EXECUTIVE SUMMARY

Having palliative care physicians facilitate communication or round on high-risk patients in the ICU reduces intensity of end-of-life care and decreases hospital length of stay, according to recent studies. To improve communication with the family of critically ill patients:

  • encourage bedside clinicians to lead conversations on goals of care,
  • give family a point person to get updated information from, and
  • address conflicting information given by providers.

Palliative care physicians acting as communication facilitators in the ICU reduced intensity of end-of-life care and length of stay, found a recent study.1

“Our findings suggest that improving communication with the families of critically ill patients provides an opportunity to reduce the prolongation of dying in the ICU, and minimize the provision of non-beneficial care,” says lead author J. Randall Curtis, MD, MPH. Curtis is director of Cambia Palliative Care Center of Excellence at UW Medicine in Seattle.

The researchers were well aware that families often report inadequate communication with clinicians. Previous research also has shown that better communication is linked to less distress among family members.2

“But we don’t know the best way to improve this communication,” says Curtis.

The researchers hypothesized that a communication facilitator could improve family outcomes, and also reduce the prolongation of dying often seen in the ICU.

“The biggest surprise from this study was the degree to which the communication facilitators were associated with a reduction in length of stay in the ICU for patients who died,” says Curtis.

A follow-up study suggests that the expense of a communication facilitator is covered by the associated cost savings, even when only considering the direct variable components of healthcare costs.3

“Even in ICUs that have already tried to improve communication with family members, there are dramatic cost savings that can be associated with improving communication,” says Curtis.

ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of quality patient care, found a survey of 598 ICU bedside nurses in five academic medical centers.4 This doesn’t always translate into clinical practice, however.

“We were struck by how few nurses engaged in discussions of prognosis and goals of care,” says lead study author Wendy Anderson, MD, MS. “Also, it was striking that nurses identified such a high rate of emotional toll as a barrier.”

The study’s findings emphasized the need to clarify roles of different professionals in communication about prognosis and goals of care, says Anderson, a palliative care physician at UCSF Medical Center in San Francisco.

“It’s important not to relegate all the communication about prognosis and goals of care to ethicists or palliative care clinicians,” she says. Anderson worked with colleagues to develop the organization’s Integrating Multidisciplinary Palliative Care into the ICU (IMPACT) project. This trains ICU bedside nurses to lead goals-of-care conversations.

“Another key piece has been rounding at the bedside,” says Anderson. Palliative care nurses or educators ask questions such as, “What is the family’s understanding of the patient’s prognosis?” or, “Where does the family need support?”

Often, bedside providers only call for help from ethicists or palliative care if conflicts are already intractable. Anderson would like for that to change. “Things have to be really bad for that to happen. What we’d like is a less formal way to reach out about a situation,” she says.

A quick phone conversation might suffice for a particular situation, as opposed to calling a formal consult. “If it doesn’t work, that’s the time to have an ethicist or palliative care expert speak directly to the patient or family,” says Anderson.

Families sometimes report conflicting messages from people involved in the patient’s care. “The surgeon, nephrology consultant, infectious disease consultant, or surgical subspecialist, are all speaking from different perspectives,” says Anderson. Sometimes it’s just that the same information is being communicated differently. “At the same time we’re engaging different disciplines, we need to give similar messages to patients and families,” notes Anderson.

Other times, there are true disagreements among clinicians. The ICU physician may have a different perspective from the surgeon, for instance. “Families are amenable to hearing those different perspectives,” says Anderson. “But it needs to be communicated.”

Families often lack a designated person to go to with questions. A bedside nurse, resident, or even a medical student can serve as a “quarterback,” involving others as needed, or scheduling discussions with physicians. “What many family members tell us is that they have to sit at the bedside constantly to be sure they catch the doctor,” says Anderson.

When a palliative care clinician interacted with ICU physicians on daily rounds for 103 high-risk patients, family meetings occurred earlier and more frequently, found a recent study.5

“At this point, everyone in critical care medicine agrees that communication with patients and family is really important,” notes William J. Ehlenbach, MD, MSc, one of the study’s authors. Ehlenbach is assistant professor of medicine in the division of pulmonary and critical care medicine at University of Wisconsin School of Medicine and Public Health in Madison.

Multiple professional societies recommend that meetings be held early in the ICU stay. “But we know from the literature that these meetings aren’t happening as early as they should,” says Ehlenbach.

The intervention designed by the research team is a simple interface with the ICU team during morning rounds. “Our hypothesis was that this could prompt the critical care team to think about the palliative care needs of the patient, and put those a little bit higher on the priority list,” Ehlenbach explains.

In Ehlenbach’s experience, when intractable conflicts occur between clinicians and families, “if we could go back in time and improve the quality of communication and make it happen earlier, I think a lot of that could be avoided.”

Problems arise when the team waits too long to honestly communicate with families of patients who are not doing well. Often, all the professionals taking care of a patient know how poor the prognosis is, but days or even weeks go by with no communication. “By the time they do communicate it, it may be brand-new news to the family,” says Ehlenbach. “They might have been thinking for weeks that the person was going to recover.”

For patients who died in the hospital, ICU and hospital length of stay were significantly shortened, found the researchers. “Our interpretation of that finding is that discussions about prognosis were happening earlier,” Ehlenbach says. For some patients who were not doing well, it moved decisions about goals of care earlier in the course of the hospital stay. “That’s an important outcome,” says Ehlenbach. “To spend two or three weeks in the ICU during a terminal hospitalization really doesn’t have much value.”

Notably, the researchers saw no difference in mortality rates. “We don’t think that the decisions being made about continuing life-sustaining therapy were any different,” says Ehlenbach. “It just changed the timing.”

REFERENCES

  1. 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(2):154-162.
  2. 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.
  3. Khandelwal N, Benkeser D, Coe NB, et al. Economic feasibility of staffing the intensive care unit with a communication facilitator. Ann Am Thorac Soc 2016 Sep 27. [Epub ahead of print].
  4. Anderson WG, Puntillo K, Boyle D, et al. ICU bedside nurses’ involvement in palliative care communication: A multicenter survey. J Pain Symptom Manage. 2016; 51(3):589-596.e2.
  5. Braus N, Campbell TC, Kwekkeboom KL, et al. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med 2016; 42(1):54-62.

SOURCES

  • J. Randall Curtis, MD, MPH, Director, Cambia Palliative Care Center of Excellence, University of Washington, Seattle. Phone: (206) 744-3356. Fax: (206) 744-8584. Email: jrc@u.washington.edu.
  • William J. Ehlenbach, MD, MSc, Assistant Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison. Phone: (608) 262-0802. Fax: (608) 263-3104. Email: wjehlen@medicine.wisc.edu.
  • Wendy Anderson, MD, MS, Palliative Care Program, University of California, San Francisco. Phone: (415) 502-2399. Email: Wendy.Anderson@ucsf.edu.