physician-family communication in the icu

Physician-Family Communication in the ICU

Douglas B. White, MD

March 31, 2004

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?

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

• 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 HD#3 and, if he hasn’t significantly improved, to discontinue MV and HD.

• On HD#3, his vent settings are higher and he has persistent hypotension despite 2 pressors. Based on the patient’s 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.

Beauchamp & Childress. Principles of Biomedical Ethics. 1994

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

Components of Autonomy

• Intentionality• Without controlling influences that determine

their action• With understanding

• How much understanding is necessary or desirable?

Sheridan SL. Am J Prev Med 2004;26:56-66

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 patient’s values and treatment preferences.

• Physician and surrogate mutually agree upon a plan.

Sheridan SL. Am J Prev Med 2004;26:56-66

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

Lloyd CB. Crit Care Med 2004; 32:649-54

Does Prognostic Information Influence Patient Decisions?

Subjects: 50 inpatients with chronic disease & estimated 6-month mortality > 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


Does Predicted Survival Influence Patient Decisions?

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.


Does Predicted QOL Influence Patient Decisions?

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.


Does Prognostic Information Influence Patient Decisions?

Conclusions:

1. Wide variation in preferences for ICU care.

2. Pre-admission QOL does not predict preferences.

3. Desire for ICU care decreases as predicted mortality increases and QOL decreases.

Pochard F. Crit Care Med 2001;29;29:1893-1897

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.

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?

Arnold RM. Crit Care Med 2003;31:S347-353

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 patient’s values: life at all

costs vs anti-technology.– Few patients have explicitly discussed their

resuscitation preferences.

Sehgal A, Lo B. JAMA 1992;267:59-63.

Family as surrogate decision-maker

• While not perfect, close family is better able to impute patient preferences than physician.

• >90% of patients want family to make decisions in conjunction with MDs (Puchalski C. JAGS 2000;48:S84-S90)

• 40% of patients want their surrogate to exercise judgement rather than strictly adhere to living wills.

Legal justification for surrogate decision-making

Pochard F. Crit Care Med 2001;29;29:1893-1897

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.

Can Surrogates Be Adequately Informed?

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

making

Hickey M. Heart Lung 1990;19:401-15

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

Heyland DK Crit Care Med 2002 Johnson D. Crit Care Med; 1998

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]”

Abbott KH. Crit Care Med 2001; 29:197-201

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

Breen CM. J Gen Intern Med 2001;16:283-289

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

Teno JM. J Am Geriatr Soc 2000;48:70-74

Communication of Prognosis in the ICU

• Subset of 905 SUPPORT patients who had ICU LOS >14days

• Day #7: prognosis estimated by SUPPORT prognostic model, by physician and by surrogate decision-maker.

• 33% could not estimate their prognosis• <40% reported that their MD had discussed

their prognosis with them.• Surrogates estimate of prognosis was

significantly different from MD or prognostic model.

Molter. Heart Lung. 1979;8:332-339 Teno JM. JAGS 2000;48:S70-74

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 >14d 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

Dep Health Human Services; transmittal No. B-99-43: Issues Related to Crit Care Policy. 1999

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 family’s questions about the patient’s condition or providing emotional support

Azoulay E. AJRCCM 2001;163:135-139

Family needs in the ICU

• Prospective multicenter study in 43 French ICUs• 920 family members completed a satisfaction

survey (CCFNI) on HD#3.

-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

Azoulay E. AJRCCM 2001; 163:135-139

Family needs in the ICU

• Multivariate analysis:• Positively associated with satisfaction:

– Patient:nurse ratio <3

– 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

Azoulay E. Crit Care Med 2000; 28:3044-49

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

HD#2 about comprehension of dx, tx and prognosis.• Comprehension assessed by a single investigator:

-diagnosis-prognosis-treatments

Azoulay E. Crit Care Med 2000;28:3044-3049


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


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 <10 minutes

• MD perceives poor understanding

• Non-French speaking• Admitted with resp failure

or coma

Dowdy M. Crit Care Med. 1998

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 >96 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

Dowdy M. Crit Care Med. 1998

Proactive Ethics Consultation in the ICU

Results: In the intervention group (p<0.05):1. More frequent communication between MD-family2. More decisions to forego life-sustaining treatment3. 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”?

Schneiderman LJ. JAMA 2003

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.


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.


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


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 (n=551)

Patient/Surrogate/MD Satisfaction:

• Intervention group only; face-to-face or telephone interviews about the utility of the ethics consult


Outcome Measures:

1. Nonbeneficial days

2. Satisfaction with ethics consultation

3. Are these appropriate outcome measures?

Lilly CM. Am J Med. 2000;109:469

An Intensive Communication Intervention in the ICU

Design: Before and after study of 530 ICU patients @ 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.


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.


Family Information Leaflet and Comprehension (FIL)

Leaflet Contents

1. General ICU contact info, visiting hours, names and titles of ICU director and head nurse.

2. Blank page on which the name of the ICU attending was written.

3. Diagram of a typical ICU room4. Glossary of 12 terms common to ICU (intubation,

extubation, ventilator, sedation, cardiac monitor, catheter, gastric tube, iatrogenic event, nosocomial infection)

Azoulay E. Crit Care Med 2000;28:3044-3049


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


Effectiveness of Family Information Leaflet


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 patient’s condition

Curtis JR. Crit Care Med 2001;29: 26-33

An Approach to the Family Meeting

Preparations• Review patient’s 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



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)

• DON’T 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



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

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.

physician-family communication in the icu

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