Support intervention for surrogate decision makers of critically ill patients (May 2018)

Link to study: https://www.nejm.org/doi/full/10.1056/NEJMoa1802637?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed

OBJECTIVES: Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences.

TYPE OF TRIAL: Stepped-wedge, cluster-randomized trial

Consensus:

  • Population: in the studies included there was 1420 patients from five ICUs that were at high risk of death

  • Intervention:

    • 1) The PARTNER nurses received advanced communication training that focused on skills for supporting families of seriously ill patients. The 12-hour training included didactic teaching, modeling of the communication skills, practice of the skills with trained medical actors, and provision of structured feedback

    • 2) a family-support pathway was instituted, in which the PARTNER nurses met with families on a daily basis, according to a standardized protocol, and arranged clinician–family meetings within 48 hours after enrollment and every 5 to 7 days thereafter 

    • 3) intensive support for implementation was provided to each ICU by a quality-improvement specialist, to incorporate the family-support pathway into clinicians’ workflow.

  • Comparison: usual care

  • Outcome:

    • Primary outcome: HADS (Hospital Anxiety and Depression Scale) at 6 months of surrogates

      • No significant difference between intervention/control group (P=0.61, 95% CI)

    • Secondary outcomes: mean scores on the Impact of Event Scale; Quality of communication scale (QOC); patient perception of patient centeredness (PPPC) scale; mean length of ICU stay

      • Surrogates mean QOC was better in intervention group (P=0.001, 95% CI)

      • PPPC was better in intervention group (P=0.006, 95% CI)

      • LOS was shorter in intervention group - among patients who died (P<0.001, 95% CI)

While ICU LOS was shorter, in-hospital mortality was higher and the quality of communication was perceived better by surrogates; these results suggest that support interventions reduce ICU LOS/improve communication between health care teams and surrogates of critically ill patients with poor prognosis but they do NOT necessarily reduce the psychological burden of decision making.

Interesting Notes:

  • Low cost way to improve QOC, PPPC and indirectly LOS

Rachel MulderCommunicationComment