Clinician-Family Communication About Patients' Values and Preferences in Intensive Care Units

Goal-Concordance in Children with Complex Chronic Conditions

OBJECTIVES

To characterize delivery of goal-concordant end-of-life (EOL) care among children with complex chronic conditions and to determine factors associated with goal-concordance.

STUDY DESIGN

This was a retrospective review of goals of care discussions for 272 children with at least 1 complex chronic condition who died at a tertiary care hospital between January 1, 2014, and December 31, 2017. Goals of care and code status were assessed before and within the last 72 hours of life. Goals of care discussions were coded as full interventions; considering withdrawal of interventions (palliation); planned transition to palliation; or actively transitioning/transitioned to palliation.

RESULTS

In total, 158 children had documented goals of care discussions before and within the last 72 hours of life, 18 had goals of care discussions only >72 hours before death, 54 only in the last 72 hours of life, and 42 had no documented goals of care. For children with goals of care, EOL care was goal-concordant for 82.2%, discordant in 7%, and unclear in 10.8%. Black children had a greater than 8-fold greater odds of discordant care compared with White children (OR 8.34, P = .007). Comparison of goals of care and code status before and within the last 72 hours of life revealed trends toward nonescalation of care. Specifically, rates of active palliation increased from 11.7% to 63.0%, and code status shifted from 32.6% do not resuscitate to 65.2% (P < .001).

CONCLUSIONS

In this cohort, a majority of children had documented goals of care discussions and received goal-concordant EOL care. However, Black children had greater odds of receiving goal-discordant care. Goals of care and code status shifted toward palliation during the last 72 hours of life.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs

INTRODUCTION

Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs.

METHODS

Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians.

RESULTS

Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts.

CONCLUSION

Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.

Integrating Narrative Goals of Care in the Medical Intensive Care Unit: Impact on Educational and Clinical Outcomes

Background

High-quality goals of care (GOC) communication is fundamental to providing excellent critical care.

Objective

Educate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation.

Methods

Guided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19).

Results

All PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% (P < 0.05); for patients age ⩾80 years, 3.54% versus 29.41% (P < 0.05); and for patients with MICU length of stay ⩾7 days, 2.78% versus 24.44% (P < 0.05).

Conclusion

Combining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.

Communication Quality Analysis: A user-friendly observational measure of patient-clinician communication

Communication Quality Analysis (CQA) is a rigorous transcript-based coding method for assessing clinical communication quality. We compared the resource-intensive transcript-based version with a streamlined real-time version of the method with respect to feasibility, validity, reliability, and association with traditional measures of communication quality. Simulated conversations between 108 trainees and 12 standardized patients were assessed by 7 coders using the two versions of CQA (transcript and real-time). Participants also completed two traditional communication quality assessment measures. Real-time CQA was feasible and yielded fair to excellent reliability, with some caveats that can be addressed in future work. CQA ratings were moderately correlated with traditional measures of communication quality, suggesting that CQA captures different aspects of communication quality than do traditional measures. Finally, CQA did not exhibit the ceiling effects observed in the traditional measures of communication quality. We conclude that real-time CQA is a user-friendly method for assessing communication quality that has the potential for broad application in training, research, and intervention contexts and may offer improvements to traditional, self-rated communication measures.

Establishing Goals of Care

Establishing goals of care (GOC) is a crucial component of a patient's treatment plan. The need for better physician-patient communication in this area has been recognized for decades, yet several gaps remain. Challenges exist for both physician and patient. Physicians should pursue a patient-led approach, exercise cultural competency, and use various communication techniques to guide patients when establishing GOC.

Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill

Background

Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.

Methods

The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset.

Results

In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008].

Conclusions

Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03971-9.

Differing Conceptualizations of the Goals of Care Discussion: A Critical Discourse Analysis

CONTEXT

The goals of care discussion (GOCD) has been positioned as an improvement strategy to address discordance between care decisions made by seriously ill patients and care received. Interventions aimed at improving GOCDs however have had limited success. This may in part be due to the considerable variation in views on the essential components and expected outcomes of a GOCD. This variability, and consequently clinical approaches to GOCDs, may reflect fundamental differences in how the GOCD is conceptualized.

OBJECTIVE

To identify and characterize differing conceptualizations of the GOCD.

METHODS

Critical discourse analysis was used to qualitatively examine GOCDs documented for inpatients of 35 Canadian palliative medicine (PM), critical care medicine (CCM) and general internal medicine (GIM) physicians. Patterns in the ways the GOCD had been constructed were characterized by identifying different aspects of the approaches used by clinicians.

RESULTS

GOCD notes varied in the predominant style and tone (from narrative to biomedical), predominant information source (patient/family to physician), and contribution of the patient's perspective. Notably binary differences were also found in the locus of goals and located either with the patient or with the broad concept of treatments. Although not exclusively, locus of goals tended to be with the patient among PM physicians and with treatments among CCM and GIM physicians.

CONCLUSION

These findings offer clinical evidence for differing conceptualizations of the GOCD and orientations to goals as either person-centered or treatment-centered. This phenomenon may be in part discipline-based and has important implications for both clinical practice and training experiences.

Decision Making for Infants With Neurologic Conditions

Parents and clinicians caring for infants with neurologic disease often make high-stakes decisions about infant care. To characterize how these decisions occur, we enrolled infants with neurologic conditions, their parents, and their clinicians in a longitudinal mixed methods study of decision making. We audio recorded family conferences as they occurred and analyzed conferences using a directed content analysis approach. We enrolled 40 infants and 61 parents who participated in 68 family conferences. Thirty-seven conferences contained a treatment decision. We identified 4 key domains of the decision-making process: medical information exchange, values-based exchange, therapeutic partnership, and integration of values into decision making. Discussion of values was typically parent initiated (n = 20, 83%); approximately one-third of conferences did not contain any discussion of parent values. Integration of family values and preferences into decision making occurred in approximately half of conferences. These findings highlight opportunities for interventions that promote values discussion and the integration of values into decision making.

Ethical reflection support for potential organ donors' relatives: A narrative review

BACKGROUND

Even in countries with an opt-out or presumed consent system, relatives have a considerable influence on the post-mortem organ harvesting decision. However, their reflection capacity may be compromised by grief, and they are, therefore, often prone to choose refusal as default option. Quite often, it results in late remorse and dissatisfaction. So, a high-quality reflection support seems critical to enable them to gain a stable position and a long-term peace of mind, and also avoid undue loss of potential grafts. In practice, recent studies have shown that the ethical aspects of reflection are rarely and often poorly discussed with relatives and that no or incomplete guidance is offered. No review of the literature is available to date, although it could be of value to improve the quality of the daily practice.

OBJECTIVES

The objective was to review and synthesize the main concepts and approaches, theories and practices of ethical reflection support of the relatives or surrogates of potential post-mortem organ donors.

RESEARCH DESIGN

A narrative review was performed in the medical, psychological and ethical fields using PubMed, PsycArticles and Web of Science databases (1980-2020).

RESULTS

Out of 150 papers, 25 were finally retained. Four themes were drawn: the moral status of the potential post-mortem organ donor, the principlistic approach with its limits and critics, the narrative approach and the transcendental approach.

DISCUSSION

This review suggests an extension of psychological support towards ethical reflection support. The process of helping relatives in their ethical exploration of post-mortem organ donation is psychologically and morally characterized. The need for specialized professionals educated and experienced both in clinical psychology and in health ethics to carry out this task is discussed.

PRACTICAL IMPACT

This review could contribute to optimize the quality of the ethical reflection support by initiating an evolution from an empirical, partial and individual-dependent support to a more systematized, professionalized and exhaustive support.

Association between prognostic awareness and quality of life in patients with advanced cancer

PURPOSE

Despite the current guidelines supporting open communication about serious news, the evidence about the impact of prognostic awareness on the quality of life in cancer patients is not clear. The aim of this study was to assess the association between quality of life and prognostic awareness in patients with advanced cancer.

METHODS

This was a cross-sectional study which involved patients (n = 129) with incurable advanced cancer (estimated by oncologist using 12-month surprise question). Data were collected at oncology departments at 3 hospitals using structured interview in which patients were asked about their quality of life (using Integrated Palliative Outcome Scale-IPOS and a single-item global measure), prognostic awareness, information needs and demographics.

RESULTS

Only 16% of the sample was completely aware of prognosis and 57% was partially aware. Accurate prognostic awareness was significantly associated (p = 0.02) with lower level of quality of life between (when measured by both the IPOS and the single-item scale) patients with accurate prognostic awareness (M = 37.1; 10.4) and partially aware (M = 31.9; 9.1) and unaware patients (M = 30; 7.4). Detailed analysis showed that significant difference between groups was found only for physical symptoms subscales (p = 0.002), not for emotional and communication subscales.

CONCLUSION

Prognostic awareness was found to be negatively associated with physical domain of quality of life, but not with emotional and communication domains. More research is needed on personality factors that might influence the development of prognostic awareness and quality of life.

Experience of African American Surrogate Decision Makers of Patients With Dementia

Dementia cases are expected to grow for African Americans and surrogate decision makers (SDMs) will have a significant role at the end of life (EOL). This qualitative exploratory case study used Cognitive Task Analysis and an integrated conceptual framework to understand the EOL decision experience of African American SDMs for patients with advanced dementia. Using a holistic multiple-case design, 8 African American SDMs were interviewed about their experiences with the decision-making process, including role acceptance, role enactment, and emotional outcomes of decision making. Thirteen themes germane to understanding the EOL decision experience of African American SDMs were identified. Findings suggest African American SDMs often lack sufficient knowledge of disease prognosis and intervention options to make informed treatment choices at EOL. In particular, African Americans extend the caregiver role to SDM for patients with dementia at EOL without being fully aware of the role and decision-making responsibilities. Surrogates lacked a general understanding of EOL options resulting in underutilization of hospice and palliative care and subsequent regret, and few interventions exist to improve the uptake of EOL care services. There is a need to develop culturally appropriate role preparation, education, and decision support to improve EOL treatment decisions and emotional adjustment of surrogates of patients with advanced dementia, which should be rendered early and throughout the illness trajectory.

Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study

IMPORTANCE

Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST.

OBJECTIVES

Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST.

DESIGN SETTING AND PARTICIPANTS

Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians.

MAIN OUTCOMES AND MEASURES

Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression.

RESULTS

Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198).

CONCLUSIONS AND RELEVANCE

It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.

Patient perspectives on states worse than death: A qualitative study with implications for patient-centered outcomes and values elicitation

BACKGROUND

Seriously ill patients rate several health outcomes as states worse than death. It is unclear what factors underlie such valuations, and whether consideration of such states is useful when making medical decisions.

AIM

We sought to (1) use qualitative approaches to identify states worse than death, (2) identify attributes common to such undesirable health states, and (3) determine how participants might use information on these states in making medical decisions.

DESIGN

Qualitative study of semi-structured interviews utilizing content analysis with constant comparison techniques.

SETTING, PARTICIPANTS

We interviewed adults age 65 or older with serious illnesses after discharge home from one of two urban, academic hospitals. Eligible patients were purposively sampled to achieve balance in gender and race.

RESULTS

Of 29 participants, 15 (52%) were female, and 15 were white (52%), with a median age of 72 (interquartile range 69, 75). Various physical, cognitive, and social impairments were identified as states worse than death. The most commonly reported attributes underlying states worse than death were perceived burden on loved ones and inability to maintain human connection. Patients believed information on states worse than death must be individualized, and were concerned their opinions could change with time and fluctuations in health status.

CONCLUSIONS

Common factors underlying undesirable states suggest that for care to be patient-centered it must also be family-centered. Patients' views on using states worse than death in decision making highlight barriers to using avoidance of such states as a quality measure, but also suggest opportunities for eliciting patients' values.

Physicians' cognitive approach to prognostication after cardiac arrest

OBJECTIVE

Elucidate how physicians formulate a neurological prognosis after cardiac arrest and compare differences between experts and general providers.

METHODS

We performed semi-structured interviews with experts in post-arrest care and general physicians. We created an initial model and interview guide based on professional society guidelines. Two authors independently coded interviews based on this initial model, then identified new topics not included in it. To describe individual physicians' cognitive approach to prognostication, we created a graphical representation. We summarized these individual "mental models" into a single overall model, as well as two models stratified by expertise.

RESULTS

We performed 36 interviews (17 experts and 19 generalists), most of whom practice in Europe (23) or North America (12). Participants described their approach to prognosis formulation as complex and iterative, with sequential and repeated data acquisition, interpretation, and prognosis formulation. Eventually, this cycle results in a final prognosis and treatment recommendation. Commonly mentioned factors were diagnostic test performance, time from arrest, patient characteristics. Participants also discussed factors rarely discussed in prognostication research including physician and hospital characteristics. We found no substantial differences between experts and general physicians.

CONCLUSION

Physicians' cognitive approach to neurologic prognostication is complex and influenced by many factors, including some rarely considered in current research. Understanding these processes better could inform interventions designed to aid physicians in prognostication.

Healthcare providers' perception of advance care planning for patients with critical illnesses in acute-care hospitals: a cross-sectional study

Background

In acute-care hospitals, patients treated in an ICU for surgical reasons or sudden deterioration are treated in an outpatient ward, ICU, and other multiple departments. It is unclear how healthcare providers are initiating advance care planning (ACP) for such patients and assisting them with it. The purpose of this study is to clarify healthcare providers’ perceptions of the ACP support provided to patients receiving critical care in acute-care hospitals.

Methods

A cross-sectional study was conducted using questionnaires. In this study, 400 acute-care hospitals with ICUs in Japan were randomly selected, and 1490 subjects, including intensivists, surgeons, ICU nurses, surgical floor nurses, and surgical outpatient nurses, participated. Survey items examined whether ICU patients received ACP support, the participants’ degree of confidence in providing ACP support, the patients’ treatment preferences, and the decision-making process, and whether any discussion was conducted on change of values.

Results

Responses were obtained from 598 participants from 157 hospitals, 41.4% of which reportedly supported ACP provision to ICU patients. The subjects with the highest level of ACP understanding were surgeons (45.8%), and differences in understanding were observed across specialties (P < 0.001). Among the respondents, physicians and nurses expressed high levels of confidence in providing ACP support to patients requiring critical care. However, 15.2% of all the subjects mentioned that they would not attempt to resuscitate the patients. In addition, 25.7% of the participants handed over patients’ values to other departments or hospitals, whereas 25.3% handed over the decision-making process.

Conclusions

Among the participating hospitals, 40% provided ACP support to patients receiving critical care. The low number is possibly because support providers lack understanding of the content of patients’ ACP or about how to support and use ACP. Second, it is sometimes too late to start providing ACP support after ICU admission. Third, healthcare providers differ in their perception of ACP, widely considered an ambiguous concept. Finally, in acute-care hospitals with different healthcare settings, it is necessary to confirm and integrate the changes in feelings and thoughts of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00900-5.

Using long-term predicted Quality of Life in ICU clinical practice to prepare patients for life post-ICU: A feasibility study

PURPOSE

To examine the feasibility of using the PREdicting PAtients' long-term outcome for Recovery (PREPARE) prediction model for Quality of Life (QoL) 1 year after ICU admission in ICU practice to prepare expected ICU survivors and their relatives for life post-ICU.

MATERIALS AND METHODS

Between June 2020 and February 2021, the predicted change in QoL after 1 year was discussed in 25 family conferences in the ICU. 13 physicians, 10 nurses and 19 patients and/or family members were interviewed to evaluate intervention feasibility in ICU practice. Interviews were analysed qualitatively using thematic coding.

RESULTS

Patients' median age was 68.0 years, five patients (20.0%) were female and seven patients (28.0%) died during ICU stay. Generally, study participants thought the intervention, which clarified the concept of QoL through visualization and served as a reminder to discuss QoL and expectations for life post-ICU, had merit. However, some participants, especially physicians, thought the prediction model needed more data on more severely ill ICU patients to curb uncertainty.

CONCLUSIONS

Using predicted QoL scores in ICU practice to prepare patients and family members for life after ICU discharge is feasible. After optimising the model and implementation strategy, its effectiveness can be evaluated in a larger trial.

Making Family-Centered Care for Adults in the ICU a Reality

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.

How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: A qualitative study

BACKGROUND

Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach.

AIM

To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care.

DESIGN

Exploratory inductive thematic analysis of 101 audio-recorded conversations.

SETTING/PARTICIPANTS

One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated.

RESULTS

We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches-a shared approach or a physician-driven approach-or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences.

CONCLUSIONS

Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences.

The Effect of Chaplain Patient Navigators and Multidisciplinary Family Meetings on Patient Outcomes in the ICU: The Critical Care Collaboration and Communication Project

OBJECTIVES

To assess the effectiveness of a chaplain patient navigator in improving outcomes and reducing costs in the ICU setting.

DESIGN

A randomized controlled trial at a large, urban, academic community hospital in Baltimore, Maryland.

SETTING/PATIENTS

All patients admitted to the Johns Hopkins Bayview Medical Center Cardiac and Medical ICUs between March 2015 and December 2015.

INTERVENTIONS

Patients in the intervention group were assigned a chaplain patient navigator to facilitate communication, offer support, and setup multidisciplinary family meetings.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were hospital and ICU length of stay. Secondary outcomes included total and ICU charges, 60- and 90-day readmission rates, and the number of palliative care consults. For all outcomes, patients were included in the intention-to-treat analyses only if they remained in the ICU greater than 24 hours. In total, 1,174 were randomly assigned to "usual care" (n = 573) or to the intervention (n = 601). In the intervention group, 44.8% (269/601) had meetings within 24 hours of admission and, of those patients, 32.8% (88/268) took part in the larger multidisciplinary family meeting 2-3 days later. The intervention group had longer mean adjusted hospital length of stay (7.78 vs 8.63 d; p ≤ 0.001) and mean ICU length of stay (3.65 vs 3.87 d; p = 0.029). In addition, they had greater total and ICU charges. There were no differences in other outcomes. Of note, only differences in total and ICU charges remained when controlling for case-mix index, which were greater in the intervention group.

CONCLUSIONS

Although the chaplain patient navigator anecdotally enhanced communication, our study found an increase in hospital and ICU length of stay as well as cost. Since other studies have shown benefits in some clinical outcomes, projects focused on patient navigators may learn lessons from our study in order to better prioritize family meetings, gather indicators of communication quality, and identify the optimal patient navigator operational context.

Evidence-Based Communication with Critically Ill Older Adults

Communication is a critical component of patient-centered care. Critically ill, mechanically ventilated patients are unable to speak and this condition is frightening, frustrating, and stressful. Impaired communication in the intensive care unit (ICU) contributes to poor symptom identification and restricts effective patient engagement. Older adults are at higher risk for communication impairments in the ICU because of pre-illness communication disorders and cognitive dysfunction that often accompanies or precedes critical illness. Assessing communication disorders and developing patient-centered strategies to enhance communication can lessen communication difficulty and increase patient satisfaction.

Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives

Background

Palliative care is a person-centered approach aiming to relieve patient’s health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care.

Aim

To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context.

Methods

For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years.

Results

Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient–physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident.

Conclusion

Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.

Use of Online Medical Records to Support Medical Decision Making: A Cross-Sectional Study of US Adults

The use of online medical records has increased over time and may enhance patient involvement in medical decisions. We explored sociodemographic, medical condition, and digital health correlates of using online medical records to support medical decision making. Cross-sectional data from the 2019 Health Information National Trends Survey (HINTS 5, Cycle 3, N = 5438) were analyzed. Final analyses included participants who accessed their online medical records within 12 months and had complete data for all variables (n = 1807). The outcome was, "In the past 12 months have you used your online medical record to help you make a decision about how to treat an illness or condition (yes/no)?" Univariate and multivariate odds ratios and 95% confidence intervals were calculated. Multivariately, the odds of using online medical records to support medical decision making were significantly higher for individuals who (a) used online medical records to securely send messages to health care providers, (b) used a smartphone health app to access their online medical records, (c) had online medical records that contained clinical notes, (d) reported that online medical records were useful for monitoring health, and (e) self-identified as African American, Asian, or "Other." Online medical records may support medical decision making depending on the context.

Reasons for physician-related variability in end-of-life decision-making in intensive care

BACKGROUND

There is increasing evidence that the individual physician is the main factor influencing variability in end-of-life decision-making in intensive care units. End-of-life decisions are complex and should be adapted to each patient. Physician-related variability is problematic as it may result in unequal assessments that affect patient outcomes. The primary aim of this study was to investigate factors contributing to physician-related variability in end-of-life decision-making.

METHOD

This is a qualitative substudy of a previously conducted study. In-depth thematic analysis of semistructured interviews with 19 critical care specialists from five different Swedish intensive care units was performed. Interviews took place between 1 February 2017 and 31 May 2017.

RESULTS

Factors influencing physician-related variability consisted of different assessment of patient preferences, as well as intensivists' personality and values. Personality was expressed mainly through pace and determination in the decision-making process. Personal prejudices appeared in decisions, but few respondents had personally witnessed this. Avoidance of criticism and conflicts as well as individual strategies for emotional coping were other factors that influenced physician-related variability. Many respondents feared criticism for making their assessments, and the challenging nature of end-of-life decision-making lead to avoidance as well as emotional stress.

CONCLUSION

Variability in end-of-life decision-making is an important topic that needs further investigation. It is imperative that such variability be acknowledged and addressed in a more formal and transparent manner. The ethical issues faced by intensivists have recently been compounded by the devastating impact of the COVID-19 pandemic, demonstrating in profound terms the importance of the topic.

Distinct Death-Preparedness States by Combining Cognitive and Emotional Preparedness for Death and Their Evolution for Family Caregivers of Terminally Ill Cancer Patients Over Their Last 6 Months of Life

CONTEXT

To identify caregivers' death-preparedness states by combining cognitive and emotional preparedness for their loved one's death as well as their evolution over cancer patients' last 6 months, which have never been explored.

METHODS

Death-preparedness states and their evolution were examined by hidden Markov modeling among 393 caregivers of cancer patients.

RESULTS

Four death-preparedness states were identified: no death preparedness, cognitive death preparedness only, emotional death preparedness only, and sufficient death preparedness. Caregivers in the no-death-preparedness state had neither accurate cognitive prognostic awareness (PA) nor adequate emotional preparedness for death. Caregivers in the sufficient-death-preparedness state reported accurate PA and adequate emotional preparedness for death. In the cognitive- and emotional-death-preparedness-only states, caregivers were accurately aware of the patient's prognosis and adequately emotionally prepared for his/her forthcoming death only, respectively. Prevalence of the sufficient-death-preparedness state fluctuated within a narrow range (40.8%-43.2%) over the patient's last six months. Proportions of caregivers decreased in the emotional-death-preparedness-only (19.5%-6.5%) and no-death-preparedness (21.0%-8.2%) states, whereas prevalence of the cognitive-death-preparedness-only state increased substantially (16.3%-44.4%) to become the most prevalent state as death approached.

CONCLUSION

Caregivers of cancer patients heterogeneously experienced combined cognitive and emotional preparedness for death. About 40% of caregivers consistently had sufficient death preparedness over their loved one's dying process. Evaluating these different aspects of death preparedness could be an important approach in high-quality end-of-life care by not only cultivating caregivers' cognitive PA, but also facilitating their emotional preparedness for the patient's death, thus helping caregivers prepare well for their loved one's forthcoming death.

Predictors to forgo resuscitative effort during Covid-19 critical illness at the height of the pandemic : A retrospective cohort study

BACKGROUND

Early in the Covid-19 pandemic, there was uncertainty regarding critical illness prognosis and challenges to traditional face-to-face family meetings. Ethnic minority populations have suffered disproportionately worse outcomes during the pandemic, which may in part relate to differences in end-of-life decision-making.

AIM

Characterize patterns of and factors associated with decisions to forgo resuscitative efforts, as measured by do-not-resuscitate orders, during critical illness with Covid-19.

DESIGN

Retrospective cohort with medical record abstraction.

SETTING/PARTICIPANTS

Adult patients diagnosed with SARS-Cov-2 virus via polymerase chain reaction and admitted to the intensive care unit at an academic hospital, which cares for the city's underserved communities, between March 1 and June 7, 2020 who underwent invasive mechanical ventilation for at least 48 hours.

RESULTS

In this cohort (n = 155), 45% were black people, and 51% spoke English as their primary language. Median time to first goals-of-care conversation was 3.9 days (IQR 1.9-7.6) after intensive care unit admission. Overall 61/155 patients (39%) transitioned to do-not-resuscitate status, and 50/62 (82%) patients who died had do-not-resuscitate orders. Multivariate analysis shows age and palliative care involvement as the strongest predictors of decision to instate do-not-resuscitate order. There was no association between race, ethnicity, or language and decisions to forego resuscitation.

CONCLUSIONS

During this time of crisis and uncertainty with limited resources and strained communication, time to first goals of care conversation was shorter than in pre-pandemic studies, but rates of foregoing resuscitation remained similar, with no differences observed by race, ethnicity, or language. This study suggests that early palliative care involvement and non-traditional communications, including videoconferencing, to facilitate goals of care conversations could have mitigated potential disparities in end-of-life decision making patterns during the pandemic.

Tracheostomy Decision-making Communication among Patients Receiving Prolonged Mechanical Ventilation

Rationale: Patients receiving prolonged mechanical ventilation experience high morbidity and mortality, poor quality of life, and significant caregiving and financial burden. It is unclear what is discussed with patients and families during the tracheostomy decision-making process.Objectives: The aim of this study was to identify themes of communication related to tracheostomy decision-making in patients receiving prolonged mechanical ventilation and to explore patient and clinical factors associated with more discussion of these themes.Methods: We conducted a mixed-methods study involving adult patients in medical or cardiac intensive care units who received continuous mechanical ventilation for ≥7 days and were considered for tracheostomy placement during the same admission. We performed a consensus-driven review of documented family meeting conversations to identify characteristics and themes related to tracheostomy decision-making. A multivariate analysis was performed to investigate patient and clinical factors associated with the discussion of one or more of the identified themes.Results: Of the 241 patients included, 191 (79.2%) had at least one documented conversation regarding tracheostomy decision-making, and 148 (61.4%) required further discussions before reaching a decision. We identified the following four themes related to tracheostomy decision-making: patient's previously expressed preferences, patient's baseline condition and functional status, long-term complications, and long-term prognosis. Of the documented conversations, 45.3% addressed none of the identified themes. Patients who did not undergo tracheostomy placement were more likely to have documented discussion of one or more themes compared with those who did (74.6% vs. 41.6%). In multivariate analysis, age ≥75, female sex, significant preadmission functional dependence, home oxygen requirement, and involvement of palliative care were associated with more documented discussion of one or more themes.Conclusions: Our findings suggest inadequate information exchange regarding patient preferences and long-term prognosis during tracheostomy decision-making, especially among patients who went on to pursue tracheostomy. There is a critical need to promote effective shared decision-making to better align tracheostomy intervention with patient values and to prevent unwanted health states at the end of life.

Shared decision-making in the ICU from the perspective of physicians, nurses and patients: a qualitative interview study

OBJECTIVE

To identify views, experiences and needs for shared decision-making (SDM) in the intensive care unit (ICU) according to ICU physicians, ICU nurses and former ICU patients and their close family members.

DESIGN

Qualitative study.

SETTING

Two Dutch tertiary centres.

PARTICIPANTS

19 interviews were held with 29 participants: seven with ICU physicians from two tertiary centres, five with ICU nurses from one tertiary centre and nine with former ICU patients, of whom seven brought one or two of their close family members who had been involved in the ICU stay.

RESULTS

Three themes, encompassing a total of 16 categories, were identified pertaining to struggles of ICU physicians, needs of former ICU patients and their family members and the preferred role of ICU nurses. The main struggles ICU physicians encountered with SDM include uncertainty about long-term health outcomes, time constraints, feeling pressure because of having final responsibility and a fear of losing control. Former patients and family members mainly expressed aspects they missed, such as not feeling included in ICU treatment decisions and a lack of information about long-term outcomes and recovery. ICU nurses reported mainly opportunities to strengthen their role in incorporating non-medical information in the ICU decision-making process and as liaison between physicians and patients and family.

CONCLUSIONS

Interviewed stakeholders reported struggles, needs and an elucidation of their current and preferred role in the SDM process in the ICU. This study signals an essential need for more long-term outcome information, a more informal inclusion of patients and their family members in decision-making processes and a more substantial role for ICU nurses to integrate patients' values and needs in the decision-making process.

Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment

Background

To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient.

Methods

Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care.

Results

A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves.

Conclusion

The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03712-4.

Goals of Care Discussions Over the Course of a Patient's End of Life Admission: A Retrospective Study

BACKGROUND

As deaths in hospitals increase, clear discussions regarding resuscitation status and treatment limitations, referred to as goals of care (GOC), are vital. GOC may need revision as disease and patient priorities change over time. There is limited data about who is involved in GOC discussions, and how this changes as patients deteriorate in hospital.

AIMS

To review the timing and clinicians involved in GOC discussions for a cohort of patients who died in hospital.

METHODS

Retrospective observational audit of 80 consecutive end of life admissions between March 11th and April 9th, 2019.

RESULTS

Of 80 patients, 75 (93.6%) had GOC recorded during their admission, about half for ward-based non-burdensome symptom management or end-of-life care. GOC were revised in 68.0% of cases. Medical staff involved in initial versus final GOC discussions included home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were involved in 34.7% versus 31.4%, and family in 53.3% versus 86.3%. Dying was documented for 92.0% of patients and this was documented to have been communicated to the family and patient in 98.6% and 19.5% of cases respectively.

CONCLUSIONS

As patients deteriorated, family and senior clinician involvement in GOC discussions increased, but patient involvement did not. Junior doctors were most heavily involved in discussions. We advocate for further GOC training and modeling to enhance junior doctors' confidence and competence in conducting and involving patients and families in GOC conversations.

Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study

BACKGROUND

End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices.

METHODS

In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision.

FINDINGS

Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation.

INTERPRETATION

Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide.

FUNDING

None.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Population Preferences for Treatments When Critically Ill: A Discrete Choice Experiment

BACKGROUND

Many patients in the intensive care unit are too unwell to participate in shared decision making or have not previously documented their wishes. In these situations, understanding the values of the general population could help doctors provide appropriate guidance to surrogate decision makers.

METHODS

Using a discrete choice experiment design, we conducted an online survey using an Australian panel. Participants were asked about their willingness to accept treatments, faced with a variety of possible outcomes and probabilities (low, moderate or high). The outcomes were across four domains: loss of functional autonomy, pain, cognitive disability and degree of burden on others. Demographic details, prior experience of intensive care unit and current health conditions were also collected. Data were analysed using logistic regression, predicting whether respondents choose to continue active treatment or not.

RESULTS

Nine hundred and eighty-four respondents, representative of age and sex completed the web-based survey. With the increasing likelihood of negative post-intensive care unit sequelae, there was a higher probability of the respondent preferring to stop ongoing active treatment, with the largest coefficients being on caring assistance and the need for full-time residential care. Those who identified as very religious, were younger or who had children under 5 years of age were more likely to choose to continue active treatment.

CONCLUSIONS

Respondents valued their independence as the most important factor in deciding whether to receive ongoing medical treatments in the intensive care unit. When clinicians are unable to obtain specific patient information, they should consider framing their decision making around the likelihood of the patient achieving functional independence rather than survival.

Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study

Supplemental Digital Content is available in the text.

To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries.

Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

BACKGROUND

There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions.

METHODS

Case report and discussion of the associated ethical issues.

RESULTS

We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team.

CONCLUSION

It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Quality of end-of-life communication in 2 high-risk ICU cohorts: a retrospective cohort study

BACKGROUND

Factors influencing the quality of end-of-life communication are relevant to improving end-of-life care. We assessed the quality of end-of-life communication and influencing factors in 2 intensive care unit (ICU) cohorts at high risk of death: patients living in nursing homes and those on extracorporeal membrane oxygenation (ECMO).

METHODS

This retrospective cohort study included admissions to 4 ICUs in Winnipeg, Manitoba, from 2000 to 2017. We identified cohorts and influencing factors from the Winnipeg ICU database and by manual chart review. We assessed quality of end-of-life communication using 18 validated, binary quality indicators to calculate a weighted, scaled, composite score (range 0-100). We used median regression to identify factors associated with the composite score.

RESULTS

The ECMO cohort (n = 109) was younger than the nursing home cohort (n = 230), with longer hospital stays and higher disease severity. Mean composite scores of end-of-life communication were extremely low in both cohorts (mean 48.5 [standard error of the mean (SEM) 1.7] for the nursing home cohort, 49.1 [SEM 2.5] for the ECMO cohort). Patient characteristics associated with higher median composite scores were older age (5.0 per decade, 95% confidence interval [CI] 2.1-7.8) and lower (worse) Glasgow Coma Scale (GCS) scores (1.8 per GCS point, 95% CI 0.5-3.2). The median composite score rose significantly over time (1.7 per year, 95% CI 0.5-2.8).

INTERPRETATION

The quality of end-of-life communication in ICUs is poor, and factors associated with better prognosis are also associated with worse communication. Direct and early communication should occur with all patients in the ICU and their surrogates, not just those who are believed most likely to die.

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

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

Conjoint cognitive and emotional death-preparedness states and their changes within cancer patients' last 6 months

BACKGROUND/OBJECTIVE

Cognitive prognostic awareness (PA) and emotional preparedness for death are distinct but related concepts that have rarely been investigated conjointly and without considering the dynamic nature of death preparedness. To fill this gap, this secondary-analysis study identified distinct patterns/states of death preparedness and their changes within cancer patients' last 6 months.

METHODS

Distinct death-preparedness states, determined by conjoint cognitive PA and emotional preparedness for death, as well as their changes between consecutive times were identified and estimated, respectively, by latent transition modeling with hidden Markov modeling among 383 cancer patients within their last 6 months.

RESULTS

Four death-preparedness states (prevalence) were initially identified: no death preparedness (17.1%), cognitive death preparedness only (23.3%), emotional death preparedness only (39.9%), and sufficient death preparedness (19.7%). Patients in the no-death-preparedness state had neither accurate PA nor adequate emotional preparedness for death. The sufficient-death-preparedness state was characterized by both accurate PA and adequate emotional preparedness for death. In the cognitive- and emotional-death-preparedness-only states, patients were accurately aware of their prognosis and adequately emotionally prepared for their forthcoming death only, respectively. As death approached, state prevalence fluctuated within a narrow range for the no- and sufficient-death-preparedness states, whereas prevalence of cognitive- and emotional-death-preparedness-only states increased and decreased substantially, respectively.

CONCLUSION

Cancer patients heterogeneously experienced conjoint cognitive PA and emotional preparedness for death, and prevalence of death-preparedness states changed substantially as death approached. Effective interventions are warranted to cultivate cognitive PA and facilitate emotional death-preparedness to improve end-of-life-care quality, thereby helping patients achieve a good death.

End-of-Life-Care Quality in ICUs Is Associated With Family Surrogates' Severe Anxiety and Depressive Symptoms During Their First 6 Months of Bereavement

OBJECTIVES

Evidence linking end-of-life-care quality in ICUs to bereaved family members' psychologic distress remains limited by methodological insufficiencies of the few studies on this topic. To examine comprehensively the associations of family surrogates' severe anxiety and depressive symptoms with end-of-life-care quality in ICUs over their first 6 months of bereavement.

DESIGN

Prospective, longitudinal, observational study.

SETTING/PARTICIPANTS

Family surrogates (n = 278) were consecutively recruited from seven medical ICUs at two academically affiliated medical centers in Taiwan.

MEASUREMENTS AND STATISTICAL ANALYSIS

Family surrogates' anxiety and depressive symptoms were assessed 1, 3, and 6 months postloss using the Hospital Anxiety and Depression Scale. Family satisfaction with end-of-life care in ICUs was assessed 1-month postloss by the Family Satisfaction in the ICU questionnaire. Patients' end-of-life care was documented over the patient's ICU stay. Associations of severe anxiety and depressive symptoms (scores ≥ 8 for each subscale) with end-of-life-care quality in ICUs (documented by patient care received and family satisfaction with end-of-life care in ICUs) were examined by multivariate logistic regression models with generalized estimating equation.

MAIN RESULTS

Prevalence of severe anxiety and depressive symptoms decreased significantly over time. Surrogates' lower likelihood of severe anxiety or depressive symptoms 3-6 month postloss was associated with death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and higher family satisfaction with end-of-life care in ICUs. Bereaved surrogates' higher likelihood of these symptoms was associated with physician-surrogate prognostic communication and conducting family meetings before patients died.

CONCLUSIONS

End-of-life-care quality in ICUs is associated with bereaved surrogates' psychologic well-being. Enhancing end-of-life-care quality in ICUs by improving the process of end-of-life care, for example, promoting death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and increasing family satisfaction with end-of-life care, can lighten bereaved family surrogates' severe anxiety symptoms and severe depressive symptoms.

Intensive Care Unit Nursing Priorities in the United States

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.