Background: Three decades of research on end-of-life care in the United States indicate that people who are dying often spend their final days in ICU settings receiving poor quality end-of-life care. This failure to receive desired end-of-life care is attributed, in large part, to communication failures among patients, families and clinicians. In order to improve end-of-life care, interventions that result in improved communication are needed. Long-term Objectives: The long term objectives of this proposal are: 1) to demonstrate the efficacy of a facilitator-assisted interdisciplinary communication intervention in the ICU to improve family and patient outcomes;and 2) to demonstrate the feasibility of making this intervention a routine part of clinical practice in the ICU setting.
Specific Aims : The study's specific aims are: 1) to evaluate the efficacy of a facilitator-assisted interdisciplinary communication intervention in the ICU to improve family symptoms of depression, anxiety and post-traumatic stress disorder;2) to evaluate the efficacy of the intervention on the patient's quality of dying and death as evaluated by both families and nurses;and 3) to evaluate the efficacy of the intervention on processes of care and processes of communication. Study Design: A five year, randomized controlled study at 4 hospitals enrolling 480 patients, 240 assigned to the intervention and 240 assigned to the control group. The intervention includes: 1) in-person interviews by the facilitator with the family prior to the family conference in order to discuss the family's concerns, questions, and communication needs;2) a pre-conference meeting with the facilitator and the patient's clinicians in which the family's concerns, questions, and communication needs are discussed;3) facilitator participation in the family conference;and 4) facilitator follow up with the family throughout the ICU stay. The efficacy of the intervention will be measured with quantitative measures collected at enrollment and at three months after the patient's death or discharge from the ICU. We will assess the efficacy of the intervention by comparing scores on questionnaires from the families and clinicians of intervention patients with scores on the questionnaires from the families and clinicians of the control patients who will receive usual care. Significance: This intervention, designed to improve communication and decision-making about end-of-life care in the ICU, offers significant potential benefits for improving patient- and family-centered care for several reasons: 1) communication is an integral component of clinician skill that affects all other aspects of end-of-life care;2) physicians and nurses in practice do not demonstrate adequate skills for communicating about end-of-life care, especially in the ICU or acute care setting;and 3) preliminary evidence suggests that interventions that have improved communication within the ICU team and between the team and the family have the potential to improve patient and family outcomes.

Public Health Relevance

Twenty percent of deaths in the US occur in or shortly after a stay in the intensive care unit (ICU), a setting in which technologically expensive care is delivered. End-of-life decisions are often made by family members in these settings, but families report experiencing poor communication with clinicians, making these decisions difficult. This proposal addresses the need for improving communication in ICU settings with a randomized trial of an interdisciplinary communication intervention in which a facilitator intervenes to assist and support communication efforts by all stakeholders. The facilitated communication intervention is designed to be easily generalizable to other hospitals and ICUs and, if successful, would improve the quality of care patients and their families receive in the ICU.

Agency
National Institute of Health (NIH)
Institute
National Institute of Nursing Research (NINR)
Type
Research Project (R01)
Project #
5R01NR005226-12
Application #
8245810
Study Section
Health Services Organization and Delivery Study Section (HSOD)
Program Officer
Aziz, Noreen M
Project Start
1999-09-30
Project End
2014-03-31
Budget Start
2012-04-01
Budget End
2014-03-31
Support Year
12
Fiscal Year
2012
Total Cost
$663,200
Indirect Cost
$238,072
Name
University of Washington
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
605799469
City
Seattle
State
WA
Country
United States
Zip Code
98195
Lee, Janet J; Long, Ann C; Curtis, J Randall et al. (2016) The Influence of Race/Ethnicity and Education on Family Ratings of the Quality of Dying in the ICU. J Pain Symptom Manage 51:9-16
Isaac, Margaret; Curtis, J Randall (2016) How to respond to an ICU patient asking if she/he is going to die. Intensive Care Med :
Ramos, Kathleen J; Downey, Lois; Nielsen, Elizabeth L et al. (2016) Using Nurse Ratings of Physician Communication in the ICU To Identify Potential Targets for Interventions To Improve End-of-Life Care. J Palliat Med 19:292-9
Downey, Lois; Hayduk, Leslie A; Curtis, J Randall et al. (2016) Measuring Depression-Severity in Critically Ill Patients' Families with the Patient Health Questionnaire (PHQ): Tests for Unidimensionality and Longitudinal Measurement Invariance, with Implications for CONSORT. J Pain Symptom Manage 51:938-46
Brown, Crystal E; Engelberg, Ruth A; Nielsen, Elizabeth L et al. (2016) Palliative Care for Patients Dying in the Intensive Care Unit with Chronic Lung Disease Compared with Metastatic Cancer. Ann Am Thorac Soc 13:684-9
Curtis, J Randall; Treece, Patsy D; Nielsen, Elizabeth L et al. (2016) Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care. Am J Respir Crit Care Med 193:154-62
Curtis, J Randall; Downey, Lois; Engelberg, Ruth A (2016) The importance and challenge of measuring family experience with end-of-life care in the ICU. Intensive Care Med 42:1179-81
Ehlenbach, William J; Larson, Eric B; Curtis, J Randall et al. (2015) Physical Function and Disability After Acute Care and Critical Illness Hospitalizations in a Prospective Cohort of Older Adults. J Am Geriatr Soc 63:2061-9
Creutzfeldt, Claire J; Holloway, Robert G; Curtis, J Randall (2015) Palliative Care: A Core Competency for Stroke Neurologists. Stroke 46:2714-9
Khandelwal, Nita; Kross, Erin K; Engelberg, Ruth A et al. (2015) Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review. Crit Care Med 43:1102-11

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