PhysicianFamily Communication in the ICU

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Physician-Family Communication in the ICU

• Douglas B. White, MD
• March 31, 2004

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• Mr. L, a 77 year-old man with inoperable CAD,
  PVD, DM and HTN, is admitted to the ICU with PNA,
  ARF and sepsis that is complicated by ARDS. He
  was intubated in the ED emergently. He is
  incapacitated and his wife is his designated
  decision-maker. You arrange to meet with her the
  following afternoon.
• How will you approach the discussion?

3
Case revisited

• Mr. L, a 77 year-old man with inoperable CAD,
  PVD, DM and HTN, is admitted to the ICU with PNA,
  ARF and sepsis that is complicated by ARDS. He
  was intubated in the ED emergently. He is
  incapacitated and his wife is his designated
  decision-maker. You arrange to meet with her the
  following afternoon.
• How will you approach the discussion?

• Before the meeting, you reassess the patient and
  see that he is on two pressors, INR 1.8, and an
  Fi02 0.8. CVVH

4

• You begin by asking the wife her understanding of
  the situation His cough is getting much
  better-when can he go home?
• You explain the nature and severity of his
  illness and counsel her that he has a high
  likelihood of not surviving to hospital
  discharge.
• You ask if he had expressed preferences about the
  intensity of medical therapy in sudden illness.
  She responds that he had clearly stated, If I
  get real sick, I would rather die than be on a
  ventilator and other machines.
• Based on this info, you make a plan to meet again
  on HD3 and, if he hasnt significantly improved,
  to discontinue MV and HD.

5

• On HD3, his vent settings are higher and he has
  persistent hypotension despite 2 pressors. Based
  on the patients known preferences, you recommend
  that MV and HD be discontinued. The wife agrees,
  morphine is titrated to patient comfort, the
  ventilator is d/ced and the patient dies
  peacefully within hours.
• The wife thanks you for taking such good care of
  her husband.

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Autonomy in ICU Patients

• Autonomy derived from Greek autos (self) and
  nomos (rule)
• Personal rule of the self that is free from both
  controlling interferences by others and from
  personal limitations that prevent meaningful
  choice, such as inadequate understanding.
• Central to American bioethics

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Components of Autonomy

• Intentionality
• Without controlling influences that determine
  their action
• With understanding
• How much understanding is necessary or desirable?

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Shared Decision-making

• Two-way information sharing and DM between the
  surrogate and physician.
• Physician provides information about the disease
  states, current treatments and prognosis.
• Surrogate provides information about patients
  values and treatment preferences.
• Physician and surrogate mutually agree upon a
  plan.

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Informed Consent vs Shared Decision-making

• Informed Consent
• Description of treatment
• Risks/benefits
• Complications
• Alternatives
• Focus on disclosure

• Shared Decision-making
• MD gives info about the dx, tx, prognosis
• Surrogate gives info about values preferences.
• Physician and surrogate mutually agree upon a
  plan.
• v
• Focus on joint participation

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Does Prognostic Information Influence Patient
Decisions?

• Subjects 50 inpatients with chronic disease
  estimated 6-month mortality gt 50.
• Design subjects were presented with 2 scenarios
• 1. Acute ICU admission with MV for 2 weeks
  with guaranteed fair/good QOL.
• 2. Chronic ICU admission with MV for 1 month
  and 1 month of rehabilitation.
• Modified time trade-off was used to vary survival
  and QOL

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Does Predicted Survival Influence Patient
Decisions?
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Does Predicted QOL Influence Patient Decisions?
13
Does Prognostic Information Influence Patient
Decisions?

• Conclusions
• Wide variation in preferences for ICU care.
• Pre-admission QOL does not predict preferences.
• Desire for ICU care decreases as predicted
  mortality increases and QOL decreases.

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Should family have decision-making authority in
the ICU?

• Patients have complicated and rapidly changing
  problems.
• MDs have years of training and can be objective
  in their assessments of risk and prognosis.
• Families rarely have medical training.
• 80 of family members of ICU patients have
  significant depressive sx during ICU stay.
• They make decisions based on what they hope will
  happen, not what is probable.

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Autonomy

• Definition the right of self-choice self
  determination
• Significant variability in perception of a good
  life
• Patients are the best arbiters of which medical
  options promote their self-interest.
• In the US, self-determination trumps paternalism.
• When a patient is incapacitated, who can best
  speak for their interests?

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Substituted judgement

• Surrogate speaks as if he/she is the patient and
  accurately describes their wishes.
• An extension of patients right to
  self-determination.
• Decisions based on
• 1. Prior specific conversations If I were ever
  in this situation, I would want
• 2. Inferences based on patients values life at
  all costs vs anti-technology.
• Few patients have explicitly discussed their
  resuscitation preferences.

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Family as surrogate decision-maker

• While not perfect, close family is better able to
  impute patient preferences than physician.
• gt90 of patients want family to make decisions in
  conjunction with MDs (Puchalski C. JAGS
  200048S84-S90)
• 40 of patients want their surrogate to exercise
  judgement rather than strictly adhere to living
  wills.

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Legal justification for surrogate decision-making
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Should family have decision-making authority in
the ICU?

• Patients have complicated and rapidly changing
  problems.
• MDs have years of training and can be objective
  in their assessments of risk and prognosis.
• Families rarely have medical training.
• 80 of family members of ICU patients have
  significant depressive symptoms.
• They make decisions based on what they hope will
  happen, not what is probable.

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Can Surrogates Be Adequately Informed?

• Language barriers
• Cultural barriers
• Physician time constraints
• Surrogates schedule and time constraints
• Physician communication skills
• Surrogates ability to comprehend and retain
• Physician/patient attitudes about decision-making

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Needs of Families in the ICU

• Systematic review of 8 primary studies of family
  needs in the ICU.
• Information needs were consistently rated most
  important
• Reassurance and convenience less important

• To feel there is hope
• To receive honest answers
• To know prognosis
• To receive understandable explanations
• To receive daily updates
• To know what is wrong with patient
• To know what is being done
• To see patient frequently
• To feel that the staff cares

22
Family Satisfaction with End-of-Life ICU Care

• 624 family members surveyed about QOC in the ICU
• Highest ratings nursing skill pain management
• Lowest ratings MD communication and waiting room
  atmosphere
• Communication is a significant component of
  respondents' satisfaction with overall ICU care

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Surrogates perceptions of the decision-making
process

• Survey of family of 102 patients who died from 6
  ICUs at an academic hospital.
• 46 perceived conflict with MDs in the ICU
• 15 over treatment decisions
• 33 over communication
• 31 over unprofessional behavior
• 19 over perceived quality of care

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Physicians perceptions of the decision-making
process

• Survey of physicians of 102 patients who died
  from 6 ICUs at an academic hospital.
• 78 described conflict during the ICU stay
• 48 described MD-family conflict
• 63 related to decisions about life-sustaining tx
• 45 related to communication
• 19 related to staff or family behavior

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Communication of Prognosis in the ICU

• Subset of 905 SUPPORT patients who had ICU LOS
  gt14days
• Day 7 prognosis estimated by SUPPORT prognostic
  model, by physician and by surrogate
  decision-maker.
• 33 could not estimate their prognosis
• lt40 reported that their MD had discussed their
  prognosis with them.
• Surrogates estimate of prognosis was
  significantly different from MD or prognostic
  model.

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Is there a communication problem in the ICU?

• 58 of families think daily communication with MD
  is very important
• 10 say they actually received daily
  communication
• SUPPORT trial
• Majority of patient/families in ICU gt14d had not
  discussed their prognosis with MD
• 25 did not know if their care was geared toward
  comfort or cure.
• 50 who wanted comfort care did not receive care
  c/w their wishes

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Financial barriers to MD-family communication in
the ICU

• Medicare limits what types of family meetings can
  be billed as critical care services.
• Reimbursable conversations that have direct
  bearing on medical decision-making
• Not reimbursable daily updates of patient
  status, answering the familys questions about
  the patients condition or providing emotional
  support

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Family needs in the ICU

• Prospective multicenter study in 43 French ICUs
• 920 family members completed a satisfaction
  survey (CCFNI) on HD3.
• -73 wanted more info about diagnosis
• -72 wanted more info about treatments
• -77 wanted more info about prognosis
• -48 would like the help of a psychologist

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Family needs in the ICU

• Multivariate analysis
• Positively associated with satisfaction
• Patientnurse ratio lt3
• Family of French descent
• Family is helped by their PMD
• Negatively associated with satisfaction
• Family reports receiving contradictory info
• Family does not know the role of each caregiver
• Desired/allowed time ratio

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Inadequate Communication in the ICU

• Question Do family members of ICU patients
  understand the diagnosis, treatment, and
  prognosis?
• Prospective, single-site study of 102 MICU
  patients
• Physician and family member interviewed
  separately on HD2 about comprehension of dx, tx
  and prognosis.
• Comprehension assessed by a single investigator
• -diagnosis
• -prognosis
• -treatments

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Inadequate Communication in the ICU

• Diagnosis
• What medical problem has caused the patient to
  be in the ICU?
• Prognosis
• Does the physician anticipate a fatal outcome?

• Treatments
• Sedation
• Mechanical ventilation
• Vasopressor agents
• Dialysis
• Surgery
• Antibiotics
• Blood transfusions
• Cancer chemotherapy
• Immunosuppressive agents
• Chest drainage

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Inadequate Communication in the ICU

• Results
• 20 did not understand the diagnosis
• 40 did not understand the treatments
• 43 did not understand the prognosis

• Predictors of poor understanding
• Duration of 1st meeting lt10 minutes
• MD perceives poor understanding
• Non-French speaking
• Admitted with resp failure or coma

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Proactive Ethics Consultation in the ICU

• Design Prospective controlled study of the
  effect of proactive ethics consult on
  communication and length of stay.
• Patients 99 ICU patients with gt96 hours of
  continuous mechanical ventilation.
• Intervention ethics consultation meeting with
  MDs only to review goals of care and to
  encourage/facilitate communication with patient
  family

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Proactive Ethics Consultation in the ICU

• Results
• In the intervention group (plt0.05)
• 1. More frequent communication between MD-family
• 2. More decisions to forego life-sustaining
  treatment
• 3. Decreased length of ICU stay
• Of note No involvement of patient or families
  in the ethics consult no assessment of patient
  satisfaction with ICU care.
• Is this really an ethics consultation? Is this
  simply plug pulling?

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Effect of Ethics Consultation in the ICU

• Questions
• 1. Do ethics consults in the ICU decrease
  nonbeneficial treatment in patients who
  ultimately die?
• 2. Do MDs, nurses, patients/surrogates support
  their use.
• Nonbeneficial treatment ICU days, hospital days
  and life-sustaining treatments who did not
  survive to hospital discharge.

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Effect of Ethics Consultation in the ICU

• Design RCT in 7 US adult ICUs (public, private,
  religious, MICU, SICU)
• Patient Enrollment nurses at each site assigned
  to find value-laden treatment conflicts in the
  ICUs.
• Randomization block randomization by site
  ethics consult was available on request to those
  in the control group.

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Effect of Ethics Consultation in the ICU

• Intervention ethics consultation by qualified
  groups. Patients/surrogates were free to refuse
  consultation.
• No standard protocol for consultation
• No content analysis of what occurred
• No documentation of how many hours spent by
  ethics committee on case/with patient

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Effect of Ethics Consultation in the ICU

• Data Collection Analysis
• Intention to treat analysis
• Blinded research assistants extracted data from
  charts. (Probably able to tell which group
  patient was in).
• Power calculation 174 subjects/group (n551)
• Patient/Surrogate/MD Satisfaction
• Intervention group only face-to-face or
  telephone interviews about the utility of the
  ethics consult

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Effect of Ethics Consultation in the ICU

• Outcome Measures
• Nonbeneficial days
• Satisfaction with ethics consultation
• Are these appropriate outcome measures?

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An Intensive Communication Intervention in the ICU

• Design Before and after study of 530 ICU
  patients _at_ BWH.
• Intervention multidisciplinary meeting within 3
  days of admission discussion of patient
  preferences, treatment plan and outline of
  clinical milestones to assess whether treatment
  was working? follow-up meetings at appropriate
  points.
• Results unchanged mortality, ICU LOS 4days?
  3days, significant decrease in disagreements.

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Family Information Leaflet and Comprehension (FIL)

• Hypothesis Giving an information leaflet to
  family at ICU admission will improve
  comprehension satisfaction.
• Design prospective RCT of 175 subjects in 34
  French ICUs
• Leaflet given to family at time of admission by
  investigator.

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Family Information Leaflet and Comprehension (FIL)

• Leaflet Contents
• General ICU contact info, visiting hours, names
  and titles of ICU director and head nurse.
• Blank page on which the name of the ICU attending
  was written.
• Diagram of a typical ICU room
• Glossary of 12 terms common to ICU (intubation,
  extubation, ventilator, sedation, cardiac
  monitor, catheter, gastric tube, iatrogenic
  event, nosocomial infection)

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Inadequate Communication in the ICU

• Diagnosis
• What medical problem has caused the patient to
  be in the ICU?
• Prognosis
• Does the physician anticipate a fatal outcome?

• Treatments
• Sedation
• Mechanical ventilation
• Vasopressor agents
• Dialysis
• Surgery
• Antibiotics
• Blood transfusions
• Cancer chemotherapy
• Immunosuppressive agents
• Chest drainage

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Effectiveness of Family Information Leaflet
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Effectiveness of Family Information Leaflet

• Improved comprehension without providing info
  about the patient
• Trend toward improved satisfaction
• Suggests that family can handle explicit info
  about the patients condition

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An Approach to the Family Meeting

• Preparations
• Review patients disease, treatments, prognosis
• Review your knowledge of pt tx preferences
• Meet briefly with the rest of your team to
  identify goals.
• Make sure all relevant people are available
• Arrange to meet in a private place w/seating

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An Approach to the Family Meeting

• At the meeting
• Introductions
• Discuss goals of conference
• Find out what the family understands
• Elicit patient values/goals
• Clarify relevant points
• Discuss prognosis frankly (acknowledge
  uncertainty)
• DONT SAY What would you like us to do?
• DO SAY If the patient were in the room, what
  would she want us to do?
• MAKE A RECOMMENDATION

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An Approach to the Family Meeting

• Ending the meeting
• Summarize what was accomplished
• Reiterate the plan
• Ask if there are questions
• Have a follow-up plan

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Summary

• In general, family members have unique knowledge
  of patients preferences and values.
• Informed families are the exception rather than
  the rule in the ICU.
• Family members rank information needs above
  comfort, reassurance.
• Simple interventions can improve family
  understanding and satisfaction.