Nurses as Intermediaries: How Critical Care Nurses Perceive Their Role in Family Meetings.

BACKGROUND: Nurses' involvement in family meetings in the intensive care unit is central to supporting consistent communication and shared understanding within the care team and with patients and patients' family members. Evidence suggests the existence of major barriers to the effective participation and contribution of nurses during family meetings. OBJECTIVES: To characterize the nature and extent of nurses' involvement in family meetings in the intensive care unit, including identifying barriers to nurses' participation and opportunities for involvement. METHODS: Meetings with focus groups of nurses at a Veterans Affairs medical intensive care unit were recorded, transcribed, and qualitatively analyzed by using the constant comparative method. RESULTS: Thirty critical care nurses participated in 6 focus groups. Three major themes describing nurses' involvement in family meetings were identified: nurses can play multiple roles in supporting conduct in family meetings, nurses face critical barriers to fully realizing these roles, and nurses end up as intermediaries in family meetings. Subthemes pertained to being well positioned to act as the patient's advocate, yet feeling undervalued and underempowered to contribute important information in family meetings, often resulting in mixed messages about care preferences, prognosis, or goals of care that nurses did not feel able to address during the meeting. CONCLUSION: Nurses are positioned to play essential roles in family meetings, but their full involvement remains unrealized. Communication training and greater attention to nurses' empowerment and to facilitating the nurse-physician relationship in the context of family meetings most likely would increase appropriate involvement of nurses in the meetings.

The Critical Care Communication project: improving fellows' communication skills.

PURPOSE: The aim of this study was to develop an evidence-based communication skills training workshop to improve the communication skills of critical care fellows. MATERIALS AND METHODS: Pulmonary and critical care fellows (N = 38) participated in a 3-day communication skills workshop between 2008 and 2010 involving brief didactic talks, faculty demonstration of skills, and faculty-supervised small group skills practice sessions with simulated families. Skills included the following: giving bad news, achieving consensus on goals of therapy, and discussing the limitations of life-sustaining treatment. Participants rated their skill levels in a pre-post survey in 11 core communication tasks using a 5-point Likert scale. RESULTS: Of 38 fellows, 36 (95%) completed all 3 days of the workshop. We compared pre and post scores using the Wilcoxon signed rank test. Overall, self-rated skills increased for all 11 tasks. In analyses by participant, 95% reported improvement in at least 1 skill; with improvement in a median of 10 of 11 skills. Ninety-two percent rated the course as either very good/excellent, and 80% recommended that it be mandatory for future fellows. CONCLUSIONS: This 3-day communication skills training program increased critical care fellows' self-reported family meeting communication skills.

Barriers and strategies to an iterative model of advance care planning communication.

BACKGROUND: Early and repeated patient-provider conversations about advance care planning (ACP) are now widely recommended. We sought to characterize barriers and strategies for realizing an iterative model of ACP patient-provider communication. METHODS: A total of 2 multidisciplinary focus groups and 3 semistructured interviews with 20 providers at a large Veterans Affairs medical center. Thematic analysis was employed to identify salient themes. RESULTS: Barriers included variation among providers in approaches to ACP, lack of useful information about patient values to guide decision making, and ineffective communication between providers across settings. Strategies included eliciting patient values rather than specific treatment choices and an increased role for primary care in the ACP process. CONCLUSIONS: Greater attention to connecting providers across the continuum, maximizing the potential of the electronic health record, and linking patient experiences to their values may help to connect ACP communication across the continuum.

Who is attending? End-of-life decision making in the intensive care unit.

PURPOSE: Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. METHODS: Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units. RESULTS: The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer. CONCLUSIONS: Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.

Life support for patients without a surrogate decision maker: who decides?

BACKGROUND: Physicians in intensive care units have withdrawn life support in incapacitated patients who lack surrogate decision makers and advance directives, yet little is known about how often this occurs or under what circumstances. OBJECTIVE: To determine the proportion of deaths in intensive care units that occur in patients who lack decision-making capacity and a surrogate and the process that physicians use to make these decisions. DESIGN: Multicenter, prospective cohort study. SETTING: Intensive care units of 7 medical centers in 2004 to 2005. PATIENTS: 3011 consecutive critically ill adults. MEASUREMENTS: Attending physicians completed a questionnaire about the decision-making process for each incapacitated patient without a surrogate or advance directive for whom they considered limiting life support. RESULTS: Overall, 5.5% (25 of 451 patients) of deaths in intensive care units occurred in incapacitated patients who lacked a surrogate decision maker and an advance directive. This percentage ranged from 0% to 27% across the 7 centers. Physicians considered limiting life support in 37 such patients or would have considered it if a surrogate had been available. In 6 patients, there was prospective hospital review of the decision, and in 1 patient, there was court review. In the remaining 30 patients, the decision was made by the intensive care unit team alone or by the intensive care unit team plus another attending physician. The authors found wide variability in hospital policies, professional society guidelines, and state laws regarding who should make life-support decisions for this patient population. Thirty-six of 37 life-support decisions were made in a manner inconsistent with American College of Physicians guidelines for judicial review. LIMITATIONS: The results are based on physicians' self-reported practices and may not match actual practices. The number of incapacitated patients without surrogates in the study is small. CONCLUSIONS: Incapacitated patients without surrogates accounted for approximately 1 in 20 deaths in intensive care units. Most life-support decisions were made by physicians without institutional or judicial review.

Withdrawal of life support: intensive caring at the end of life.

The technology and expertise of critical care practice support patients through life-threatening illnesses. Most recover; some die quickly; others, however, linger--neither improving nor acutely dying, alive but with a dwindling capacity to recover from their injury or illness. Management of these patients is often dominated by the question: Is it appropriate to continue life-sustaining therapy? Patients rarely participate in these pivotal discussions because they are either too sick or too heavily sedated. As a result, the decision often falls to the family or the surrogate decision maker, in consultation with the medical team. Decisions of such import are emotionally stressful and are often a source of disagreement. Failure to resolve such disagreements may create conflict that compromises patient care, engenders guilt among family members, and creates dissatisfaction for health care professionals. However, the potential for strained communications is mitigated if clinicians provide timely clinical and prognostic information and support the patient and family with aggressive symptom control, a comfortable setting, and continuous psychosocial support. Effective communication includes sharing the burden of decision making with family members. This shift from individual responsibility to patient-focused consensus often permits the family to understand, perhaps reluctantly and with great sadness, that intensive caring may involve letting go of life-sustaining interventions.