A Communication Strategy and Brochure for Relatives of Patients Dying in the ICU

Lautrette, Alexandre; Darmon, Michaël; Mégarbane, Bruno; Joly, Luc Marie; Chevret, Sylvie; Adrie, Christophe; Barnoud, D.; Bleichner, G; Bruel, Cédric; Choukroun, G.; Curtis, J. Randall; Fieux, Fabienne; Galliot, Richard; Garrouste-Orgeas, Maïté; Georges, Hugues; Goldgran-Tolédano, Dany; Jourdain, M.; Loubert, G.; Reignier, Jean; Saidi, F; Souweine, Bertrand; Vincent, François; Kentish-Barnes, Nancy; Pochard, Frédéric; Schlemmer, Benoı̂t; Azoulay, Élie

doi:10.1056/nejmoa063446

Cited by 1,121 publications

(903 citation statements)

References 35 publications

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“…Among the many potential contributors to these adverse bereavement outcomes are the circumstances surrounding and processes of limiting life support. This hypothesis is supported by evidence that ICU deaths are commonly preceded by decisions to withdraw life support [3], and evidence that both ICU processes of care [4,5] and behaviors of ICU clinicians [1,6] near the end of life can influence family members' post-ICU psychological outcomes. Thus, uncertainty regarding which approaches to withdrawing mechanical ventilation are least distressing for patients and families [7,8] represents an important area for rigorous investigation.…”

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confidence: 94%

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Life after death in the ICU: detecting family-centered outcomes remains difficult

2017

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Family members of patients who die in the ICU experience significant and lasting psychological burdens, such as post-traumatic stress disorder (PTSD), anxiety, depression, and prolonged grief [1,2]. Among the many potential contributors to these adverse bereavement outcomes are the circumstances surrounding and processes of limiting life support. This hypothesis is supported by evidence that ICU deaths are commonly preceded by decisions to withdraw life support [3], and evidence that both ICU processes of care [4,5] and behaviors of ICU clinicians [1,6] near the end of life can influence family members' post-ICU psychological outcomes. Thus, uncertainty regarding which approaches to withdrawing mechanical ventilation are least distressing for patients and families [7,8] represents an important area for rigorous investigation.In this context, Reignier and colleagues performed a prospective observational cohort study to compare psychological symptoms in over 400 family members of patients who died after withdrawal of mechanical ventilation by immediate extubation vs. terminal weaning in 43 French ICUs [9]. Impressively, the authors were able to assess the primary endpoint of PTSD symptoms 3 months after death among over 95% of enrolled family members. Secondary endpoints included symptoms of anxiety, depression, and complicated grief among family members, symptom burdens of patients during the dying process, and strains on ICU staff.The authors found no differences between groups in any of the psychological outcomes reported by family members at 3 months. This was a durable finding when adjusted for patient characteristics and center effects, and at 6-and 12-month follow-up assessments. ICU staff experienced similar levels of job strain regardless of the withdrawal method chosen, with the exception of nursing assistants who reported less strain with immediate extubation. Patients in the immediate extubation group experienced more gasping and airway obstruction and received significantly lower doses, on average, of sedatives and analgesics compared to those undergoing terminal weaning. Given these results, the authors conclude that the choice between these two approaches to withdrawal of mechanical ventilation does not impact psychological symptoms among family members. They also suggest, and we agree, that standardized approaches to medication administration near the end of life may reduce patient suffering.This study is innovative in empirically evaluating the impact of how mechanical ventilation is withdrawn on family-centered outcomes. It is also strengthened by the diverse sample of ICUs, and the outstanding follow-up rate. However, the ability to draw conclusions is tempered by the non-randomized design. Although the authors appropriately note that randomly assigning ICUs to an unfamiliar withdrawal method might engender low adherence to the assigned interventions, the observational design amounts to a comparison of withdrawal methods on family members who chose (or whose clinicians chose for them) a particul...

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confidence: 94%

“…Although several measures have been found to be reliable and valid, responsiveness to ICUbased interventions has been a much more elusive goal. Few studies have found changes in the Impact of Events Scale (IES) [4,5] among family members of critically ill patients, and even fewer have shown responsiveness of the Inventory of Complicated Grief (ICG).…”

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confidence: 99%

Life after death in the ICU: detecting family-centered outcomes remains difficult

2017

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“…While one large trial of an integrative ICU-based palliative care approach studied in 22 French ICUs was associated with significant decreases in family member anxiety, depression, and post-traumatic stress disorder levels [14], only a handful of ICU-based palliative care studies [15][16][17] have measured family-reported outcomes other than ''family satisfaction''. Moreover, ICU-based palliative care trials have thus far not measured truly patient-centered outcomes, such as symptom scores or quality of life [18].…”

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confidence: 99%

“…Moreover, ICU-based palliative care trials have thus far not measured truly patient-centered outcomes, such as symptom scores or quality of life [18]. Furthermore, other than the previously mentioned French trial [14], all ICU-based palliative care trials have been completed in North America. There is a dearth of adequately powered studies concerning both the impact of ICU-based palliative care on patient-and family-centered outcomes and the delivery of palliative care in non-North American critical care settings.…”

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confidence: 99%

Tasking the tailor to cut the coat: How to optimize individualized ICU-based palliative care?

Aslakson¹,

Spronk

2015

Intensive Care Med

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“…In this sense, many interventions have been tested to improve the quality of EOL care with different results. Ethics and palliative care consultations, intensive communication strategies, formal family conferences combined with the bereavement brochure have been demonstrated to improve the quality of EOL care by reducing the length of stay and the use inappropriate ICU resources, preventing conflicts and reducing psychological burden on family members [8][9][10][11]. Unfortunately, such interventions are still not widely adopted in ICUs [7].…”

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confidence: 99%

Physicians just need to be better trained to provide the best care at the end-of-life

Soares¹,

Piva

2012

Intensive Care Med

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Over the last decades, caring for terminally ill patients, either in the latter phases of progressive chronic diseases or in the setting of refractory organ failures in the course of acute critical illnesses, has become very frequent in intensive care units (ICUs) and such demand is expected to increase substantially in the next decades [1]. Although the end-of-life (EOL) decision-making process and the consequent strategy vary largely depending on several factors such as cultural aspects, religious beliefs, legal burdens, ethical and moral values, medical knowledge regarding terminally ill diseases and palliative care, up to three-quarters of all ICU deaths are preceded by limitations of treatment [2,3]. However, the care provided to patients at the EOL and their families needs to be urgently improved. Current information indicates that EOL care in ICUs is frequently inappropriate as a consequence of several factors including poor communication [4], inadequate symptom control [5] and divergence among the ICU team, families and the patients themselves regarding their expectations and values [6]. It is well known that conflicts in the context of EOL are perceived as much more severe and dangerous when compared to other conflicts [6].Several relevant barriers to improving EOL care at the levels of the patient/family (e.g. inability to participate in EOL discussions, lack of advance directives, unrealistic expectations), the clinician (e.g. both insufficient training in communication and expertise in symptom management, and competing demands on intensivists' time) and the hospital/institution (e.g. inadequacy or absence of local family conferences and lack of palliative care service) were raised by nurse and physician ICU directors in a survey involving 468 ICUs in the United States [7]. In this sense, many interventions have been tested to improve the quality of EOL care with different results. Ethics and palliative care consultations, intensive communication strategies, formal family conferences combined with the bereavement brochure have been demonstrated to improve the quality of EOL care by reducing the length of stay and the use inappropriate ICU resources, preventing conflicts and reducing psychological burden on family members [8][9][10][11]. Unfortunately, such interventions are still not widely adopted in ICUs [7]. On the other hand, the benefit of multifaceted quality improvement strategies remains unclear [12,13].In the current issue of Intensive Care Medicine, Forte et al. [14] present the results of a questionnaire submitted to 105 Brazilian ICU physicians selected from 11 ICUs in Intensive Care Med (2012) 38:342-344 DOI 10.1007/s00134-011-2432 EDITORIAL a university=affiliated hospital evaluating EOL decisions involving a hypothetical severely brain-damaged patient with no family members or advance directives The study has two major findings: (1) physicians who would not apply do-not-resuscitate (DNR) orders less frequently attended EOL classes; and (2) almost half of respondents would not proceed a...

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A Communication Strategy and Brochure for Relatives of Patients Dying in the ICU

Abstract: Providing relatives of patients who are dying in the ICU with a brochure on bereavement and using a proactive communication strategy that includes longer conferences and more time for family members to talk may lessen the burden of bereavement. (ClinicalTrials.gov number, NCT00331877.)

Cited by 1,121 publications

References 35 publications

Life after death in the ICU: detecting family-centered outcomes remains difficult

Life after death in the ICU: detecting family-centered outcomes remains difficult

Tasking the tailor to cut the coat: How to optimize individualized ICU-based palliative care?

Physicians just need to be better trained to provide the best care at the end-of-life

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