Missed Opportunities to Improve the Quality of End-of-Life Care
Missed Opportunities to Improve the Quality of End-of-Life Care
Abstract & Commentary
By Leslie A. Hoffman RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert
Department of Acute/Tertiary Care School of Nursing, University of Pittsburgh
Ms. Hoffman reports no financial relationships related to this field of study.
Synopsis: When communicating about end-of-life care, the most common missed opportunities involved responding to family concerns, acknowledging and addressing family emotions, and sharing key principles of medical ethics.
Source: Curtis JR, et al. Missed Opportunities during Family Conferences About End-of-Life Care in the Intensive Care Unit. Am J Respir Crit Care Med. 2005;171:844-849.
The majority of deaths in American ICUS involve withholding or withdrawing life-sustaining therapy. When such decisions are considered, patients are typically unable to communicate for themselves and, therefore, family members may become the decision-makers. Few guidelines exist to direct the structure of family conferences in these circumstances, despite their importance.
Curtis and colleagues identified 51 family conferences when the attending physician anticipated discussion of withdrawing life-sustaining therapy or delivering bad news. The conferences were audiotaped and their content analyzed using qualitative methods. The study was conducted in 4 hospitals, including a county hospital, a university hospital, and 2 community hospitals. Participants included 20 attending physicians, 15 residents or fellows, 50 nurses, 25 social workers, 12 clergy members, and 227 family members. The number of clinicians present ranged from 1 to 12 (mean, 4.3). Most (86%) conferences involved discussions of withdrawing or withholding treatment, and the remainder dealt with relaying news regarding a worsening prognosis or worsening clinical status.
"Missed opportunities" were defined as passages when all clinicians present failed to provide information or emotional support to the family. These passages, identified in 29% of the conferences, fell into 3 categories:
- missed opportunities to answer family questions or follow-up on important statements, the most common category. For example, when asked whether brain damage had occurred, the response focused on how brain function is tested without relating this information to patient status;
- missed opportunities to acknowledge emotions, support family grief, or attempt to alleviate family guilt. For example, when family members expressed sadness or guilt, the conversation was changed to an unrelated topic; and
- missed opportunities to explain key tenets of medical ethics and palliative care, including exploration of patient treatment preferences, explanation of surrogate decision-making, or affirmation that the patient would not be abandoned. For example, clinicians failed to explicitly state that the patient would not be abandoned when transitioning to palliative care or to explore beliefs influencing choices in surrogate decision-making.
The study also assessed family satisfaction with these conversations, and found significantly lower satisfaction ratings for conferences with missed opportunities.
Commentary
Although recognized as extremely important, communication about withdrawing and withholding life-sustaining treatment is commonly assessed as less than optimal by family members. There is no simple way to teach "improved communication;" and studies testing interventions to improve communication are often sketchy in regard to the details of the communication intervention. Curtis et al did not provide demographic information about the participating clinicians, with the exception of physicians leading the conferences, who were predominately male (66%) attending physicians (57%) with a specialty in internal medicine (74%), neurology (14%), surgery (7%), or anesthesiology (3%) who had been practicing for 12.4 ± 9.7 years. Given the experience of these attending physicians, it is likely that they, as others attending the conferences, viewed their communication to be appropriate. Of significance, the large majority (71%) of audiotaped conferences were judged to meet family needs.
The contribution of this study is the specific examples cited in the text illustrating missed opportunities. These circumstances, coded into 3 categories, included missed opportunities to actively listen and directly respond to family questions, to acknowledge and support the emotional distress experienced, to provide insight regarding the ethical basis for surrogate decision-making, and to affirm that the patient will not be abandoned in the process of withdrawing or withholding treatment.
There is increasing evidence that attention to family communication matters. Symptoms consistent with a moderate-to-major risk of post-traumatic stress disorder (PTSD) have been reported by 33% of family members 90 days after ICU discharge or death.1 Higher rates of PTSD were noted among family members who felt information was incomplete (48%), whose relative died in the ICU (50%), and who shared in end-of-life decision-making (82%). These findings support the need to sharpen listening skills, to continuously evaluate success in communicating in difficult circumstances, to identify deficiencies, and to work toward improving these things. By taking full advantage of opportunities to provide information to families, clinicians can address the specific needs of each family, improve shared decision-making, and help to decrease family stress.
Reference
- Azoulay E, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005:171:987-994.
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