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

Targeted Simulation Training in ICU Shared Decision-Making Boosts Confidence and Competence in Medical Students

IntroductionShared decision-making (SDM) is the standard of communication. Many providers receive little or no training in SDM. In our study, we implemented a training simulation aimed at boosting medical student confidence and competence in SDM.Methods, Study DesignProspective, non-randomized, observational pilot study.Study SettingSimulation center in large, urban, academic medical center.RecruitmentParticipants were recruited by electronic mail invitation. Participation was voluntary and paid.ConsentParticipants were consented for participation in the study, including video recording, prior to starting the study.ParticipantsParticipants were recruited from our medical school's second (M2), third (M3), and fourth (M4) year classes. Each participant completed two confidence surveys, two simulations, and a communication training session. Seven months later, participants were invited to complete a confidence survey and an assessment of attitudes.ResultsThirty seven participants completed the study: 17 M2 (46%), 9 M3 (24%) , and 11 M4 (30%). We observed an improvement in learner confidence in 8 of 8 communication domains (100%). Following training, statistically significant improvement in learner competence was measured in 7 of 8 domains (87.5%). Our retention rate was 59% (n = 22) at seven months, at which time confidence in nonverbal communication was significantly higher. Participants rated the simulation highly.ConclusionSimulation is effective at improving medical student communication skill and confidence. Students maintained their increased confidence for at least seven months. We recommend the implementation of targeted simulation training early in medical school to establish a standard for SDM and enhance student communication skill and confidence.

Surrogates may not accurately estimate resilience and spirituality in neurologically critically ill patients

BACKGROUND

Surrogates often provide substituted judgement for neurologically critically ill patients. Resilience and spirituality are understudied constructs in this patient population. In this study we examine how accurately surrogates estimate measures of resilience and spirituality for neurologically critically ill patients.

METHODS

A convenience sample of English/Spanish speaking neurologically critically ill patient-surrogate dyads was enrolled from March 2016 to 2018. Questionnaires related to resilience (CD-RISC-10), spiritual wellbeing (positive Brief R-COPE), and spiritual turmoil (negative Brief R-cope) were completed by patients for themselves and surrogates on behalf of patients while in the Neurosciences Intensive Care Unit. Responses were evaluated by Spearman's rank-order correlation, Bland-Altman analysis and Cohen's weighted kappa.

RESULTS

51 dyads were included. No correlation was found between patient and surrogate CD-RISC-10 (0.17, p = 0.238); moderate, positive correlations for positive (0.47, p < 0.001) and negative (0.33, p = 0.021) Brief R-COPE. Mean differences between patient and surrogate scores were low for CD-RISC-10 (-1.0 point), positive R-COPE (- 0.14 point), and negative R-COPE (0.02 point) suggesting lack of bias towards over/under-estimation. Kappa scores demonstrate fair inter-rater agreement for positive/negative R-COPE and no agreement for CD-RISC-10.

CONCLUSION

Surrogate evaluations lack systematic bias, but may not estimate resilience and spirituality reliably for neurologically critically ill patients.

Nudging Clinicians to Promote Serious Illness Communication for Critically Ill Patients: A Pragmatic Cluster Randomized Trial

Importance

Guidelines recommend that intensive care unit (ICU) clinicians consider prognosis and offer a comfort-focused treatment alternative to patients with limited prognoses to promote preference-sensitive treatment decisions.

Objective

To determine whether nudging ICU clinicians to adhere to communication guidelines improves outcomes among critically ill patients at high risk of death or severe functional impairment.

Design, Setting, and Participants

This 4-arm pragmatic, stepped-wedge, cluster randomized trial (conducted February 1, 2018-October 31, 2020, follow-up through April 29, 2021, and analyses December 2023-January 2024) involved 3500 encounters of adults with chronic serious illness receiving mechanical ventilation for at least 48 hours at 10 hospitals comprising 17 medical, surgical, specialty, or mixed ICUs in community, rural, and urban settings.

Interventions

Two clinician-directed electronic health record nudge interventions were each compared with usual care alone and combined: document of 6-month functional prognosis and whether a comfort-focused treatment alternative was offered or a reason why not.

Main Outcomes and Measures

The primary outcome was hospital length of stay, with death coded at the 99th percentile. Secondary end points included 22 measures of acute care utilization, end-of-life care processes, and mortality.

Results

Of 3500 patient encounters among 3250 patients (mean [SD] age, 63.2 [13.5] years; 46.1% female), 3384 encounters (96.7%) had complete baseline data and were included in risk-adjusted analyses. The overall intervention document completion rate for all patients was 75.0% (n = 1714) and similar across groups. Among the 3500 encounters, observed hospital mortality was 35.7% (n = 1249), and the median observed length of stay was 8.93 days (IQR, 4.64-16.23). The median length of stay with deaths coded as the 99th percentile did not differ between any intervention and usual care groups (for length of stay, all adjusted median difference 95% CIs include 0; for hospital mortality, all adjusted risk difference [RD] 95% CIs include 0). Results were similar in sensitivity analyses with death coded as low at the fifth percentile and without ranking deaths. Compared with usual care, a higher percentage of patients were discharged to hospice in the treatment alternative group (10.9% vs 7.3%; adjusted RD, 6% [95% CI, 1%-10%]) and the combined group (8.9% vs 7.3%; adjusted RD, 6% [95% CI, 0%-12%]). The treatment alternative intervention led to earlier comfort-care orders (3.6 vs 4.5 days; adjusted hazard ratio, 1.42 [95% CI, 1.06-1.92]). The 20 other secondary end points were unaffected by the interventions.

Conclusions and Relevance

This cluster randomized clinical trial found that electronically nudging ICU clinicians to adhere to communication guidelines was feasible but did not reduce hospital length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT03139838.

Medical Professionals' Treatment Decisions for Critical Patients With Ambiguous Treatment Wishes: A Cross-Sectional Study

Background and Aims

Many patients do not want life-prolonging treatments at critical stages of their illnesses, and are able to communicate their wishes to their families or surrogates. However, few among them have clarity on what such life-prolonging treatments mean or entail. This study clarifies differences in the perspectives of medical professionals based on levels of expertise with respect to treatment decisions for intensive care unit (ICU) patients whose wishes for end-of-life care are ambiguous.

Methods

The cross-sectional study included intensivists, surgeons, and ICU nurses working in 171 Japanese hospitals with ICUs. A total of 837 participants were mailed questionnaires which included questions on the current status and approaches to decision-making with end-of-life care for ICU patients. Additionally, a simulated case study was conducted to investigate the decision-making process for treating patients with uncertain survival rates.

Results

Responses were obtained from 489 participants from 151 hospitals. More than half of the intensivists and ICU nurses reported that family members' requests were respected when the patient had ambiguous treatment preferences. Participants considered the patients' survival probability when deciding to perform emergency surgery, with nurses having significantly higher thresholds than intensivists and surgeons (intensivists: 20.8 ± 20.6, surgeons: 26.6 ± 25.2, ICU nurses: 36.4 ± 26.4; p < 0.001).

Conclusions

Family preferences take precedence over patient preferences when deciding on end-of-life treatments for ICU patients. Shared decision-making should be promoted to correctly share patients' end-of-life medical wishes with surrogate decision-makers and medical practitioners.

Supporting the bereaved child in the adult ICU: a narrative review

Childhood bereavement is a significant issue globally, affecting millions of children each year, with incidence rates significantly increasing following the COVID-19 pandemic. The loss of an important adult, particularly in the ICU environment, can lead to lasting psychological and behavioural challenges for children. While family-centred practices in the ICU have advanced, the unique bereavement needs of grieving children in the family remain insufficiently addressed. Both families and healthcare professionals (HCPs) often feel unprepared and uncomfortable engaging in honest, supportive conversations with children about bereavement, further complicating children's grief processing. This narrative review examines the pivotal role ICU HCPs can play in facilitating child-centred bereavement support, focusing on promoting honest communication, supportive visitation practices, creating a child-friendly and humanised ICU environment, and encouraging child involvement during end-of-life care. It recommends prioritising research on the lived experiences of bereaved children, caregivers, and ICU HCPs to inform targeted interventions addressing children's developmental and psychological needs during ICU bereavement. The review also advocates for specialised training to equip ICU staff with the necessary skills to support grieving children and families. Developing comprehensive, child-centred ICU bereavement guidelines will provide evidence-based frameworks that recognise children as integral family members during end-of-life care while advocating for the participation of children in meaningful rituals will empower families to make informed decisions about their involvement. Together, these recommendations aim to create a more compassionate, inclusive, and supportive bereavement experience in ICU settings, prioritising the unique needs of children and promoting healthy emotional adjustment after losing an important adult.

Families' Experiences of Surrogate Decision-Making and Challenges of Shared Decision-Making: A Cross-Sectional Study

INTRODUCTION

Family members who make surrogate decisions tend to be emotionally burdened and may have difficulty making decisions that fit the patient's wishes. It is unclear what support family members making surrogate decisions expect from health professionals. This study aims to clarify the information needed for surrogate decision-making and the support needs of healthcare professionals.

METHODS

This cross-sectional study used questionnaires. Family members with experience in making surrogate decisions for treatments that affected the patient's life and prognosis were included. Participants were recruited using an online panel through a private research company in Japan. For the survey items, 60 participants were asked to specify one case in which they made a surrogate decision and describe the resources they used to support their decision-making. In addition, participants were assessed on a 10-point scale to determine their sense of satisfaction with the decision, whether the decision was per the patient's wishes, and their level of emotional burden. Knowledge and understanding of life-sustaining treatments were also investigated.

RESULTS

 Family members tended to make decisions that were more aligned with the patient's desires than with theirs (P = 0.005). In addition, decisions that prioritized the patient's desires tended to result in higher levels of satisfaction after the decision was made (r = 0.349, P < 0.01). Family members who understood the treatment being given to the patient tended to experience lower psychological stress after the decision was made (r = -0.394, P < 0.01). The information that families considered important for making decisions on the patient's behalf included whether the patient would regain consciousness (70%) and the patient's age (66.7%).

CONCLUSION

 The findings suggest that medical professionals should encourage family members to make decisions in keeping with the patient's wishes and provide the patient's information, including risk information, to help them understand the treatment. In addition, considering the mental stress and burden on family members, it is necessary to consider the process of discussion among family members while providing mental support to facilitate the decision-making process.

Electronic Health Records and Family Satisfaction in the ICU: Communication, Care Processes, and Decision-Making

Objectives: To evaluate electronic health records and explore associations with the satisfaction of families of critically ill patients. Methods: Exploratory cohort study. Included 94 patients with severe chronic illnesses or chronic critical illness who were admitted to the ICU and their family members. Family satisfaction was assessed using the Family Satisfaction ICU (FS-ICU 24) questionnaire, through the FS-ICU Care score (perception of care itself), FS-ICU Decision Making score (perception of decision-making), and FS-ICU Total score, and queried about the use of a room suitable for communication. Electronic health records were analyzed for elements of communication with family members, care processes, and decision-making. Results: The scores were FS-ICU Care 91.1 (76.8-98.0), FS-ICU DM 90.0 (77.5-97.5), and FS-ICU total 90.7 (78.0-97.0). In 17 (18.1%) of the medical records, there was a documented family meeting within the first 72 hours, and in 9.6%, there was documentation of communication about functionality, wishes and values, and consultation for palliative care. The use of a suitable room for communication was reported as "never" or "rarely" by 45 (47.8%) of the family members. There was a trend towards greater satisfaction with social support and lower satisfaction among family members of deceased patients, with 9 (25.8%) of these family members feeling that the patient was uncomfortable before death, and the records of meetings and communication of poor prognosis were associated with a lower perception of discomfort (P < .05). Conclusions: The satisfaction of family members of critically ill patients was high and was not significantly associated with the documentation deficiencies found. Deficiencies in communication appear to have influenced the perception of family members. Various perspectives are necessary for analyzing the care provided to patients and families in the ICU.

Characterizing Physician Recommendations within Code Status Documentation: A Multicentre Cohort Study and Qualitative Discourse Analysis

BACKGROUND

Discussion of patients' treatment preferences for cardiopulmonary resuscitation is routine practice for adults admitted to hospital. Ideally, these "code status discussions" provide an opportunity to ensure patients receive care that is concordant with their values and priorities. The degree of physician recommendations that occur during these discussions is unknown.

OBJECTIVE

This study sought to characterize physician treatment recommendations during code status discussions in older hospitalized medical patients.

DESIGN, PARTICIPANTS, AND APPROACH

We conducted a retrospective cohort study of 200 patients, 75 years or older, admitted to the general medical service in one of four hospitals in Toronto, Canada. Medical records were reviewed to abstract documentation by physicians that referenced a code status discussion. We used qualitative discourse analysis to characterize the nature of these documented code status discussions, with a focus on physician treatment recommendations.

KEY RESULTS

The majority of recommendations involved de-escalation or avoidance of invasive treatments. The strength of recommendations ranged from a passive physician role of providing advice, where the ultimate decision was deferred to the patient/surrogate, to an active role of explicitly not offering interventions, which involved informed non-dissent. Physicians often documented a brief rationale for specific recommendations, either focused on their estimation that the patient had a poor prognosis or their interpretation of the patient's goals and priorities. However, there was a paucity of documentation supporting how physicians determined these interpretations. Some physicians used the term "quality of life" to imply that invasive life-sustaining treatments were unlikely to benefit the patient.

CONCLUSIONS

We uncovered a range of physician practices in providing recommendations during code status discussions. While the strength and rationale varied, physicians often failed to document patients' goals and priorities when making treatment recommendations. These findings highlight an opportunity to improve how physicians formulate, communicate, and document their recommendations around code status.

Integrating Compassion and Collaboration into the Care of Intensive Care Unit Survivors: A Modest Proposal

The number of intensive care unit (ICU) survivors continues to grow, largely due to the emergence of more sophisticated treatment options. Yet despite this remarkable life-saving progress, far too little attention is paid to the survivor's long-term quality of life after discharge. Post-Intensive Care Syndrome continues to impact many survivors' physical, cognitive, and mental health, as well as their social functioning related to these new impairments. In light of this knowledge, there is room to enhance compassionate care, both in and after the ICU, starting with improved collaboration with the patient, their caregivers, and other providers on the patient's care team.

How to communicate with families living in complete isolation

IMPORTANCE

During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.

OBJECTIVE

This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation.

EVIDENCE REVIEW

PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.

FINDINGS

Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.

CONCLUSIONS AND RELEVANCE

The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Obstacles to effective communication between physical/occupational therapists and patients in the Saudi Arabian context: a cross-sectional study

BACKGROUND

Effective communication between healthcare providers and patients is essential for high-quality care and patient satisfaction. Barriers to communication can lead to misunderstandings and poorer health outcomes. This study aims to identify communication obstacles between physical/occupational therapists (PTs/OTs) and patients in the Saudi Arabian context.

METHODS

This cross-sectional study, which was conducted from September 2022 to January 2023, involved 228 patients and 46 therapists from the rehabilitation services department. Data were collected via two self-administered questionnaires and analyzed via Pearson's chi-square test of independence and Fisher's exact test for categorical nominal data to assess associations between variables. A p value of less than 0.05 was considered statistically significant.

RESULTS

Most patients (25.4%) were young adults aged 18-30 years, predominantly Saudi nationals (96.5%), with undergraduate degrees (63%). High satisfaction with therapists was reported by 69.3% of patients. The key barriers identified included limited consultation time (15.8%) and the use of medical records (4.8%). Therapists, primarily young professionals aged 25-30 years (54.3%) with 3-5 years of experience (43.5%), also reported time limitations (30.4%), physical setup issues (37.0%), and poor patient history-taking (56.5%) as significant barriers. Additional findings from our study indicated that monolingual Arabic-speaking therapists faced greater challenges in understanding language (p = 0.02), and younger therapists (aged 25-30) reported greater difficulties in managing multiple problems during sessions (p = 0.03), highlighting age and linguistic background as significant factors influencing communication efficacy.

CONCLUSIONS

Addressing communication barriers through targeted interventions, such as enhanced training, improved clinical structures, and advanced electronic health records, can improve patient satisfaction and treatment outcomes. Future research should focus on longitudinal studies and specific communication training programs.

A conceptual model of the nurse's role as primary palliative care provider in goals of care communication

Objective

Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses.

Methods

An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria.

Results

Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training.

Conclusion

This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care.

Innovation

The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.

Teaching Residents Patient-Centered Communication: A Call for Standardized Programming

OBJECTIVE

Surgical residency Program Directors (PDs) use the Accreditation Council for Graduate Medical Education (ACGME) milestones to measure general surgery competencies including interpersonal communication skills and professionalism. These programs face myriad barriers implementing communication training, including competing educational priorities and insufficient local expertise. The goal of this work is to generate hypotheses regarding barriers and facilitators to successful communication, leadership, and professionalism training (CLPT) in surgical residency programs.

DESIGN AND SETTING

We implemented a qualitative study using semi structured 30-minute interviews; grounded theory guided our systematic data collection, coding, and analysis to enable us to identify patterns and relationships within the available dataset.

PARTICIPANTS

Eligible participants were surgical educators known to provide or interested in providing communication training or were surgical trainees focused on education and/or CLPT. Surgeon participants (N=18) included 4 communication researcher/content experts, 9 Program Director (PD) or former PD faculty, 4 Associate PDs, 1 fellow, and 2 residents.

RESULTS

Themes abstracted from interview data include 1) the importance of providing formal CLPT, 2) readiness of residency programs to include CLPT, 3) challenges and barriers to implementing CLPT, and 4) recommendations for implementation. Barriers included the "crowded educational schedule," lack of local expertise, absence of programmatic guidance nationally, and paucity of standardized materials. Facilitators to implementation included the nature of CLPT curricula such as content, approach, and ease of implementation, and suggestions to achieve learner and leadership support. The availability of expert guidance and standardized materials would ease the incorporation of sustainable CLPT into a residency program that could become increasingly engaged and skilled in communication.

CONCLUSIONS

This research serves as a call for direction from ACGME regarding CLPT educational priorities and urges surgical educators to continue to test and develop CLPT content and assessment materials for wide distribution along with providing guidance on implementation.

Effectiveness of decision aids on critically ill patients' outcomes and family members' knowledge, anxiety, depression and decisional conflict: A systematic review and meta-analysis

BACKGROUND

Decision aids (DAs) have been proposed to support patients and families with disease information processing and decision-making, but their effectiveness for critically ill patients and their families is incompletely understood.

AIM

To systematically synthesize evidence on the effectiveness of the DAs on the prognosis of critically ill patients and knowledge, anxiety, depression and decisional conflict of their family members.

STUDY DESIGN

Systematic review and meta-analysis. We conducted a systematic search of literature using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature database, Scopus, PsycNet, CNKI and Wanfang Database from the inception of the databases until May 2023 to identify randomized clinical trials (RCTs) describing DAs interventions targeted at adult intensive care unit (ICU) patients or their families. We also searched grey literature in four databases: Chinese Clinical Trials Registry, Chinese Cochrane Center, Open Grey and GreyNet International.

RESULTS

Seven RCTs were included in the review. Meta-analysis identified longer hospital length of stay (LOS) among all patients compared with usual care (mean difference [MD] = 5.64 days, 95% confidence interval, CI [0.29, 10.98], p = .04), but not in surviving patients (MD = 2.09 days, 95% CI [-3.70, 7.89], p = .48). However, there was no evidence of an effect of DAs on hospital mortality (RR = 1.25, 95% CI [0.92, 1.70], p = .15), ICU LOS (MD = 3.77 days, 95% CI [-0.17, 7.70], p = .06) and length of mechanical ventilation (MD = 0.88 days, 95% CI [-2.22, 3.97], p = .58). DAs led to a statistically significant improvement in family members' knowledge (standard mean difference = 0.84, 95% CI [0.12, 1.56], p = .02). We found no significant effect of DAs on anxiety, depression, post-traumatic stress disorder, decisional conflict and quality of communication of family members.

CONCLUSIONS

This review provides effective evidence that DAs can potentially improve the knowledge level of family members while prolonging the hospital LOS among critically ill patients.

RELEVANCE TO CLINICAL PRACTICE

Well-designed large-scale studies with DAs tailored to the individuals' preferences and existing cultural values are warranted.

European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

Communication, Shared Decision-making and Goals of Care in the ICU through Electronic Health Records: A Scoping Review

Introduction

The care of critically ill patients involves communication and shared decision-making with families and determination of goals of care. Analyzing these aspects through electronic health records (EHRs) can support research in ICUs, associating them with outcomes. This review aims to explore studies that examine these topics.

Methods

A scoping review was conducted through a systematic literature search of articles in PubMed, Web of Science, and Embase databases using MESH terms up to 2024, conducted in ICU settings, focusing on communication with families, shared decision-making, goals, and end-of-life care.

Results

A total of 10 articles were included, divided into themes: Records and family, and records in quality improvement projects. Variables based on records with common characteristics were identified. Outcome analysis was performed through questionnaires to family members, healthcare professionals or by analyzing care processes. The studies revealed associations between family members' perceptions and mental health symptoms and documented elements such as communication, therapeutic limitations, social and spiritual support. Studies evaluating quality communication improvement projects did not show significant impact on documented care, except for those that assessed improvements based on palliative care.

Conclusion

The analysis of documented care for critically ill patients can be conducted from various perspectives. Processes amenable to improvement, such as communication with family members, definition of goals of care, limitations, shared decision-making, evaluated through EHRs, are associated with mental health symptoms and perceptions of families of critically ill patients. Documentation-based studies can contribute to improvements in patient- and family-centered care in the ICU.

How to cite this article

de Aquino VW, da Silveira GF, Boniatti MM, Terres MS. Communication, Shared Decision-making and Goals of Care in the ICU through Electronic Health Records: A Scoping Review. Indian J Crit Care Med 2024;28(10):977-987.

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

INTRODUCTION

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

OBJECTIVE

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

Clinicians' Use of Choice Framing in ICU Family Meetings

OBJECTIVES

To quantify the frequency and patterns of clinicians' use of choice frames when discussing preference-sensitive care with surrogate decision-makers in the ICU.

DESIGN

Secondary sequential content analysis.

SETTING

One hundred one audio-recorded and transcribed conferences between surrogates and clinicians of incapacitated, critically ill adults from a prospective, multicenter cohort study.

SUBJECTS

Surrogate decision-makers and clinicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four coders identified preference-sensitive decision episodes addressed in the meetings, including topics such as mechanical ventilation, renal replacement, and overall goals of care. Prior critical care literature provided specific topics identified as preference-sensitive specific to the critical care context. Coders then examined each decision episode for the types of choice frames used by clinicians. The choice frames were selected a priori based on decision science literature. In total, there were 202 decision episodes across the 101 transcripts, with 20.3% of the decision episodes discussing mechanical ventilation, 19.3% overall goals of care, 14.4% renal replacement therapy, 14.4% post-discharge care (i.e., discharge location such as a skilled nursing facility), and the remaining 32.1% other topics. Clinicians used default framing, in which an option is presented that will be carried out if another option is not actively chosen, more frequently than any other choice frame (127 or 62.9% of decision episodes). Clinicians presented a polar interrogative, or a "yes or no question" to accept or reject a specific care choice, in 43 (21.3%) decision episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation.

CONCLUSIONS

Clinicians frequently use default framing and polar questions when discussing preference-sensitive choices with surrogate decision-makers, which are known to be powerful nudges. Future work should focus on designing interventions promoting the informed use of these and the other most common choice frames used by practicing clinicians.

Simplifying Serious Illness Communication: Preparing or Deciding

Clinicians have a sincere desire to ensure that the decision-making processes of seriously ill patients are well informed throughout illness trajectories. A quagmire of variable terminology (e.g., advance care planning, serious illness conversations, goals-of-care discussions, etc.), however, currently predominates the field of serious illness communication. This creates uncertainty among clinicians as to the overall purpose, tasks, and specific outcomes of conversations that address serious illness. The Preparing or Deciding model is a unifying framework that provides conceptual clarity by helping clinicians understand their role in leading these important conversations. The Preparing or Deciding model simply posits that conversations with seriously ill patients are about either preparing or deciding. It considers these tasks to be mutually exclusive, which can help bypass many of the barriers to having these conversations. The Preparing or Deciding model compliments all existing resources and frameworks and is applicable to all healthcare practitioners in every care setting. To help move forward serious illness communication education and research, as well as process improvement efforts more effectively, here, we describe the Preparing or Deciding model.

Barriers and Strategies to Effective Serious Illness Communication for Patients with End-Stage Liver Disease in the Intensive Care Setting

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

It Starts With a Story: A Four-Step Narrative-Based Framework for Serious Illness Conversations

Background: As a key component of advance care planning, serious illness conversations form a core intervention in palliative care. To achieve effective serious illness conversations, acknowledgment and inclusion of patient sense of self and identity are critical. However, no framework exists to describe how goals, values, and choices relate to patient identity. This conceptual gap hinders the advancement of palliative care education and practice. Objective: This philosophical investigation aimed to explicate two items: first, a novel conceptual framework for serious illness conversations; second, a structured approach to optimize these conversations within the palliative care clinical context. Methods: A philosophical and theoretical analysis was performed within an interdisciplinary context, by scholars in palliative care, medical humanities, philosophy, and bioethics. Key literature in psychology, qualitative research on the experience of serious illness, medical ethics, and choice architecture in medical decision-making were reviewed, and a structured conceptual and narrative analysis was performed. Results: An original and innovative identity-centered conceptual framework for serious illness conversations was developed. The framework consists of a four-step, reproducible approach: (1) attend to patient narrative identity, (2) identify values, (3) cocreate goals, and (4) actively promote choices. In short: attend, identify, create, and promote (AICP). Discussion: By using this conceptual framework and four-step approach, clinicians can accomplish goal-concordant serious illness care and build rich clinical relationships that foster trust and goodwill.

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

BACKGROUND

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Common mistakes and evidence-based approaches in goals-of-care conversations for seriously ill older adults in cardiac care unit

For older adults with serious, life-limiting illnesses near the end of life, clinicians frequently face difficult decisions about the medical care they provide because of clinical uncertainty. This difficulty is further complicated by unique challenges and medical advancements for patients with advanced heart diseases. In this article, we describe common mistakes encountered by clinicians when having goals-of-care conversations (e.g. conversations between clinicians and seriously ill patients/surrogates to discuss patient's values and goals for clinical care near the end of life.). Then, we delineate an evidence-based approach in goals-of-care conversations and highlight the unique challenges around decision-making in the cardiac intensive care unit.

Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies

OBJECTIVE

The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications.

STUDY DESIGN

Retrospective database review.

SETTING

United States hospitals.

METHODS

The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications.

RESULTS

A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001).

CONCLUSION

This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.

The Challenges in Using eHealth Decision Resources for Surrogate Decision-Making in the Intensive Care Unit

The mortality rate in intensive care units (ICUs) is notably high, with patients often relying on surrogates for critical medical decisions due to their compromised state. This paper provides a comprehensive overview of eHealth. The challenges of applying eHealth tools, including economic disparities and information inaccuracies are addressed. This study then introduces eHealth literacy and the assessment tools to evaluate users' capability and literacy levels in using eHealth resources. A clinical scenario involving surrogate decision-making is presented. This simulated case involves a patient with a hemorrhagic stroke who has lost consciousness and requires medical procedures such as tracheostomy. However, due to the medical surrogate's lack of familiarity with eHealth devices and limited literacy in using eHealth resources, difficulties arise in assisting the patient in making medical decisions. This scenario highlights challenges related to eHealth literacy and solution strategies are proposed. In conclusion, effective ICU decision-making with eHealth tools requires a careful balance between efficiency with inclusivity. Tailoring communication strategies and providing diverse materials are essential for effective eHealth decision resources in the ICU setting. Health professionals should adopt a patient-centered approach to enhance the decision-making experience, particularly for individuals with limited eHealth literacy.

Feasibility and Acceptability of a Novel Intensive Care Unit Communication Intervention ("Let's Talk") and Initial Assessment Using the Multiple Goals Theory of Communication

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.

Incorporating parental values in complex paediatric and perinatal decisions

Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.

Varying (preferred) levels of involvement in treatment decision-making in the intensive care unit before and during the COVID-19 pandemic: a mixed-methods study among relatives

BACKGROUND

In the intensive care unit (ICU) relatives play a crucial role as surrogate decision-makers, since most patients cannot communicate due to their illness and treatment. Their level of involvement in decision-making can affect their psychological well-being. During the COVID-19 pandemic, relatives' involvement probably changed. We aim to investigate relatives' involvement in decision-making in the ICU before and during the pandemic and their experiences and preferences in this regard.

METHODS

A mixed-methods study among relatives of ICU patients admitted to an ICU before or during the COVID-19 pandemic. Relatives in six ICUs completed a questionnaire (n = 329), including two items on decision-making. These were analysed using descriptive statistics and logistic regression analyses. Subsequently, relatives (n = 24) were interviewed about their experiences and preferences regarding decision-making. Thematic analysis was used for analysing the qualitative data.

RESULTS

Nearly 55% of the relatives indicated they were at least occasionally asked to be involved in important treatment decisions and of these relatives 97.1% reported to have had enough time to discuss questions and concerns when important decisions were to be made. During the first COVID-19 wave relatives were significantly less likely to be involved in decision-making compared to relatives from pre-COVID-19. The interviews showed that involvement varied from being informed about an already made decision to deliberation about the best treatment option. Preferences for involvement also varied, with some relatives preferring no involvement due to a perceived lack of expertise and others preferring an active role as the patient's advocate. Discussing a patient's quality of life was appreciated by relatives, and according to relatives healthcare professionals also found this valuable. In some cases the preferred and actual involvement was in discordance, preferring either a larger or a smaller role.

CONCLUSIONS

As treatment alignment with a patient's values and preferences and accordance between preferred and actual involvement in decision-making is very important, we suggest that the treatment decision-making process should start with discussions about a patient's quality of life, followed by tailoring the process to relatives' preferences as much as possible. Healthcare professionals should be aware of relatives' heterogeneous and possibly changing preferences regarding the decision-making process.

Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report

In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

Shared decision making in older people after severe stroke

Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.

An Update on Palliative Care in Neurocritical Care: Providing Goal‑Concordant Care in the Face of Prognostic Uncertainty

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.

Vagueness in Goals-of-Care Conferences for Critically Ill Patients: Types of Hedge Language Used by Physicians

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.

A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application

In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.

Assessing Communication Quality in the Intensive Care Unit

Introduction: Successful shared decision-making for critically ill intensive care unit (ICU) patients requires bidirectional communication. Through observation of ICU conversations, our study aimed to identify communication skill deficiencies in providers who care for patients in the ICU. Methods: This was an observational prospective study performed in a single urban academic medical center (671 beds) from June 2021 through August 2021. Twenty-three providers were recruited from medical and surgical ICU services (56 beds). Thirty-nine surrogate decision makers were identified. Provider skills were assessed using a customized observational tool that examined nonverbal communication, verbal communication, opening the discussion, gathering information, understanding the family's perspective, sharing information, reaching agreements on problems and plans, and providing closure. Results: Thirty-nine conversations were observed for six attending physicians, four fellow physicians, eight resident physicians, two nurse practitioners, and three physician assistants during the coronavirus 19 (COVID19) pandemic. A dedicated critical care provider engaged in 19 observed conversations; 20 discussions occurred with individuals rotating/consulting in the ICU. Communication skill did not depend on experience or area of expertise. Less than half of conversations achieved bidirectional communication proficiency. Scheduled conversations (n = 14) had significantly higher average communication scores than unscheduled encounters (n = 25). Conclusions: Superficial unidirectional communication with decision makers was commonly observed. Providers were less proficient at advanced communication skills needed for shared decision-making. We recommend that providers have more scheduled conversations, which were more productive in achieving bidirectional communication. A targeted simulation curriculum addressing these areas may improve patient, decision maker, and provider satisfaction, while promoting patient-centered care.

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review

OBJECTIVE

Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU.

SETTING AND DESIGN

Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

PARTICIPANTS

Adults (age 18 and over) undergoing WMV in the ICU.

MEASUREMENTS

Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients.

CONCLUSION

High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.

Decision Aids in the ICU: a scoping review

OBJECTIVE

The purpose of this scoping review was to synthesise the effectiveness and acceptability of decision aids for critically ill patients and family members in the intensive care unit (ICU).

METHODS

A systematic search of four electronic databases and grey literature was undertaken to identify relevant studies on the application of decision aids in the ICU, without publication date restriction, through March 2023. The methodological framework proposed by Arksey and O'Malley was used to guide the scoping review.

RESULTS

Fourteen papers were ultimately included in this review. However, only nine decision aids were available, and it is noteworthy that many of these studies focused on the iterative development and testing of individual decision aids. Among the included studies, 92% (n=13) were developed in North America, with a primary focus on goals of care and life-sustaining treatments. The summary of the effect of decision aid application revealed that the most common indicators were the level of knowledge and code status, and some promising signals disappeared in randomised trials.

CONCLUSIONS

The complexity of treatment decisions in the ICU exceeds the current capabilities of existing decision aids. There is a clear gap in decision aids that are tailored to different cultural contexts, highlighting the need to expand the scope of their application. In addition, rigorous quality control is very important for randomised controlled trial, and indicators for assessing the effectiveness of decision aids need to be further clarified.

Impact of the COVID-19 Pandemic on Providing Recommendations During Goals-of-Care Conversations: A Multisite Survey

Background: Goals-of-care conversations (GoCCs) are essential for individualized end-of-life care. Shared decision-making (SDM) that elicits patients' goals and values to collaboratively make life sustaining treatment (LST) decisions is best practice. However, it is unknown how the COVID-19 pandemic onset and associated changes to care delivery, stress on providers, and clinical uncertainty affected SDM and recommendation-making during GoCCs. Aim: To assess providers' attitudes and behaviors related to GoCCs during the COVID-19 pandemic and identify factors associated with provision of LST recommendations. Design: Survey of United States Veterans Health Administration (VA) health care providers. Setting/Participants: Health care providers from 20 VA facilities with high COVID-19 caseloads early in the pandemic who had authority to place LST orders and practiced in select specialties (n = 3398). Results: We had 323 respondents (9.5% adjusted response rate). Most were age ≥50 years (51%), female (63%), non-Hispanic white (64%), and had ≥1 GoCC per week during peak-COVID-19 (78%). Compared with pre-COVID-19, providers believed it was less appropriate and felt less comfortable giving an LST recommendation during peak-COVID-19 (p < 0.001). One-third (32%) reported either "never" or "rarely" giving an LST recommendation during GoCCs at peak-COVID-19. In adjusted regression models, being a physician and discussing patients' goals and values were positively associated with giving an LST recommendation (B = 0.380, p = 0.031 and B = 0.400, p < 0.001, respectively) at peak-COVID-19. Conclusion: Providers who discuss patients' preferences and values are more likely to report giving a recommendation; both behaviors are markers of SDM during GoCCs. Our findings suggest potential areas for training in conducting patient-centered GoCCs.

Do They Have a Choice? Surrogate Decision-Making After Severe Acute Brain Injury

OBJECTIVES

In the early phase of severe acute brain injury (SABI), surrogate decision-makers must make treatment decisions in the face of prognostic uncertainty. Evidence-based strategies to communicate uncertainty and support decision-making are lacking. Our objective was to better understand surrogate experiences and needs during the period of active decision-making in SABI, to inform interventions to support SABI patients and families and improve clinician-surrogate communication.

DESIGN

We interviewed surrogate decision-makers during patients' acute hospitalization for SABI, as part of a larger ( n = 222) prospective longitudinal cohort study of patients with SABI and their family members. Constructivist grounded theory informed data collection and analysis.

SETTING

One U.S. academic medical center.

PATIENTS

We iteratively collected and analyzed semistructured interviews with 22 surrogates for 19 patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Through several rounds of coding, interview notes, reflexive memos, and group discussion, we developed a thematic model describing the relationship between surrogate perspectives on decision-making and surrogate experiences of prognostic uncertainty. Patients ranged from 20 to 79 years of age (mean = 55 years) and had primary diagnoses of stroke ( n = 13; 68%), traumatic brain injury ( n = 5; 26%), and anoxic brain injury after cardiac arrest ( n = 1; 5%). Patients were predominantly male ( n = 12; 63%), whereas surrogates were predominantly female ( n = 13; 68%). Two distinct perspectives on decision-making emerged: one group of surrogates felt a clear sense of agency around decision-making, whereas the other group reported a more passive role in decision-making, such that they did not even perceive there being a decision to make. Surrogates in both groups identified prognostic uncertainty as the central challenge in SABI, but they managed it differently. Only surrogates who felt they were actively deciding described time-limited trials as helpful.

CONCLUSIONS

In this qualitative study, not all surrogate "decision-makers" viewed themselves as making decisions. Nearly all struggled with prognostic uncertainty. Our findings underline the need for longitudinal prognostic communication strategies in SABI targeted at surrogates' current perspectives on decision-making.

Sense of Coherence at End of Life in Older People: An Interpretive Description

As people age, losses accumulate (ie, the death of family and friends, the loss of agility, and the loss of independence). Such losses have an impact on one's Sense of Coherence, that is, one's ability to see the world as comprehensible, manageable, and meaningful. Antonovsky deemed Sense of Coherence as a mostly stable state by the age of 30 years. Until now, there has not been an investigation into how serial loss of resources affects older people as they near the end of life. Sense of Coherence was used as the theoretical framework for this study to answer the question of how older people maintain or regain a Sense of Coherence in the presence of serious illness as they near death. Data were gathered using semistructured interviews and guided by interpretive description. This investigation found new concepts that contribute to Antonovsky's midlevel theory of salutogenesis and the construct of Sense of Coherence. Those are Incomprehensibility and Serial Loss of General Resistance Resources. The results indicate that the crux of a strong Sense of Coherence for this population is excellent communication and a coherent "big-picture" conversation.

Association Between Shared Decision-Making During Family Meetings and Surrogates' Trust in Their ICU Physician

BACKGROUND

Although trust is central to successful physician-family relationships in ICUs, little is known about how to promote surrogates' trust of ICU physicians in this setting.

RESEARCH QUESTION

Does the conduct of family conferences and physicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the physician?

STUDY DESIGN AND METHODS

A mixed-methods secondary analysis was done of a multicenter prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at six US medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range, 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine physicians' use of five SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by physicians during the family meeting impacted trust scores.

RESULTS

In adjusted models, conduct of a family meeting was associated with increased trust (average change, pre- to post family meeting: 0.91 point [95% CI, 0.4-1.4; P < .01]). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI, 0.08-0.67; P = .01). If all four elements were used, trust increased by 1.48 points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and was excluded from the final model.

INTERPRETATION

The conduct of family meetings and physicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating physician.

Spiritual Care in the Intensive Care Unit: Experiences of Dutch Intensive Care Unit Patients and Relatives

BACKGROUND/OBJECTIVE

To gain insight into both patients' and relatives' experiences with spiritual care (SC) in the intensive care unit (ICU).

METHODS

Method used was qualitative interviewing. This was a thematic, topic-centered, biographical, and narrative approach, using semistructured interviews with thematic analysis. A purposive sampling method was used to select a sample of ICU patients and ICU patients' relatives. An interview guide facilitated individual, semistructured interviews. The interview data were recorded by means of note-taking and audio-recording. Verbatim transcripts were compiled for analysis and interpretation.

RESULTS

All 12 participants-7 ICU patients and 5 family members of 5 other ICU patients-experienced ICU admission as an existential crisis. Participants would appreciate the signaling of their spiritual needs by ICU health care professionals (HCPs) at an early stage of ICU admission and subsequent SC provision by a spiritual caregiver. They regarded the spiritual caregiver as the preferred professional to address spiritual needs, navigate during their search for meaning and understanding, and provide SC training in signaling spiritual needs to ICU HCPs.

DISCUSSION

Early detection of existential crisis signals with ICU patients and relatives contributes to the mapping of spiritual and religious needs. Spiritual care training of ICU HCPs in signaling spiritual needs by ICU patients and relatives is recommended. Effective SC contributes to creating room for processing emotions, spiritual well-being, and satisfaction with integrated SC as part of daily ICU care.

Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit

Objectives

This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care.

Methods

This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission.

Intervention

Clinical communication skills training (iValidate) and clinical support program are the intervention for this study.

Results

A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001).

Conclusions

Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.

The Perspectives of Surrogates and Healthcare Providers Regarding SDM (Shared Decision-Making)

The purpose of this paper is to explore the attitudes of surrogacy and medical service providers toward SDM and to identify the barriers and promoters of SDM in this population. To this end, we conducted a qualitative study of surrogacy and medical service providers in the First Affiliated Hospital of Soochow University using semistructured interviews. Thirty participants (11 agents, 12 ICU physicians, and 7 ICU nurses) were interviewed. The three stakeholders showed different attitudes toward SDM. They reported barriers to SDM, including insufficient cognition of decision-makers, high expectations, negative psychological experiences, previous decision-making experiences, excessive workload, heavy financial burden, and lack of decision AIDS. They reported facilitators of SDM, including trust, effective communication, decision support, value clarification, outcome commitment, and continuous service. This study explored the different attitudes of the three stakeholders and identified various barriers and facilitators of SDM. It highlights the need to develop localised decision AIDS and to involve agents and nurses more in the decision-making process. Therefore, this paper identifies barriers and facilitators of SDM in this population. In addition, the study identified various barriers and facilitators to SDM and highlighted the need to develop localised decision AIDS and involve agents and nurses more in the decision-making process. Finally, the barriers and facilitators of SDM are established. The paper also shows that the development of localized decision AIDS and greater involvement of agents and nurses in the decision-making process are integral to good treatment outcomes.

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.