Study Finds Flaws in Palliative Care Approach

A new study finds the use of palliative care-led informational and emotional support meetings did not reduce anxiety or depression symptoms among families of individuals with chronic illness, compared with usual care.

The study appears in the Journal of the American Medical Association (JAMA).

Patients are considered to have developed chronic critical illness when they experience acute illness requiring prolonged mechanical ventilation or other life-sustaining therapies but neither recover nor die within days to weeks.

It is estimated that chronic critical illness affected 380,000 patients in the United States in 2009. Family members of patients in the intensive care unit (ICU) experience emotional distress including anxiety, depression, and post-traumatic stress disorder (PTSD).

Palliative care specialists are trained to provide emotional support, share information, and engage patients and surrogate decision makers in discussions of patient values and goals of care.

According to the authors, clinical trials of interventions to improve communication about prognosis and goals of care in the ICU have shown mixed results, and none has focused on the high-risk population with chronic critical illness.

To address this gap, Shannon S. Carson, M.D., of the University of North Carolina School of Medicine, Chapel Hill, N.C., Judith E. Nelson, M.D., J.D., of the Memorial Sloan Kettering Cancer Center, New York, and colleagues performed a multicenter randomized clinical trial.

The objective was to determine the effect of informational and emotional support meetings for families of patients with chronic critical illness led by palliative care specialists on family- and patient-centered outcomes.

The researchers hypothesized that more intensive informational and emotional support during periods of decision making would reduce symptoms of anxiety and depression in families of patients with chronic critical illness compared with the routine sharing of information and support provided by ICU teams.

In the study, investigators randomly assigned adult patients requiring seven days of mechanical ventilation and their family surrogate decision makers to at least two structured family meetings. The meetings were led by palliative care specialists and provision of an informational brochure (intervention). A control group received an informational brochure and took part in routine family meetings conducted by ICU teams.

A large sample was studied with 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group. The study was conducted at four medical ICUs.

At three months, researchers discovered there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group.

Moreover, post-traumatic stress disorder symptoms were higher in the intervention group compared with the control group. There was no difference between groups regarding the discussion of patient preferences. The median number of hospital days for patients in the intervention vs the control group and 90-day survival were not significantly different.

Potential explanations for this lack of benefit may relate to the high perceptions of quality of communication, emotional support, and family satisfaction in the usual care control.

“When informational support provided by the primary team is sufficient, additional focus on prognosis may not help and could further upset a distressed family, even when emotional support is concurrently provided,” the authors write.

“Alternatively, the intervention may have been insufficient to overcome the high levels of family stress associated with having a relative with chronic critical illness.”

Source: JAMA/EurekAlert