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Family Conferences in the ICU Infrequently Address The Patient's Prognosis for Survival
Abstract & Commentary
By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Dr. Hoffman reports no financial relationship to this field of study.
Synopsis: Although the majority (> 85%) of conferences included statements about functional ability and quality of life, prognosis for survival was not mentioned in one third of conferences.
Source: White DB, et al. Prognostication during physician-family discussions about limiting life support in intensive care units. Critical Care Med. 2007;35:442-448.
Although prognostic information is viewed as very important to family members of incapacitated, critically ill patients, little is known about what prognostic information clinicians provide during family conferences. This study presents an analysis of 51 patient-family conferences that involved deliberations about major end-of-life treatment decisions. The study was conducted in four Seattle area hospitals, including two community hospitals, one inner city hospital and one university hospital.
Of the 68 families approached, 51 (75%) agreed to participate. Mean duration of the conferences was 32.0 ± 14.8 min (range 7-74 min). The majority of conferences (86%) contained discussions about the patient's anticipated functional status or quality of life, compared with 63% in which the chances for survival (short or long term) were discussed. Four factors were associated with a greater number of prognostic statements about survival, including a longer duration of the conference (p < .001), increased amount of conflict between the physician and family about withdrawing life support (p <.001), the physician's race being white (p = .009) and higher educational level of the family (p < .001). There was considerable physician-to-physician variability in the amount of prognostic information provided but consistency in information provided by individual physicians.
ICUs admit critically ill patients with the goal of providing technically sophisticated care that leads to their recovery. Despite advances in care provision, surveys indicate that many patients do not respond to treatment or experience complications that suggest they have limited potential for survival, either short- or long-term, or will have severe limitations in functional status, quality of life, or neurological outcome. In such situations, surveys suggest that the majority of families indicate they want to actively participate in end-of-life decision-making. In order do this, it is important that that they clearly understand the patient's expected prognosis.
A positive aspect of this study was the finding that, with one exception, all recorded conferences included at least one statement about prognosis, and the overwhelming majority (86%) included statements about functional outcomes or quality of life. There was a strong positive association between the length of the conference and the number of prognostic statements. While most included statements about prognosis for survival, such comments were missing from approximately one-third of family conferences. Prior studies have shown that families with the most optimistic expectations tend to opt for more aggressive treatment. Consequently, this finding has implications for decision-making.
Moral distress is defined as a situation in which an individual feels a certain way about the appropriate ethical choice but is constrained from taking this action. In a recent study of nurse-physician perceptions of moral distress, the three situations ranked as most troubling were "being expected to continue life support because of a family decision when not in the patient's best interests" "initiating lifesaving actions that only prolong death" and "avoiding the decision to pull the plug".1 Continuing aggressive interventions when the patient has no chance of recovery risks adverse consequences for all involved—patients, families, and clinicians. Although prognostication is admittedly inexact, it is possible to introduce the topic in general terms, eg, "I'm afraid that things may not turn out well" and then proceed to more specific statements, eg, "I don't see her surviving more than a few months." Findings of this study suggest that it is important to ensure that prognostic information is shared and understood by families with less education, who may not ask leading questions, and to allow a reasonable period of time for the discussion.