Elsevier

General Hospital Psychiatry

Volume 32, Issue 4, July–August 2010, Pages 433-442
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
End-of-life communication in the intensive care unit

https://doi.org/10.1016/j.genhosppsych.2010.04.007Get rights and content

Abstract

Objective

Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life (EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current research and recommendations for ICU EOL communication.

Design

For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent bibliographies and cross-referenced known EOL ICU communication researchers.

Results

Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency.

Conclusions

Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality of ICU palliative care and EOL communication.

Introduction

Because approximately 22% of all deaths in the United States occur during or after an intensive care unit (ICU) admission [1], the potential role for palliative care communication is considerable. For example, the need for clinician–family communication about withholding or withdrawing life-supporting therapies is the norm when a person dies in the ICU, rather than the exception [2], [3], [4], [5], [6]. Nevertheless, a palliative care philosophy towards dying is often perceived to be incongruent with the lack of hospitality shown to dying patients and their families, the impersonal technology and the action-oriented ICU ethos [7], [8], [9].

Difficulties with ICU EOL communication are well documented. Fifty-four percent of family members may have a poor understanding of the patient's diagnosis, treatment and prognosis; comprehension is particularly poor when physician–family meetings last for less than 10 min [10]. A recent study demonstrated that physicians tended to discuss EOL life-sustaining treatment in a scripted, depersonalized and procedure-focused manner, while surrogate decision makers showed a poor integration of the medical dilemma that was the goal of the decision-making discussion [11].

Another study showed that 40% of family members of ICU patients retrospectively perceived that conflict had occurred with ICU staff and 31% cited unprofessional behavior [12]. Examples included the physicians saying that another patient needed the dying patient's bed, talking to a sister-in-law who was a nurse while ignoring the primary caregiver and having a do-not-resuscitate (DNR) discussion at the bedside of a ventilated patient where the family members were uncertain whether he could hear or not. Curtis et al. [13] described frequent missed communication opportunities in EOL family meetings, such as addressing family emotions, affirming nonabandonment of the family and discussing palliative care or ethics. Even clear, signed advance directives and well-intentioned, competent physicians do not mitigate the intrinsic complexity of EOL communication [14] and the potential to cause iatrogenic emotional harm [15].

This concise review aims to consider barriers to better ICU EOL communication, approaches to counteracting these barriers and evidence that better communication and communication skills training might improve patient outcomes. This is followed by a practical overview of EOL ICU communication strategies.

The first step in implementing EOL palliative care is usually family communication-reorienting goals of care from hope of cure to palliation [16], [17]. Delirium and use of sedatives and analgesia result in the majority of critically ill patients unable to make their own treatment decisions, even after extubation [18], [19]. The family therefore links the patient to the ICU team. American College of Critical Care consensus statements support the importance of family-centered EOL communication [20], [21].

One problem in this regard is that doctor–family communication is not taught in most medical schools or critical care programs. Another problem is that there are considerable barriers to better ICU family communication, which is multifaceted rather than linear, and these are considered below.

Section snippets

Emotional barriers to EOL ICU communication

ICU physicians must be able to deal effectively with strong and chaotic emotions, as well as promote consensus among family and staff. When emotions, communication or deciding what is best for the patient cannot be managed within the ICU or the hospital (ethics committees, psychiatric consultations), external court intervention becomes necessary (e.g., Quinlan, Cruzan and Schiavo cases) with dramatic and long-lasting consequences [22], [23], [24], [25].

There are many inter-related reasons for

Conclusions

The ICU has become an increasingly frequent site for the implementation of EOL care and therefore critical care physicians need to be competent in family-centered EOL communication. They should be able to manage a family meeting so as to promote consensus and discuss the transition from curative to palliative goals of care, AND/DNR directives, withdrawal of life-extending treatment and the dying process.

The need for palliative care in the ICU setting is predictable when viewed from a macro

Acknowledgments

The authors gratefully acknowledge Drs. Malcolm Fisher, Stephen Streat, Rinaldo Belloma, Stephen Warrillow and Peter Saul for their thoughtful feedback on an earlier version of this manuscript.

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    Work performed at Memorial Sloan-Kettering Cancer Center.

    1

    Tomer Levin's research is supported by a grant from the Martell Foundation. No other financial support is disclosed.

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