The Timing of Family Meetings in the Medical Intensive Care Unit

Healthcare Resource Utilization and Goals of Care Discussions in Patients with Cirrhosis and Acute Kidney Injury

BACKGROUND

Patients with cirrhosis and acute kidney injury (AKI) are critically ill and have high health care resource utilization (HCRU). The impact and timing of goals of care discussions on HCRU are not well described.

METHODS

221 patients enrolled in a prospective cohort study of patients admitted with AKI and cirrhosis were reviewed. Documentation and timing of a goals of care discussions were analyzed as predictors of HCRU, defined as a composite outcome of intubation, initiation of renal replacement therapy, and/or admission to the intensive care unit.

RESULTS

Median MELD score was 26 [IQR 19, 33]. 29% patients were listed for liver transplant. 90-day mortality was 61%. 51% patients had at least one HCRU episode. Code status changed from admission to discharge from 91%/7%/0% to 68%/14%18% (full code/do not resuscitate/comfort measures, p < 0.001). 28% patients underwent goals of care discussions, with change in code status at a median of 16 [9, 22] days into admission. Only 18% of discussions were within 7 days of admission and all were after an HCRU event. Being listed for liver transplant was not associated with whether goals of care discussions occurred (23% listed vs. 31% non-listed, p = 0.24) but was associated with higher HCRU (69% vs. 43%; p < 0.001).

CONCLUSION

Goals of care discussions occurred late into the hospital course, after episodes of HCRU. Efforts should be made to engage in these discussions earlier in the hospital stay, which may decrease HCRU rates in this critically ill population and align with patients' goals of care.

Life-Sustaining Treatment Decision in Palliative Care Based on Electronic Health Records Analysis

AIMS AND OBJECTIVES

This study sought to explore the present status of life-sustaining treatment decisions in a tertiary hospital to improve the life-sustaining treatment decision-making process.

BACKGROUND

Life-sustaining treatment decisions are crucial for palliative care because they encompass decisions to withdraw treatments when patients cannot articulate their values and preferences. However, surrogate decisions have settled many life-sustaining treatment cases in South Korea, and this trend is prevalent.

DESIGN

We conducted a retrospective, descriptive study employing a review of electronic health records.

METHODS

We extracted and analysed electronic health records of a tertiary hospital. Our inclusion criteria included adult patients who completed life-sustaining treatment forms in 2019. A total of 2,721 patients were included in the analysis. We analysed the decision-maker, the timing of the decision, and patients' health status a week before the decision. We followed the STROBE checklist.

RESULTS

Among 1,429 deceased patients, those whose families had made life-sustaining treatment decisions totalled 1,028 (70.6%). The median interval between life-sustaining treatment documentation completion to death was three days, more specifically, two days in the family decision group and 5.5 days in the patient decision group. As the decision day neared, there were marked changes in patients' vital signs and laboratory test results, and the need for nursing care increased.

CONCLUSIONS

Life-sustaining treatment decisions were made when death was imminent, suggesting that the time required to discuss end-of-life care was generally insufficient among patients, family, and healthcare professionals in Korea.

RELEVANCE TO CLINICAL PRACTICE

Monitoring changes in laboratory test results and symptoms could help screen the patients who need the life-sustaining treatment discussion. As improving the quality of death is imperative in palliative care, institutional efforts, such as clinical ethics support services, are necessary to improve the life-sustaining treatment decision-making process for patients, families, and healthcare providers.

Intensive Care Unit Clinicians' Perspectives on Achieving Proactive Interprofessional Family Meetings

BACKGROUND

Although proactive interprofessional family meetings are widely recommended as a best practice for patient- and family-centered care in intensive care units (ICUs), adherence to this recommendation is low.

OBJECTIVES

To enhance understanding of practices, barriers, and facilitators related to the conduct of family meetings from the perspective of ICU clinicians and to elicit clinicians' ideas and opinions about strategies to achieve proactive interprofessional family meetings.

METHODS

Semistructured telephone interviews were conducted with ICU clinicians who were purposively selected from among a national sample. Constant comparative analysis was used to generate a matrix of themes; enrollment ceased when no new ideas emerged.

RESULTS

Interviews were conducted with 14 participants (10 nurses, 3 physicians, and 1 care manager). Rather than having a protocol for proactive family meetings, participants primarily held family meetings when physicians thought that it was time to discuss a transition to comfort-focused care. Other barriers included clinicians' discomfort with end-of-life conversations, physicians' time constraints, and nurses' competing clinical responsibilities. Facilitators included physicians' skill and comfort with difficult conversations, advocacy for family meetings from care managers/ social workers, and having full-time intensivists. Participants offered/endorsed multiple intervention ideas, including scheduling preemptively, monitoring unit performance, and adding discussion of a family meeting to daily rounds.

CONCLUSIONS

A key barrier to proactive family meetings is the mindset that family meetings need occur only when a clinical decision must be made, rather than proactively to support and engage families. Clinicians suggested ways to make proactive family meetings routine.

A national Position Statement on adult end-of-life care in critical care

Patient death in critical care is not uncommon. Rather, the provision of end-of-life care is a core feature of critical care nursing, yet not all nurses feel adequately prepared for their role in the provision of end-of-life care. For this reason, the Australian College of Critical Care Nurses (ACCCN) supported the development of a Position Statement to provide nurses with clear practice recommendations to guide the provision of end-of-life care, which reflect the most relevant evidence and information associated with end-of-life care for adult patients in Australian critical care settings. A systematic literature search was conducted between June and July, 2020 in CINAHL Complete, Medline, and EMBASE databases to locate research evidence related to key elements of end-of-life care in critical care. Preference was given to the most recent Australian or Australasian research evidence, where available. Once the practice recommendations were drafted in accordance with the research evidence, a clinical expert review panel was established. The panel comprised clinically active ACCCN members with at least 12 months of clinical experience. The clinical expert review panel participated in an eDelphi process to provide face validity for practice recommendations and a subsequent online meeting to suggest additional refinements and ensure the final practice recommendations were meaningful and practical for critical care nursing practice in Australia. ACCCN Board members also provided independent review of the Position Statement. This Position Statement is intended to provide practical guidance to critical care nurses in the provision of adult end-of-life care in Australian critical care settings.

Impact of Structured and Scheduled Family Meetings on Satisfaction in Patients Admitted to Hospitalist Service

Effective communication is key to patient satisfaction. Family meetings been shown to be effective in other settings such as critical care and palliative medicine. We evaluated the impact of scheduled and structured family meetings on patients admitted to the hospitalist service in terms of satisfaction with care delivery. More patients in the intervention group reported better understanding of their diagnosis, treatment plan, medications, and discharge plan. Based on these results, we advocate for structured and scheduled family meetings to be implemented as a communication tool for selected patients on the hospital medicine service to improve patient experience and satisfaction.

Using a Modified Surprise Question as a Tool to Improve Primary Palliative Care in a Neurocritical Care Unit

BACKGROUND

Specialty palliative care is a limited resource. The surprise question ("Would you be surprised if this patient died within the next 12 months?") is a screening tool for clinicians to identify people nearing the end of life. The researchers used a modified surprise question (MSQ) to improve primary palliative care in a neurocritical care unit.

METHODS

A palliative care physician attended interdisciplinary rounds up to three days a week and asked the primary neurocritical care team, for each patient admitted in the previous 24 hours, the MSQ: "Would you be surprised if this patient died during this hospital stay?" If the response was "No," the unit social worker identified the patient's surrogate decision maker (SDM), and the primary team was encouraged to conduct a goals of care (GOC) conversation. The frequency of SDM documentation, occurrence and timing of GOC conversations, and palliative care and hospice consultations were measured for the baseline six months before the intervention, and six months after.

RESULTS

Among 350 patients admitted to the neurocritical care unit during the study, the age, gender, prehospitalization presence of advance directives, and mortality were comparable between the baseline (n = 173) and intervention (n = 177) periods. Compared to the baseline period, there was a higher frequency during the intervention period of documentation of SDM (31.8% vs. 54.2%, p = 0.00002), all GOC conversations (35.3% vs. 53.1%, p = 0.008), GOC conversations conducted by the primary team (27.2% vs. 47.5%, p = 0.00009), palliative care consultations (11.6% vs. 23.2%, p = 0.004), and hospice consultations (2.3% vs. 9.6%, p = 0.004).

CONCLUSION

The MSQ can be used as a tool to identify the risk of mortality, facilitate palliative care delivered by the primary team, and improve end-of-life care.

Family Meetings in the Intensive Care Unit During the Coronavirus Disease 2019 Pandemic

Purpose:

Visitor restrictions during the COVID-19 pandemic limit in-person family meetings for hospitalized patients. We aimed to evaluate the quantity of family meetings by telephone, video and in-person during the COVID-19 pandemic by manual chart review. Secondary outcomes included rate of change in patient goals of care between video and in-person meetings, the timing of family meetings, and variability in meetings by race and ethnicity.

Methods:

A retrospective cohort study evaluated patients admitted to the intensive care unit at an urban academic hospital between March and June 2020. Patients lacking decision-making capacity and receiving a referral for a video meeting were included in this study.

Results:

Most patients meeting inclusion criteria (N = 61/481, 13%) had COVID-19 pneumonia (n = 57/61, 93%). A total of 650 documented family meetings occurred. Few occurred in-person (n = 70/650, 11%) or discussed goals of care (n = 233/650, 36%). For meetings discussing goals of care, changes in patient goals of care occurred more often for in-person meetings rather than by video (36% vs. 11%, p = 0.0006). The average time to the first goals of care family meeting was 11.4 days from admission. More documented telephone meetings per admission were observed for White (10.5, SD 9.5) and Black/African-American (7.1, SD 6.6) patients compared to Hispanic or Latino patients (4.9, SD 4.9) (p = 0.02).

Conclusions:

During this period of strict visitor restrictions, few family meetings occurred in-person. Statistically significant fewer changes in patient goals of care occurred following video meetings compared to in-person meetings, providing support limiting in-person meetings may affect patient care.