaction. Family meetings been shown to be effective in other settings such as critical care and palliative medicine. We evaluated the impact of scheduled and structured family meetings on patients admitted to the hospitalist service in terms of satisfaction with care delivery. More patients in the intervention group reported better understanding of their diagnosis, treatment plan, medications, and discharge plan. Based on these results, we advocate for structured and scheduled family meetings to be implemented as a communication tool for selected patients on the hospital medicine service to improve patient experience and satisfaction.
Collapse
Affiliation(s)
| | - Samantha Goodrick
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Amit Dhamoon
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Viren Kaul
- Division of Pulmonary and Critical Care Medicine, Crouse Health/SUNY Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
47
|
Withdrawal of Mechanical Ventilation: Considerations to Guide Patient and Family Centered Care and the Development of Health Care Policy. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
48
|
Huth K, Growdon AS, Stockman LS, Brett-Fleegler M, Shannon MT, Taylor M, Hundert ES, Kesselheim JC. Establishing trust within interprofessional teams with a novel simulation activity in the pediatric clerkship. J Interprof Care 2020:1-6. [PMID: 33290114 DOI: 10.1080/13561820.2020.1840338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022]
Abstract
Interprofessional trust is essential for effective team-based care. Medical students are transient members of clinical teams during clerkship rotations and there may be limited focus on developing competency in interprofessional collaboration. Within a pediatric clerkship rotation, we developed a novel simulation activity involving an interprofessional conflict, aiming to foster trusting interprofessional relationships. Active participants included a nurse educator and a medical student participant, with additional students using a checklist to actively observe. The debrief focused on teaching points related to interprofessional competencies and conflict resolution. Students completed a written evaluation immediately following the simulation. Descriptive statistics were used to analyze Likert-type scale questions. Conventional content analysis was used to analyze open-ended responses. Two hundred and fourteen students participated in the simulation between June 2018-June 2019. Most students indicated that the simulation was effective (86%) and improved their confidence to constructively manage disagreements about patient care (88%). Students described anticipated changes in practice including developing their role on the interprofessional team as a medical student, developing a shared mental model, and establishing a shared goal. Our findings suggest that simulation-based learning may present an opportunity for developing interprofessional trust in academic health centers.
Collapse
Affiliation(s)
- Kathleen Huth
- Physician, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Amanda S Growdon
- Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Leah S Stockman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Marisa Brett-Fleegler
- Physician, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Teresa Shannon
- East Nurse Education Coordinator, Boston Children's Hospital, Boston, MA, USA
| | - Matthew Taylor
- Curriculum Development Manager, Simulator Program, Boston Children's Hospital, Boston, MA, USA
| | | | - Jennifer C Kesselheim
- Pediatrics, Harvard Medical School, Boston, MA, USA
- Pediatric Hematology-Oncology, Boston Children's/Dana-Farber Cancer and Blood Disorders Center, Boston, MA, USA
| |
Collapse
|
49
|
Roze des Ordons AL, Au S, Blades K, Stelfox HT. Family participation in ICU rounds-Working toward improvement. J Eval Clin Pract 2020; 26:1620-1628. [PMID: 31916653 DOI: 10.1111/jep.13345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Family participation in Intensive Care Unit (ICU) bedside rounds has been advocated as a way to improve communication between families and health care providers; however, the associated impact and modulators have not been fully described. The purpose of this study was to explore benefits, drawbacks, barriers, and facilitators to family participation in ICU rounds in order to inform ways to improve how families are integrated into rounds. METHODS This was a qualitative exploratory study of ICU patients' family members (n = 29) and health care providers (n = 35) who work in ICU settings. Interviews and focus groups were conducted, and thematic analysis was used for data analysis. RESULTS Benefits and drawbacks for families were related to knowledge and emotional impact and for health care providers were related to knowledge and transparency, with rapport as an additional benefit and logistical impact as a drawback. Barriers and facilitators during rounds and outside of rounds were identified, and suggestions for improvement included preparing and orienting families, summarizing, teaching modifications, follow-up, and organizational culture. CONCLUSIONS Our study provides insight into the multiple processes involved in family participation in ICU rounds, along with suggestions for improvement. Our findings may help guide development of a structured approach to family participation in ICU rounds that can be adapted to local contexts.
Collapse
Affiliation(s)
- Amanda L Roze des Ordons
- Department of Critical Care Medicine; Department of Anesthesiology; Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Selena Au
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kenneth Blades
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
| |
Collapse
|
50
|
Validation and Analysis of the European Quality Questionnaire in Italian Language. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17238852. [PMID: 33260777 PMCID: PMC7729862 DOI: 10.3390/ijerph17238852] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 01/28/2023]
Abstract
The European Quality Questionnaire (euroQ2) is the culturally-adapted version to the European context of the Family Satisfaction in Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) tools in a single instrument divided into three parts (the last is optional). These tools were created for an adult setting. The aim of this study was the Italian validation and analysis of the euroQ2 tool. The Italian version of euroQ2 questionnaire was administered to the relatives, over 18 years of age, of adult intensive care unit patients, with the Hospital Anxiety and Depression Scale (HADS) and the Impact of Event Scale—Revised (IES-r). For the re-test phase the questionnaire was administered a second time. One hundred questionnaires were filled in. The agreement between test and retest was between 17–19 out of 20 participants with an upward trend in the re-test phase. A measure of coherence and cohesion between the euroQ2 variables was given by Cronbach’s alpha: in the first part of the questionnaire alpha was 0.82, in the second part it was 0.89. The linear Pearson’s correlation coefficients between all questions showed a weak positive correlation. The results obtained agreed with the original study. This study showed a good stability of the answers, an indication of an unambiguous understanding of the Italian translation.
Collapse
|