By Elaine Chen, MD
Assistant Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Section of
Palliative Medicine, Rush University Medical Center, Chicago
Dr. Chen reports no financial relationships relevant to this field of study.
SYNOPSIS: Highly trained communication facilitators who counseled families and met with physicians and nurses were shown to decrease symptoms of depression in family members at six months and decreased ICU length of stay without affecting mortality.
SOURCE: Curtis JR, Treece PD, Nielsen EL, et al. Randomized trial of communication facilitators to reduce family distress and intensity of end-of-life care. Am J Respir Crit Care Med 2016;193:154-162.
Studies have shown that interventions designed to improve clinician-family communication in the ICU can lead to better care. This study was a parallel-group, randomized trial of a “communication facilitator” intervention. Researchers trained a nurse and a social worker to act as communication facilitators to improve goals of care discussions in the ICU and improve communication between ICU team and families of critically ill patients.
The study included five ICUs in two hospitals, an academic level I trauma center, and a community-based hospital. Over five years, researchers screened 2,209 patients, of which 488 met eligibility criteria that included such parameters as mechanically ventilated and high Sequential Organ Failure Assessment scores. Additionally, 168 subjects underwent randomization to either intervention or control in a 1:1 ratio. The final analysis included 86 control patients with 137 family members (51%) and 82 intervention patients with 131 family members (49%).
Facilitators received extensive, evidence-based training in clinician-family communication in the ICU. Facilitators interviewed families and summarized concerns to physicians and nurses. Facilitators participated in family conferences and followed up with family after the patient was discharged to acute care.
Symptoms of depression were assessed using Patient Health Questionnaire-9 at baseline, three months, and six months. Symptoms of anxiety were assessed using the Generalized Anxiety Disorder-7 at baseline, three months, and six months. Symptoms of post-traumatic stress disorder (PTSD) were assessed using the PTSD Checklist Civilian Version (PCL) at three and six months.
There were no statistically significant differences in symptoms of anxiety or PTSD between controls or interventions, although at six months the PTSD difference was just short of statistical significance (P = 0.056) in favor of the intervention group demonstrating lower PCL scores. There was a statistically significant decrease in symptoms of depression at six months in the intervention group compared with the control group (P = 0.017), but not at three months.
There were no differences in ICU mortality (29% in control group vs. 26% in intervention group; P = 0.615) or withdrawal of life support among those who died (71.4% in control group vs. 80% in intervention group; P = 0.737). However, time to withdrawal of life support was significantly shorter in the intervention group (16.5 days in control group vs. 7.2 days in intervention group; P = 0.001). Among survivors, ICU and hospital length of stay (LOS) were similar. Among decedents, both ICU LOS (28.5 days in control group vs. 7.7 days in intervention group; P = 0.001) and hospital LOS (31.8 days in control group vs. 8 days in intervention group; P = 0.001) were shorter in the intervention group. Total ICU costs were significantly reduced in the intervention group, but only in decedents. However, average ICU costs per day also decreased in the intervention group among both survivors and decedents.
Reductions in ICU and hospital LOS among patients who died suggest that LOS reduction was due to an earlier decision to withdraw life-sustaining treatments. Mortality did not change; withdrawing life support earlier did not lead to increased mortality. In this study, reduced LOS in the intervention group was associated with reduced costs for patients who died, suggesting that reduced intensity of end-of-life care occurred with no worsening, but instead possibly a reduction in family distress.
This study showed that a communication facilitator trained to improve communication between the ICU team and family may be associated with reduced symptoms of depression for family members six months after a patient’s ICU stay. There were no significant differences at three months or in symptoms of anxiety or PTSD. The authors concluded that differences in symptoms of depression only can be viewed as exploratory, and further study is warranted. Overall goals of future studies should be to identify the most beneficial and cost-effective interventions to support families of critically ill patients and reduce intensity of non-beneficial care at the end of life.
There is no doubt that improved communication with families of critically ill patients with a high risk of mortality is beneficial. But how exactly is it beneficial? And how is it best delivered? This study suggests that it improves family distress at six months, but only in depressive symptoms. An earlier study showed that improving communication decreased levels of depression, anxiety, and PTSD three months after a patient died in the ICU.1
This study was limited by a small sample size, difficulty recruiting patients, and loss of follow-up. The results in this study may not be generalizable, given that the intervention involved only two facilitators who were highly skilled and extensively trained and took place in two hospitals that have been the venue for multiple palliative care interventions by perhaps the most well-known U.S. research group on palliative care in the critical care setting. The likely pre-existing high level of communication skills in these ICUs may bias the outcome, decreasing the likelihood of a positive result. Variability in the model of intensive care delivery can also significantly affect communication. Factors such as location, referral base, availability of palliative care, resident or mid-level provider support, number of beds, and whether the unit is open or closed may all contribute, and the level of significance is difficult to measure. Additionally, this study population was relatively racially homogeneous, with more than 80% of family members classified as Caucasian. Racial issues in trust and withdrawal of life support have been controversial, but data from a more heterogeneous population would be interesting and perhaps more generalizable.
Compassionate and thorough communication is an integral part of the practice of medicine, an art that drew many to medicine in the first place. Clinicians should strive to be excellent communicators with families of critically ill patients, knowing that words can make a difference. But if someone else (e.g., a facilitator) is a better communicator or has more time available to discuss complex issues, why not use one? Additionally, cost of care, LOS, and intensity of non-beneficial treatments at the end of life are issues hospital administrators and payors value highly. If interventions can simultaneously improve family outcomes as well as control costs, shouldn’t clinicians pursue this solution aggressively? I look forward to future research in this direction.
- Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478.