Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care.

RATIONALE: Communication with family of critically ill patients is often poor and associated with family distress. OBJECTIVES: To determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care. METHODS: We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict. MEASUREMENTS AND MAIN RESULTS: Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001). CONCLUSIONS: Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. Clinical trial registered with www.clinicaltrials.gov (NCT 00720200).

Ebola, team communication, and shame: but shame on whom?

Examined as an isolated situation, and through the lens of a rare and feared disease, Mr. Duncan's case seems ripe for second-guessing the physicians and nurses who cared for him. But viewed from the perspective of what we know about errors and team communication, his case is all too common. Nearly 440,000 patient deaths in the U.S. each year may be attributable to medical errors. Breakdowns in communication among health care teams contribute in the majority of these errors. The culture of health care does not seem to foster functional, effective communication between and among professionals. Why? And more importantly, why do we not do something about it?

Hospital variation and temporal trends in palliative and end-of-life care in the ICU.

OBJECTIVES: Although studies have shown regional and interhospital variability in the intensity of end-of-life care, few data are available assessing variability in specific aspects of palliative care in the ICU across hospitals or interhospital variability in family and nurse ratings of this care. Recently, relatively high family satisfaction with ICU end-of-life care has prompted speculation that ICU palliative care has improved over time, but temporal trends have not been documented. DESIGN/SETTING: Retrospective cohort study of consecutive patients dying in the ICU in 13 Seattle-Tacoma-area hospitals between 2003 and 2008. MEASUREMENTS: We examined variability over time and among hospitals in satisfaction and quality of dying assessed by family, quality of dying assessed by nurses, and chart-based indicators of palliative care. We used regression analyses adjusting for patient, family, and nurse characteristics. MAIN RESULTS: Medical charts were abstracted for 3,065 of 3,246 eligible patients over a 55-month period. There were significant differences between hospitals for all chart-based indicators (p < 0.001), family satisfaction (p < 0.001), family-rated quality of dying (p = 0.03), and nurse-rated quality of dying (p = 0.003). There were few significant changes in these measures over time, although we found a significant increase in pain assessments in the last 24 hours of life (p < 0.001) as well as decreased documentation of family conferences (p < 0.001) and discussion of prognosis (p = 0.020) in the first 72 hours in the ICU. CONCLUSIONS: We found significant interhospital variation in ratings and delivery of palliative care, consistent with prior studies showing variation in intensity of care at the end of life. We did not find evidence of temporal changes in most aspects of palliative care, family satisfaction, or nurse/family ratings of the quality of dying. With the possible exception of pain assessment, there is little evidence that the quality of palliative care has improved over the time period studied.

Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial.

IMPORTANCE: Communication about end-of-life care is a core clinical skill. Simulation-based training improves skill acquisition, but effects on patient-reported outcomes are unknown. OBJECTIVE: To assess the effects of a communication skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes. DESIGN, SETTING, AND PARTICIPANTS: Randomized trial conducted with 391 internal medicine and 81 nurse practitioner trainees between 2007 and 2013 at the University of Washington and Medical University of South Carolina. INTERVENTION: Participants were randomized to an 8-session, simulation-based, communication skills intervention (N = 232) or usual education (N = 240). MAIN OUTCOMES AND MEASURES: Primary outcome was patient-reported quality of communication (QOC; mean rating of 17 items rated from 0-10, with 0 = poor and 10 = perfect). Secondary outcomes were patient-reported quality of end-of-life care (QEOLC; mean rating of 26 items rated from 0-10) and depressive symptoms (assessed using the 8-item Personal Health Questionnaire [PHQ-8]; range, 0-24, higher scores worse) and family-reported QOC and QEOLC. Analyses were clustered by trainee. RESULTS: There were 1866 patient ratings (44% response) and 936 family ratings (68% response). The intervention was not associated with significant changes in QOC or QEOLC. Mean values for postintervention patient QOC and QEOLC were 6.5 (95% CI, 6.2 to 6.8) and 8.3 (95% CI, 8.1 to 8.5) respectively, compared with 6.3 (95% CI, 6.2 to 6.5) and 8.3 (95% CI, 8.1 to 8.4) for control conditions. After adjustment, comparing intervention with control, there was no significant difference in the QOC score for patients (difference, 0.4 points [95% CI, -0.1 to 0.9]; P = .15) or families (difference, 0.1 [95% CI, -0.8 to 1.0]; P = .81). There was no significant difference in QEOLC score for patients (difference, 0.3 points [95% CI, -0.3 to 0.8]; P = .34) or families (difference, 0.1 [95% CI, -0.7 to 0.8]; P = .88). The intervention was associated with significantly increased depression scores among patients of postintervention trainees (mean score, 10.0 [95% CI, 9.1 to 10.8], compared with 8.8 [95% CI, 8.4 to 9.2]) for control conditions; adjusted model showed an intervention effect of 2.2 (95% CI, 0.6 to 3.8; P = .006). CONCLUSIONS AND RELEVANCE: Among internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients' depressive symptoms. These findings raise questions about skills transfer from simulation training to actual patient care and the adequacy of communication skills assessment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00687349.

Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial.

RATIONALE: Because of high mortality, end-of-life care is an important component of intensive care. OBJECTIVES: We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care. METHODS: We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics. MEASUREMENTS AND MAIN RESULTS: All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81). CONCLUSIONS: We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

A web-based team-oriented medical error communication assessment tool: development, preliminary reliability, validity, and user ratings.

BACKGROUND: Multiple-choice exams are not well suited for assessing communication skills. Standardized patient assessments are costly and patient and peer assessments are often biased. Web-based assessment using video content offers the possibility of reliable, valid, and cost-efficient means for measuring complex communication skills, including interprofessional communication. DESCRIPTION: We report development of the Web-based Team-Oriented Medical Error Communication Assessment Tool, which uses videotaped cases for assessing skills in error disclosure and team communication. Steps in development included (a) defining communication behaviors, (b) creating scenarios, (c) developing scripts, (d) filming video with professional actors, and (e) writing assessment questions targeting team communication during planning and error disclosure. EVALUATION: Using valid data from 78 participants in the intervention group, coefficient alpha estimates of internal consistency were calculated based on the Likert-scale questions and ranged from α=.79 to α=.89 for each set of 7 Likert-type discussion/planning items and from α=.70 to α=.86 for each set of 8 Likert-type disclosure items. The preliminary test-retest Pearson correlation based on the scores of the intervention group was r=.59 for discussion/planning and r=.25 for error disclosure sections, respectively. Content validity was established through reliance on empirically driven published principles of effective disclosure as well as integration of expert views across all aspects of the development process. In addition, data from 122 medicine and surgical physicians and nurses showed high ratings for video quality (4.3 of 5.0), acting (4.3), and case content (4.5). CONCLUSIONS: Web assessment of communication skills appears promising. Physicians and nurses across specialties respond favorably to the tool.

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

This article provides findings on the role of the nurse in simulated team-based error disclosures. Triangulation of 3 qualitative data sets revealed that a tension exists for nurses in the error disclosure process as they attempt to balance professional boundaries. Study findings point to multilevel strategies including cultural, structural, and educational approaches to enhancing the key roles that nurses need to play in error disclosure to patients and families.

Conversations in end-of-life care: communication tools for critical care practitioners.

BACKGROUND: Communication skills are the key for quality end-of-life care including in the critical care setting. While learning general, transferable communication skills, such as therapeutic listening, has been common in nursing education, learning specific communication tools, such as breaking bad news, has been the norm for medical education. Critical care nurses may also benefit from learning communication tools that are more specific to end-of-life care. STRATEGY: We conducted a 90-min interactive workshop at a national conference for a group of 78 experienced critical care nurses where we presented three communication tools using short didactics. We utilized theatre style and paired role play simulation. The Ask-Tell-Ask, Tell Me More and Situation-Background-Assessment-Recommendation (SBAR) tools were demonstrated or practiced using a case of a family member who feels that treatment is being withdrawn prematurely for the patient. The audience actively participated in debriefing the role play to maximize learning. The final communication tool, SBAR, was practiced using an approach of pairing with another member of the audience. At the end of the session, a brief evaluation was completed by 59 nurses (80%) of the audience. SUMMARY: These communication tools offer nurses new strategies for approaching potentially difficult and emotionally charged conversations. A case example illustrated strategies for applying these skills to clinical situations. The three tools assist critical care nurses to move beyond compassionate listening to knowing what to say. Ask-Tell-Ask reminds nurses to carefully assess concerns before imparting information. Tell Me More provides a tool for encouraging dialogue in challenging situations. Finally, SBAR can assist nurses to distill complex and often long conversations into concise and informative reports for colleagues.

Integrating palliative and critical care: evaluation of a quality-improvement intervention.

RATIONALE: Palliative care in the intensive care unit (ICU) is an important focus for quality improvement. OBJECTIVES: To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU. METHODS: We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results. MEASUREMENTS AND MAIN RESULTS: There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01). CONCLUSIONS: We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Disclosing errors to patients: perspectives of registered nurses.

BACKGROUND: Disclosure of medical errors has been conceptualized as occurring primarily in the physician-patient dyad. Yet, health care is delivered by interprofessional teams, in which nurses share in the culpability for errors, and hence, in responsibility for disclosure. This study explored nurses' perspectives on disclosure of errors to patients and the organizational factors that influence disclosure. METHODS: Between October 2004 and December 2005, 11 focus groups were conducted with 96 registered nurses practicing in one of four health care organizations in the Puget Sound region of Washington State. Focus groups were analyzed using qualitative content analysis. FINDINGS: Nurses reported routinely independently disclosing nursing errors that did not involve serious harm, but felt the attending physician should lead disclosures when patient harm had occurred or when errors involved the team. Nurses usually were not involved in the error disclosure discussion among the team to plan for the disclosure or in the actual disclosure, leading to ethically compromising situations in nurses' communication with patients and families. Awareness of existing error disclosure policies was low. Nonetheless, these nurses felt that hospital policies that fostered a collaborative process would be helpful. Nurse managers played a key role in creating a culture of transparency and in being a resource for error disclosures. DISCUSSION: Nurses conceived of the disclosure process as a team event occurring in the context of a complex health care system rather than as a physician-patient conversation. Nurses felt excluded from these discussions, resulting in their use of ethically questionable communication strategies. The findings underscore the need for organizations to adopt a team disclosure process. Health care organizations that integrate the entire health care team into the disclosure process will likely improve the quality of error disclosure.

Forensic Medical Examinations: Imagining Justice.

Depending on the type of physical contact involved during a sexual assault offense, samples collected from a suspect's body may carry greater probative value than samples collected from a victim's body. However, unlike forensic medical examinations for persons identified as victims of a sexual assault, no professional consensus exists for what constitutes a high-quality forensic medical examination standard for persons identified as suspects, or the accused. The purpose of this article is to explore underlying assumptions that may contribute to disparate practices and inequalities in the provision of forensic medical examinations for persons suspected of committing a sexual offense and persons identified as victims of a sexual offense.

Nurse preparation and organizational support for supervision of unlicensed assistive personnel in nursing homes: a qualitative exploration.

PURPOSE: Nursing supervision of the routine daily care (e.g., grooming, feeding, and toileting) that is delegated to unlicensed assistive personnel (UAP) is critical to nursing home service delivery. The conditions under which the supervisory role is organized and operationalized at the work-unit level, taking into account workloads, registered nurse/licensed practical nurse staffing, and role expectations, are not well understood. The purpose of this paper is to describe the organizational, managerial, and nurse-level factors associated with the nurse's role as supervisor of UAP in nursing homes. DESIGN AND METHODS: An ethnographic approach to data collection included 31 interviews, 170 hr of observation, and organizational document review at three nursing homes. Analysis included micro-coding and content analysis. RESULTS: Findings revealed (a) considerable variation in organizational resources, systems, and processes to support organization and operationalization of the supervisory role; and (b) limited evidence of nurses' estimation of the potential benefits of training and organizational systems to support supervisory practice and the complexity of the supervisory role. IMPLICATIONS: Delivery of high-quality nursing home care is a matter of national importance, and these findings offer a call to action for nursing home leaders in policy, academia, and ownership and management positions. Nurses must be equipped with competencies and skills that reflect the complex organizational environments in which they work. Additionally, nursing home administrators and managers must be equipped with the competencies and skills needed to effectively and efficiently organize and operationalize care delivery practices to support nurses' role enactment.

Transitions regarding palliative and end-of-life care in severe chronic obstructive pulmonary disease or advanced cancer: themes identified by patients, families, and clinicians.

BACKGROUND: Classic trajectories of illness at end of life (EOL) suggest different care needs for patients with cancer versus chronic obstructive pulmonary disease (COPD) and may lead to different experiences of transitions over the course of a life-limiting illness. Patients may experience transitions in different ways than clinicians. No prior studies have examined this issue from patients', families', and clinicians' perspectives. OBJECTIVES: We sought to explore transitions, defined as experiences that patients and family members viewed as milestones in the evolution of their illnesses and therapies, and compare these perceptions with the perspectives of the patient's physician and nurse to provide insights about communication concerning EOL care. METHODS: We conducted a qualitative study using grounded theory to examine participants' perspectives on the experiences of key transitions in the context of living with advanced COPD or cancer. In-depth interviews with patients, family members, nurses, and physicians were conducted by experienced interviewers. RESULTS: Six themes were identified regarding participants' experiences with transitions. Themes that defined transitions among both patients with COPD and those with cancer included: new or different treatments and no more treatments available. Themes unique to patients with COPD were activity limitations due to functional decline and initiation of oxygen therapy. One theme unique to clinicians was acute exacerbation of illness or hospitalization. CONCLUSIONS: This study identified differences in the meaning of transitions for patients versus clinicians and for patients with COPD versus those with cancer. These findings may offer clinicians the opportunity to provide a more patient-centered approach to communication about end-of-life care by acknowledging and addressing transitions in palliative care from the perspective of the patient and family.

"Hot Seat" Simulation Model for Conflict Resolution: A Pilot Study.

BACKGROUND: Unresolved conflicts in health care threaten both clinician morale and quality of patient care. We piloted a training model that targeted clinicians' conflict resolution skills. METHODS: Sixty clinicians from local hospitals were randomized into an intervention group (n = 30), completing a 3-hour conflict resolution training session, and a control group (n = 30) without training. The training included facilitated practice with actors, coaching, and feedback. Evaluation of 60 participants' conflict resolution skills was done in videotaped simulations with actors portraying interprofessional colleagues. Global ratings and checklist items developed for assessing clinicians' performance mirrored steps in the conflict communication model. RESULTS: The intervention group's performance exceeded the control group on global scores, 7.2 of 10 (SD = 1.6) versus 5.6 (SD = 1.5), p < .05, and checklist scores, 9.3 of 11 (SD = 2.9) versus 7.9 (SD = 1.5), p < .05. Two checklist items showed statistically significant differences: (1) subjects opened the dialogue on a neutral ground before jumping into conflict discussions (intervention: 97% and control: 73%, p < .05) and (2) subjects elicited the colleague's story before sharing their own story (intervention: 70% and control: 27%, p < .05). CONCLUSIONS: The pilot results suggest that a health care-specific approach to conflict resolution can be effectively taught through facilitated practice, coaching, and feedback.

Self-Assessment Scores Improve After Simulation-Based Palliative Care Communication Skill Workshops.

BACKGROUND: We conducted a randomized trial of a simulation-based multisession workshop to improve palliative care communication skills (Codetalk). Standardized patient assessments demonstrated improved communication skills for trainees receiving the intervention; however, patient and family assessments failed to demonstrate improvement. This article reports findings from trainees' self-assessments. AIM: To examine whether Codetalk resulted in improved self-assessed communication competence by trainees. DESIGN: Trainees were recruited from the University of Washington and the Medical University of South Carolina. Internal medicine residents, medicine subspecialty fellows, nurse practitioner students, or community-based advanced practice nurses were randomized to Codetalk, a simulation-based workshop, or usual education. The outcome measure was self-assessed competence discussing palliative care needs with patients and was assessed at the start and end of the academic year. We used robust linear regression models to predict self-assessed competency, both as a latent construct and as individual indicators, including randomization status and baseline self-assessed competency. RESULTS: We randomized 472 trainees to the intervention (n = 232) or usual education (n = 240). The intervention was associated with an improvement in trainee's overall self-assessment of competence in communication skills ( P < .001). The intervention was also associated with an improvement in trainee self-assessments of 3 of the 4 skill-specific indicators-expressing empathy, discussing spiritual issues, and eliciting goals of care. CONCLUSION: Simulation-based communication training was associated with improved self-assessed competency in overall and specific communication skills in this randomized trial. Further research is needed to fully understand the importance and limitations of self-assessed competence in relation to other outcomes of improved communication skill.

Interprofessional Error Disclosure Training for Medical, Nursing, Pharmacy, Dental, and Physician Assistant Students.

INTRODUCTION: Errors that harm patients often have many contributing factors and ideally should be disclosed by a team rather than an individual provider. However, most health professions students learn about errors and error disclosure in a single-profession class. METHODS: We developed a 2-hour small-group session in which our students practice discussing and disclosing a medical error that involves several professions, following a communication map. As they practice, students gain an understanding of the roles, skills, and perspectives of the other professions represented in the group. RESULTS: Over the last 5 years, student evaluations have been very positive. In 2016, our students strongly agreed that "The small group skills practice was a useful and interesting learning opportunity," "Learning with other professional students was valuable," and "Thinking about error disclosure from a team perspective was helpful." Student comments consistently indicated that they learned both about disclosing medical errors as well as other professionals' roles and perspectives. DISCUSSION: This activity has met both of our major goals. The first was to bring health professions students together to learn with, from, and about each other. The second was to practice a critical and challenging communication skill. This activity has been successfully implemented at other institutions, and can be adapted to fit other groups of students.

A Quality Improvement Project to Identify Patients With Advanced Heart Failure for Potential Palliative Care Referral in Telemetry and Cardiac Intensive Care Units.

Background: Although national guidelines recommend timely initiation of palliative care for hospitalized patients with advanced heart failure (AHF), providers may not recognize which patients who have heart failure are most in need of consultation. Measures: A tool was developed and pilot-tested to screen patients admitted to a cardiology inpatient service with a left ventricular ejection fraction (LVEF) of 50% or less for potential triggers signifying palliative care needs in the telemetry or cardiac intensive care unit (CICU). Intervention: The tool was completed during cardiology rounds. Outcomes: Of the 21 patients evaluated, the median LVEF was lower in the telemetry group (22%) than in the CICU group (28%). Trigger patients in the telemetry unit were less adherent to medical management (χ2 = 6.034, p = .014) and had greater psychosocial and spiritual needs (χ2 = 3.956, p = .047) than those in the CICU. Conclusion: We describe a feasible palliative care screening tool for patients with AHF hospitalized in a telemetry unit or CICU that may identify opportunities for early palliative care referrals. Additional study is needed to determine whether this tool can be used to improve patient care or patient outcomes.

Implementing an error disclosure coaching model: A multicenter case study.

National guidelines call for health care organizations to provide around-the-clock coaching for medical error disclosure. However, frontline clinicians may not always seek risk managers for coaching. As part of a demonstration project designed to improve patient safety and reduce malpractice liability, we trained multidisciplinary disclosure coaches at 8 health care organizations in Washington State. The training was highly rated by participants, although not all emerged confident in their coaching skill. This multisite intervention can serve as a model for other organizations looking to enhance existing disclosure capabilities. Success likely requires cultural change and repeated practice opportunities for coaches.

Contradictions and communication strategies during end-of-life decision making in the intensive care unit.

PURPOSE: The aim of this study was to identify inherent tensions that arose during family conferences in the intensive care unit, and the communication strategies clinicians used in response. MATERIALS AND METHODS: We identified 51 clinician-family conferences in the intensive care unit from 4 hospitals in which the attending physician believed discussion of withdrawing life-sustaining treatments or delivery of bad news would occur. The communication between clinicians and family members was analyzed using a dialectic perspective. RESULTS: The tension of choosing whether to "let the patient die now" versus to "not let the patient die now" was the central contradiction within the conferences. Under this overriding theme were 5 categories: killing or allowing to die; death as a benefit or a burden; honoring the patient's wishes or following the family's wishes; weighing contradictory versions of the patient's wishes; and choosing an individual family member as decision maker or the family as a unit as decision maker. In response to these contradictions, clinicians used 2 clusters of communication strategies: decision-centered strategies and information-seeking strategies. CONCLUSIONS: This study offered insights into end-of-life decision making, prompting clinicians to be conscious of the contradictions that arise and to use specific strategies to address these contradictions in their communication with families.

Measuring intensive care nurses' perspectives on family-centered end-of-life care: evaluation of 3 questionnaires.

BACKGROUND: Attempts to improve end-of-life care increasingly focus on family-centered care, but few validated assessment tools exist. OBJECTIVES: To evaluate 3 new short questionnaires measuring nurses' perspectives on family-centered end-of-life care in the intensive care unit and to show the usefulness of the questionnaires. METHODS: Principal components analysis of data from 141 critical care nurses evaluating care given to families of 218 patients was used to develop domain scores for number of nursing activities with each family, number of barriers experienced, and nurses' satisfaction that the family's needs were met. Random effects models were used to test associations between critical care processes and outcome. RESULTS: Nursing activities fell into 2 domains: general and culture-related communication/support. Barriers consisted of 2 domains: patient/family barriers and system/team barriers. Meeting the needs of patients' families represented a single dimension. In a path model based on domain scores, general activities had significant associations with both nurse communication and meeting families' needs; patient/family barriers, with nurse communication; and nurse and physician communication, with meeting families' needs. In a path model based on total activities and barriers scores, total activities and total barriers had significant associations with nurse communication ratings and meeting families' needs. Patients' and nurses' characteristics were not significant independent predictors of meeting the needs of patients' families. CONCLUSIONS: The 3 questionnaires provide a consistent, valid picture of nurses' perspectives on family-centered critical care and may be useful in evaluating family care processes and outcomes and in targeting areas for improvement.