The study found that there are some fairly simple steps physicians can take, including providing more emotional support and allowing family members more time to speak during these discussions about end-of-life care, which will make families feel more satisfied, said lead investigator J. Randall Curtis, M.D., M.P.H.
"We know that most deaths in the ICU setting are preceded by withholding or withdrawing life support, and we know that family members rate physician communication skills as just as or even more important than their clinical skills," said Dr. Curtis, who is Associate Professor of Medicine at the University of Washington in Seattle, and Director of the Harborview End-of-Life Research Program. "Therefore being able to communicate well with family members is an important part of good quality ICU care."
Dr. Curtis and colleagues audiotaped 50 conferences between physicians and nurses and family members of critically ill patients in the ICU who were too sick to be able to communicate.
The conferences were chosen if the physician leading the conference believed discussion about withholding or withdrawing life support was likely, and if all participants gave their consent. Permission was given by all participants to audiotape the conferences in about half the cases. The researchers then transcribed and analyzed the audiotaped conferences.
"We looked for missed opportunities in these conferences, and they tended to fall into three categories," he said. First, physicians missed the opportunity to listen to family members and further explore the comments that family members made that seemed important. Second, they missed opportunities to provide emotional support for family members by acknowledging or addressing emotions that are expressed during the conference. And third, they missed the opportunity to discuss important principles of end-of-life care. For instance, they did not accurately describe the details of making end-of-life decisions for their loved ones, known as surrogate decision-making or take opportunities to explicitly state that they would not abandon the family or patient if life support was withdrawn.
Dr. Curtis found that doctors varied in their ability to provide emotional support--including acknowledging the difficulty of the situation for family members, providing support for the decisions that family members made, and easing the guilt of family members for making those decisions. "By providing this support, physicians can go a long way toward helping families during this very difficult time," he said.
During the conferences, which averaged 35 minutes, family members spoke for only 29% of the time on average. "When we surveyed family members afterwards about their satisfaction with the conference, we found the factor most strongly correlated with satisfaction was the proportion of time the family members spoke and not the duration of the conference," Dr. Curtis said. "The higher the proportion of the conference that was made up by families speaking, the more satisfied the family was with the conference and the less they were likely to report conflict during the conference. These data suggest that it is not the duration of the conference, but the amount of time that clinicians spend listening that most affects family satisfaction."
The conferences tended to have a similar agenda, starting with information exchange covering specific topics such as the patient's condition, his or her treatment preferences and values, then moving to discussions of the future, including the patient's prognosis for survival and quality of life, and finally discussing decisions to be made, often including the possibility of withholding or withdrawing life support.
"This gives us a roadmap of how these conferences tend to go, which may be helpful for clinicians, since many of them don't have a set approach to running these conferences," Dr. Curtis said. "My sense is that if the doctor gives the family an outline of the agenda for what the conference will be about, and then asks them if there is anything else they would like to talk about, the conference will go further toward meeting the family's needs."