A Randomized Trial of a Family-Support Intervention in Intensive Care Units.

BACKGROUND: Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences. METHODS: We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates' mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates' mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay. RESULTS: A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates' mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates' mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001). CONCLUSIONS: Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates' burden of psychological symptoms, but the surrogates' ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492 .).

Ethics and palliative care consultation in the intensive care unit.

It is clear that ethics and palliative care consultation have, in our view, much to offer intensivists as they attempt to work through the very complex and often tragic cases they face in their daily practice.Potential strengths include clarification of tangled normative issues, facilitation of shared decision making, conflict resolution,and expertise in the provision of comfort care. Despite this, it is an unfortunate fact that many intensivists remain reluctant to use ethics and palliative care services. There are, of course, many possible reasons for this, including the absence of quality services in certain institutions, issues, or power and control, and role misperceptions. It is our hope that we have helped to clarify appropriate roles for ethics and palliative care in the intensive care unit. We urge the continued development of quality ethics and palliative care services, and the use of those services by intensivists.

Physician-patient relationship in the intensive care unit: erosion of the sacred trust?

With the advent of the increasing technology and multispecialty medicine, the strong relationship or "sacred trust" between patient and family physician has gradually eroded. Various subspecialists are now entrusted with patient care at different phases of evaluation and treatment. Because of the transient nature of these physician-patient interactions, a strong bond is often not established before critical decisions must be made concerning ongoing patient care. As a result, multiple members of the different healthcare teams (the care cooperative) may be confronted with addressing end-of-life discussions, which in the past was the responsibility of the primary physician. Because of this need to move into a previously viewed private territory, communication conflicts may arise between members of the healthcare team. In an effort to understand and deal with observed recurrent problems that occurred when patient care was transferred between specialty care teams, our institution has addressed communication conflicts that arise in the care of oncology patients transferred to the intensive care unit. Our goal has been to initiate and maintain a dialog to avoid misunderstandings and to reduce anxiety between members of the intensivist and oncology services. To this end, we have addressed the various pitfalls that come with the transition from the traditional physician-patient relationship to the more fluid and comprehensive care-cooperative mode. We believe this approach to be useful in improving communication between healthcare providers in the multispecialty care setting, which will ultimately enhance the quality of patient care.