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Elder Care News
Better Communications in ICU about End-of-Life Care
Benefits Family
Reduces symptoms of stress, anxiety, depression in
family members
 February
1, 2007 - An intervention to improve communication between clinicians in
the Intensive Care Unit and family members of a dying patient
significantly reduces feelings of stress, anxiety, and depression in the
family members, according to a study that appears today in the New
England Journal of Medicine.
This intervention also allows family members to
express their emotions and arrive at a more realistic expectation of the
outcome, says the study, funded in part by the National Institute of
Nursing Research (NINR), a component of the National Institutes of
Health (NIH).
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The researchers evaluated a set of communication
guidelines for family conferences between ICU clinicians and family
members. Based on earlier, extensive end-of-life research conducted by
one of the collaborating researchers, Dr. J. Randall Curtis of the
University of Washington, and funded by NINR, the guidelines followed a
mental technique for making information easier to memorize:
● VALUE: to Value what the family members said,
● ACKNOWLEDGE their emotions,
● LISTEN,
● UNDERSTAND the patient as a person through asking questions, and
● ELICIT questions from the family members.
“Communication in these difficult situations is
vital to all involved, including the patients, the family members, and
the ICU physicians and nurses,” said Dr. Patricia Grady, the Director of
NINR.
“This research furthers our understanding of how
clinicians can work with family members in the decision-making process
and help them cope with the impending loss of a critically ill loved
one.”
“I think this is a remarkable moment in end-of-life
care,” said Dr. Curtis, “because [this study] shows that improving
communication about end-of-life care in the ICU results in a dramatic
reduction in symptoms” related to post-traumatic stress disorder in
family members up to 3 months later.
Families of a patient near death in the ICU are
often under great stress, and they rely on clinicians for information
and support. A family conference, bringing together the family and the
involved clinicians in a quiet room to discuss the patient’s prognosis
and care options, can be an important component of communication.
However, the structure and conduct of these conferences has not
previously been evaluated.
The study involved the family members of 126
critically ill patients cared for in 22 ICUs. When an ICU physician
believed that the death of the patient was likely within a few days, a
proactive family conference was called, with the aim of deciding whether
life-sustaining measures such as mechanical ventilation should be
continued or withdrawn. In half of these cases, the family conference
proceeded under the customary ICU practice. In the other half, the
physicians conducted the conferences in accordance with the VALUE
guidelines. They also provided the families with a brochure on
bereavement.
The ICU patients ranged in age from 56 to 80 years,
most were male, and they were admitted to the ICU for respiratory,
cardiac, or renal failure; coma; or shock. The involved family members
averaged 54 years of age, most were female, over 60 percent were
Catholic, and over 80 percent were either the spouse or the child of the
patient.
On average, the customary-practice conferences
involved two family members and lasted 20 minutes, with the family
speaking roughly five minutes; the intervention conferences involved
three family members and lasted 30 minutes, with the family speaking for
over 13 minutes.
While all conferences were led by the attending ICU
physician, the patient’s nurse was also present in 60 percent of the
customary-practice conferences and 81 percent of the intervention
conferences. All conferences resulted in a decision to forgo further
life-sustaining treatment.
After the conference, 95 percent of family members
in the intervention group reported they had been able to express their
emotions to the ICU clinicians, as compared to 75 percent of family
members in the customary-practice group. In addition, among family
members who initially disagreed with the decision to forgo
life-sustaining treatments, those in the intervention group were more
likely to concur with the decision at a later time.
“Since 1997, NINR has been the lead institute at
NIH for end-of-life research. We will continue to investigate this area
of science that eventually affects every one of us,” Dr. Grady noted.
“Findings from this study will help inform clinicians world-wide who are
involved with critically ill patients and their families.”
Editor’s Notes:
This project was led by Dr. Alexandre Lautrette
of the Hopitaux de Paris, France. Other collaborators include Dr.
Michael Darmon, Dr. Sylvie Chevret, Dr. Fabienne Fieux, Dr. Nancy
Kentish Barnes, Dr. Frederic Pochard, Dr. Benoit Schlemmer, and Dr. Elie
Azoulay, of the Hopitaux de Paris; Dr. Bruno Megarbane of Lariboisiere
Hospital; Dr. Cedrid Bruel of Bichat-Claude Bernard Hospital; Dr. Gerald
Choukroun, of Cochin Hosptial and Paris 5 Rene Descartes University; Dr.
Luc Marie Joly of Rouen University Hosptial; Dr. Cristophe Adrie of
Saint-Denis Hospital; Dr. Didier Barnoud of University Hospital,
Grenoble; Dr. Gerard Bleichner of Argenteuil Hospital; Dr. Richard
Galliot of Pontoise Hospital; Dr. Maite Garrouste-Orgeas of Saint-Joseph
Hospital; Dr. Hugues Georges of Tourcoing Hospital; Dr. Dany
Goldgran-Toledano of Gonesse Hospital; Dr. Merce Jourdain of Salengro
Hospital; Dr. George Loubert of Raymond Pointcare Hosptial, University
of Versailles; Dr. Jean Reignier of La Roche sur Yon Hospital; Dr.
Faycal Saidi of Nemours Hospital; Dr. Bertrand Souweine of
Clermont-Ferrand Hospital; and Dr. Francois Vincent of Avicenne
Hospital. In addition to NINR, this research was funded by Assistance
Publique-Hopitaux de Paris and the French Society for Critical Care
Medicine.
The primary mission of the NINR, one of 27
Institutes and Centers at the National Institutes of Health, is to
support clinical and basic research and establish a scientific basis for
the care of individuals across the life span. For additional
information, visit the NINR web site at
http://ninr.nih.gov.
The National Institutes of Health (NIH) — The
Nation's Medical Research Agency — includes 27 Institutes and Centers
and is a component of the U.S. Department of Health and Human Services.
It is the primary federal agency for conducting and supporting basic,
clinical and translational medical research, and it investigates the
causes, treatments, and cures for both common and rare diseases. For
more information about NIH and its programs, visit
www.nih.gov.
>>
National Institute of Nursing Research (NINR)
Reference: Lautrette, A., et al. (2007). A
communication strategy and brochure for relatives of patients dying in
the ICU. The New England Journal of Medicine, 365:469-478.
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