As Baby Boomers start to enter old age and their surviving parents into the older-old age cohort, family members are increasingly having to make difficult medical choices.
With the number of intensive care patients predicted to hit more than 600,000 patients annually by 2020, Case Western Reserve University developed a model to facilitate communication and family decision-making for chronically ill loved ones in medical ICUs that proved quite successful. But the model was less effective for surgical and neurological ICU patients.
Barbara Daly, Ph.D., and Sara Douglas, Ph.D., the study’s lead researchers from the Frances Payne Bolton School of Nursing at Case Western Reserve, attribute the varied results to different types of patients served by the three types of ICUs and differences among ICU cultures.
“We found the same approach is not going to have the same results for everyone,” Daly said.
The researchers repeated a study from a Boston hospital that resulted in shorter stays and fewer unneeded tests and treatments when families were routinely informed through a systemized communications intervention about their family member’s progress in a medical ICU. They compared the effect of the new communication system in 346 patients to usual practice in 135 patients.
The intervention involved a 30-minute communication meeting between the clinical staff and family, beginning five days after a patient requiring a ventilator was admitted to the ICU. The staff and family covered five components: medical update, preferences and goals for the patient, treatment plans, prognosis, and milestones (the markers that can tell whether a person is improving).
The meetings continued weekly until the patient was transferred to a regular hospital ward, to a long-term facility, went home or died.
According to Daly, the discussions are important because up to 40 percent of these ICU patients do not survive beyond two months if they have spent more than five days on a mechanical ventilator.
For survivors, the most likely outcome is for long-term care, which raises issues about the quality of life that the patient might want to have, she said.
Overall, the researchers found no significant differences between the control and intervention groups in length of stay in the ICU or in limitations of aggressive interventions.
“The Boston study had been the ideal situation where the director of the ICU was conducting the study and the ICU staff accepted the intervention as part of its routine practices,” said Daly, professor of nursing and clinical ethics director at University Hospitals Case Medical Center. “We took the study into real-life situations.”
Daly attributes the varying effectiveness of the new communication system to different ages and needs of patients in the medical versus surgical units and to differences in clinical staff attitudes towards decisions to limit aggressive interventions, such as feeding tubes and tracheostomy.
In the medical units, the patients generally are older and chronically ill—many suffering several chronic illnesses. The other ICUs generally serve younger patients who are more likely to have suffered a sudden acute health crisis, such as an emergency surgery or trauma from a motor vehicle accident.
Daly said many treatments in the medical ICU will not sustain life, and families face complicated end-of-life decisions to stop or continue ineffective treatments.
The research group also tracked conversational interchanges between family members and doctors.
All families received medical updates. About 86 percent of the meetings covered treatment plans; 94 percent prognosis; 78 percent, preferences and goals; and only 68 percent, milestones.
Daly said analyses of the types of conversations found that 98 percent of the time was spent relaying facts about the patient, and only 2 percent was spent on personal, emotional, or relationship conversation.
The researchers also found that on average, doctors asked families one question, which was: “Do you have any questions?”
The families asked an average of six.
“Better communications is needed. Overall the process is not working as well as we would like and there are missed opportunities to better support families in their decisions,” Daly concluded.
The full results of the National Institute for Nursing Research-funded study were published in the journal Chest.
Source: Case Western Reserve University