Despite recent advances in treatment, 30-40% of patients with acute lung injury (ALI) do not survive. Three decades of research on end-of-life care in the United States indicates that Americans dying in intensive care units often spend their final days receiving life sustaining treatment they would not choose. One reason for this is that family who are acting as surrogate decision-makers frequently do not understand how poor a patient's prognosis is. This problem has negative effects on both patient-centered care at the end-of-life and also on effective use of health care resources. Unfortunately, no empirical studies have addressed what disclosure strategies effectively convey news of a poor prognosis to family of critically ill patients. The long-term goal of this research program is to improve decision-making and communication about prognosis for patients with acute respiratory failure at high risk of death or severe functional impairment through the development and testing of evidence-based interventions. In the proposed research, we address 3 critical gaps in knowledge that limit our ability to develop such interventions.
Aim 1 : to identify disclosure strategies that effectively convey prognostic information to family of critically ill patients.
Aim 2 : to determine the extent to which families'misperceptions about prognosis are associated with prolonged use of life-sustaining treatments before death.
Aim 3 : to determine physicians'and families'perceptions about how prognosis should be communicated in the setting of critical illness, and the barriers to changing physicians'behavior in this regard. We will use the infrastructure of the ARDS Clinical Research Network to conduct a prospective cohort study of communication about prognosis for 175 patients with acute respiratory failure from ALI. We will audiotape physician-family conferences and quantitatively code how physicians disclose prognosis. We will elicit quantitative prognostic estimates from physicians and families after these conferences, and use multivariate methods to identify strategies that effectively convey prognostic information. We will conduct semi-structured interviews with 30 physicians and 60 family members regarding strategies to disclose news of a poor prognosis. The research is significant because it will provide new information about effective and acceptable methods to communicate about prognosis as well as an estimate of the extent to which poor communication about prognosis is associated with more use of life-sustaining treatment. This research is innovative because we will combine quantitative and qualitative methods, new measurement tools developed by our group, and a multidisciplinary research team to study communication about prognosis. These insights will allow us to develop a targeted intervention to improve the care of patients with acute respiratory failure.
Twenty percent of deaths in the US occur in or shortly after a stay in an intensive care unit (ICU), a setting in which highly technological, expensive care is delivered. Families are often asked to participate in decisions about whether to continue life-sustaining treatment, but many families experience inadequate communication with clinicians and do not understand the patient's prognosis, making these decisions difficult. The results of the proposed study will provide information about effective and acceptable strategies to disclose news of a poor prognosis to family members of critically ill patients. These insights will allow us to develop an intervention to improve communication about prognosis for patients with acute respiratory failure.
|Chiarchiaro, Jared; Ernecoff, Natalie C; Scheunemann, Leslie P et al. (2017) Physicians Rarely Elicit Critically Ill Patients' Previously Expressed Treatment Preferences in Intensive Care Units. Am J Respir Crit Care Med 196:242-245|
|Chiarchiaro, Jared; White, Douglas B; Ernecoff, Natalie C et al. (2016) Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists. Crit Care Med 44:934-42|
|Turnbull, Alison E; Davis, Wesley E; Needham, Dale M et al. (2016) Intensivist-reported Facilitators and Barriers to Discussing Post-Discharge Outcomes with Intensive Care Unit Surrogates. A Qualitative Study. Ann Am Thorac Soc 13:1546-52|
|Ernecoff, Natalie C; Witteman, Holly O; Chon, Kristen et al. (2016) Key stakeholders' perceptions of the acceptability and usefulness of a tablet-based tool to improve communication and shared decision making in ICUs. J Crit Care 33:19-25|
|White, Douglas B; Ernecoff, Natalie; Buddadhumaruk, Praewpannarai et al. (2016) Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients. JAMA 315:2086-94|
|Chiarchiaro, Jared; Schuster, Rachel A; Ernecoff, Natalie C et al. (2015) Developing a simulation to study conflict in intensive care units. Ann Am Thorac Soc 12:526-32|
|Ernecoff, Natalie C; Curlin, Farr A; Buddadhumaruk, Praewpannarai et al. (2015) Health Care Professionals' Responses to Religious or Spiritual Statements by Surrogate Decision Makers During Goals-of-Care Discussions. JAMA Intern Med 175:1662-9|
|Chiarchiaro, Jared; Buddadhumaruk, Praewpannarai; Arnold, Robert M et al. (2015) Prior Advance Care Planning Is Associated with Less Decisional Conflict among Surrogates for Critically Ill Patients. Ann Am Thorac Soc 12:1528-33|
|Scheunemann, Leslie P; Cunningham, Thomas V; Arnold, Robert M et al. (2015) How clinicians discuss critically ill patients' preferences and values with surrogates: an empirical analysis. Crit Care Med 43:757-64|
|Chiarchiaro, Jared; Buddadhumaruk, Praewpannarai; Arnold, Robert M et al. (2015) Quality of communication in the ICU and surrogate's understanding of prognosis. Crit Care Med 43:542-8|
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