Written Communication, Visitation Policies, and Awareness of Medical Issues Among Intensive Care Unit Families.

BACKGROUND: Open intensive care unit (ICU) visitation policies facilitate communication between clinicians and patients' families. Restrictive visitation policies (eg, during a pandemic) may reduce families' comprehension of information. OBJECTIVES: To determine whether written communication increased awareness of medical issues among ICU families and whether the effect size depended on the visitation policies in place when participants were enrolled. METHODS: Families of ICU patients were randomly assigned to receive usual care with or without daily written patient care updates from June 2019 to January 2021. Participants were asked whether patients had experienced 6 ICU problems at up to 2 time points during the ICU stay. Responses were compared with the study investigators' consensus. RESULTS: Of 219 participants, 131 (60%) were restricted from visiting. Participants in the written communication group were more likely than participants in the control group to correctly identify shock, renal failure, and weakness and were just as likely as participants in the control group to correctly identify respiratory failure, encephalopathy, and liver failure. Participants in the written communication group were more likely than participants in the control group to correctly identify the patient's ICU problems when all 6 were grouped as a composite outcome, with the adjusted odds ratio of correct identification tending to be higher among participants enrolled during restricted versus open visitation periods: 2.9 (95% CI, 1.9-4.2; P < .001) vs 1.8 (95% CI, 1.1-3.1; P = .02), P = .17 for difference. CONCLUSIONS: Written communication helps families correctly identify ICU issues. The benefit may be enhanced when families cannot visit the hospital. ClinicalTrials.gov Identifier: NCT03969810.

Daily Written Care Summaries for Families of Critically Ill Patients: A Randomized Controlled Trial.

OBJECTIVES: To determine the effect of daily written updates on the satisfaction and psychologic symptoms of families of ICU patients. DESIGN: Randomized controlled trial. SETTING: Single, urban academic medical center. SUBJECTS: Surrogates of nondecisional, critically ill adults with high risk of mortality ( n = 252) enrolled from June 2019 to January 2021. INTERVENTIONS: Usual communication with the medical team with or without written communication detailing the suspected cause and management approach of each ICU problem, updated each day. MEASUREMENTS AND MAIN RESULTS: Participants completed surveys at three time points during the ICU stay: enrollment ( n = 252), 1 week ( n = 229), and 2 weeks ( n = 109) after enrollment. Satisfaction with care was measured using the Critical Care Family Needs Inventory (CCFNI). The presence of anxiety, depression, and acute stress were assessed using the Hospital Anxiety and Depression Scale (HADS) and Impact of Events Scale Revised (IES-R). CCFNI, HADS, and IES-R scores were similar among participants assigned to the intervention group and control group upon enrollment and during the first week after enrollment ( p > 0.05). From enrollment to the second week after enrollment, there was an improvement in CCFNI and HADS scores among participants assigned to the intervention group versus the control group. At week 2, CCFNI scores were significantly lower among participants in the intervention group versus the control group, indicating greater satisfaction with care: 15.1 (95% CI, 14.2-16.0) versus 16.4, (95% CI, 15.5-17.3); p = 0.04. In addition, 2 weeks after enrollment, the odds of symptoms of anxiety, depression, and acute stress among participants assigned to the intervention versus control group were 0.16 (95% CI, 0.03-0.82; p = 0.03); 0.15 (95% CI, 0.01-1.87; p = 0.14); and 0.27 (95% CI, 0.06-1.27; p = 0.10), respectively. CONCLUSIONS: Written communication improved satisfaction and the emotional well-being of families of critically ill patients, supporting its use as a supplement to traditional communication approaches.

Challenges faced by families of critically ill patients during the first wave of the COVID-19 pandemic.

OBJECTIVE: To understand how surrogates of critically ill patients adjusted to challenges that resulted from the COVID-19 pandemic. METHODS: Participants (N = 62) were surrogates of critically ill adults with COVID-19 in the ICU at an urban, academic medical center from March to June 2020. Participants were recruited using convenience sampling and took part in one-time qualitative individual interviews via telephone. Qualitative data were analyzed using thematic content analysis. RESULTS: Qualitative analyses yielded four types of challenges: Communication with the medical team, communication among family members, understanding and tracking medical information, and distress related to visitor restrictions. To adjust to challenges related to communication, participants developed routines for receiving updates from the medical team and providing updates to other family members. To adjust to the challenge related to comprehension, participants sought information from external sources such as family members in healthcare fields. To adjust to the challenge related to visitation, participants found some comfort in video calls with the patient. CONCLUSIONS: Surrogates of critically ill patients with COVID-19 faced multiple types of challenges yet adjusted to those challenges. PRACTICAL IMPLICATIONS: Future research should focus on ways to support the wellbeing of surrogates during times of restricted hospital visitation. Clinical trial registered at ClinicalTrials.gov (NCT03969810).

Surrogate and Physician Decision Making for Mechanically Ventilated Patients According to Expected Patient Outcome.

Background: Surrogates and physicians may differ in their priorities and perspectives when making decisions for incapacitated, critically ill patients. Objectives: To determine the extent to which surrogate and physician decisions to sustain life support are associated with their expectations for patient outcomes. Setting/Subjects: Surrogates and physicians of 100 mechanically ventilated patients at an academic, tertiary care medical center in the United States were surveyed. Measurements: Linear regression was used to determine if participant expectations for patient survival, good quality of life, and confidence in these expectations were associated with their agreement that mechanical ventilation should be continued if required for patient survival. Results: Surrogates were more likely than physicians to expect that patients would be alive in three months (91% interquartile range [IQR 70-95%] vs. 65% [IQR 43-77%], p < 0.001) and have good quality of life in three months (71% [IQR 50-90%] vs. 40% [IQR 19-50%], p < 0.001). Surrogates who were most confident in their prognostic abilities were also the most optimistic for good patient outcomes. As such, expectations for patient survival and good quality of life were not associated with level agreement that mechanical ventilation should be continued among confident surrogates, (R2 = 0.03, p = 0.13) and (R2 = 0.01, p = 0.53), respectively. In contrast, among physicians, confidence was not synonymous with optimism. Instead, the significant associations between expectations for patient survival and good quality of life with the agreement that mechanical ventilation should be continued were strengthened when physicians were confident, (R2 = 0.34, p < 0.01) and (R2 = 0.47, p < 0.001), respectively. Conclusion: Surrogates and physicians have different approaches to incorporating their expectations for patient prognosis and their confidence in these expectations when they are making decisions for incapacitated critically ill patients.

Written Care Summaries Facilitate Communication Between Families and Providers of ICU Patients: A Pilot Study.

ICU providers may invite families to participate in daily rounds to inform them of the patient's condition and to support their emotional well-being. Daily written summaries of care may provide complementary benefits. DESIGN: Qualitative interviews with surrogates of ICU patients who received daily written summaries of care. SETTING: Single, urban academic medical center. PATIENTS/SUBJECTS: A convenience sample of 30 surrogates of nondecisional, medical ICU patients. INTERVENTIONS: Daily written summaries detailed each of the patient's main ICU problems, the presumed causes of each of the problems, and the medical team's plan to address each of the problems for each ICU day. MEASUREMENTS AND MAIN RESULTS: There were four ways that written summaries affected the participant's experience: 1) providing clarity to participants regarding the patient's condition, 2) facilitating participant understanding of the patient's clinical course, 3) facilitating communication between participants and medical providers, and 4) facilitating communication between participants and other family members. Overarching themes were that summaries were understandable, had appropriate level of detail, and added value to the ICU experience. CONCLUSIONS: In this pilot study, family members had positive impressions of receiving daily written summaries of care. Further study is needed to determine the extent to which written communication may affect family and patient outcomes.

Surrogates and Physician Preferences regarding the Continuation of Mechanical Ventilation among Critically Ill Adults.

Rationale: For an incapacitated patient who is difficult to liberate from mechanical ventilation, surrogates and physicians will decide to continue life support if they believe doing so is consistent with the patient's prognosis and values. Little is known about the factors that surrogates and physicians prioritize during this decision-making process, in part because there is not a validated method to assess their preferences.Objectives: To evaluate trends in surrogate and physician preferences for continuing mechanical ventilation.Methods: One hundred surrogates and respective physicians of patients requiring mechanical ventilation for at least 7 days were prospectively enrolled at an academic, tertiary care medical center. During the second and third week of mechanical ventilation, participant preferences for continuing mechanical ventilation were assessed in two ways, the first emphasizing patient survival and the second emphasizing patient comfort as the primary goal.Results: During the patient's second week of mechanical ventilation, surrogates agreed more strongly than did physicians that mechanical ventilation should be continued to maximize the chance for patient survival (73% vs. 63%, respectively, P = 0.02 for difference). In contrast, at this same point in time, surrogates and physicians agreed similarly that mechanical ventilation should be discontinued to maximize patient comfort (37% vs. 38%, respectively, P = 0.34 for difference). Both surrogates and physicians agreed less strongly during week 3 than they did during week 2 that mechanical ventilation should be continued with a goal of maximizing patient survival, with preferences to limit the use of mechanical ventilation for patients with the poorest prognoses according to physiological variables. In contrast, only physicians agreed more strongly during week 3 than they did during week 2 that mechanical ventilation should be discontinued to maximize patient comfort.Conclusions: Level of surrogate and physician agreement that mechanical ventilation should be continued to maximize the chance for patient survival reflected their preferences more accurately than level of surrogate and physician agreement that mechanical ventilation should be discontinued to maximize patient comfort. Over time, surrogates and physicians were less likely to agree that mechanical ventilation should be continued, particularly when patients had poor prognoses.