Improving Communication in the ICU about
End-of-Life Care in the ICU Reduces Symptoms of Stress, Anxiety,
and Depression in Family Members
An intervention to improve communication between clinicians in
the Intensive Care Unit (ICU) 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 in the
February 1, 2007 issue of the New England Journal of Medicine.
The study, funded in part by the National Institute of Nursing
Research (NINR), a component of the National Institutes of Health
(NIH), showed that this intervention also allows family members
to express their emotions and arrive at a more realistic expectation
of the outcome.
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 the
mnemonic 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.”
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. |