End-of-Life Care Family Meeting

Reviewed and revised 20 July 2016

OVERVIEW

• The End-of-Life Care Family Meeting is a core component of ICU care
• Evidence suggests that communication with families is often inadequate
• The principles apply to end-of-life discussions in other settings (e.g. ED) as well

STRATEGIES TO IMPROVE COMMUNICATION

General

• communication training for staff
• interdisciplinary team rounds
• availability of palliative care and/or ethics consultation
• development of a supportive hospital culture for ethical practice and communication
• advance planning for the discussion among the clinical team
• identify family and clinician participants who should be involved

Specifics during Family Meeting

• find a private location
• increase proportion of time spent listening to family
• value statements made by family members
• acknowledge emotions
• listen to family members
• understand who the patient is as a person
• elicit questions from family members
• listen and respond to family members
• acknowledge and address family emotions
• explore and focus on patient values and treatment preferences
• affirm non-abandonment of patient and family
• assure family that the patient will not suffer
• provide explicit support for decisions made by the family
• focus on the goals and values of the patient
• use an open, flexible process
• anticipate possible issues and outcomes of the discussion
• give families support and time

VALUE APPROACH

The VALUE approach has been studied for communicating to families about critical illness (Lautrette et al, 2009):

• Value and appreciate what the family members said
• Acknowledge the family members’ emotions
• Listen
• Understand who the patient was as a person by asking questions of the family members
• Elicit questions from the family members

EVIDENCE

Communication with families about prognosis and goals of care is often inadequate

• SUPPORT study (Teno et al, 2005):
  • <40% of patients treated in ICUs for >2/52 reported having a discussion with their physician about prognosis or preferences for life-sustaining treatment
  • ~ 50% of those who preferred care focused solely on their comfort even at the expense of shorter life thought that the treatment they received was contrary to their preference
• 54% of families failed to comprehend the diagnosis, prognosis, or treatment after meeting with a physician at a university-affiliated ICU (Azoulay et al, 2000)
• Almost 20% of 70 surrogate decision makers for patients expected to stay more than 3 days in medical or surgical ICUs at 2 medical centers reported receiving no prognostic information (LeClaire et al, 2005)
• In ICU family conferences, physicians commonly missed opportunities to explore comments about patient treatment preferences, as would be required for appropriate clinical decision making (Curtis et al, 2005)
• VALUE study:
  • Longer family conferences: 30 min vs 20 min
    • Family talked more: 14 min vs 5 min
    • Physician talked the same
  • Lower prevalence of PTSD-like symptoms, anxiety, and depression in family members 3 months later

References and Links

Journal articles

• Azoulay E, Chevret S, Leleu G. Half the families of intensive care unit patients experience inadequate communication with physicians. Critical care medicine. 28(8):3044-9. 2000. [pubmed]
• Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. American journal of respiratory and critical care medicine. 171(8):844-9. 2005. [pubmed]
• Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008 Oct;134(4):835-43. doi: 10.1378/chest.08-0235. Review. PMID: 18842916; PMCID: PMC2628462.
• Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the intensive care unit. Lancet. 2010 Oct 16;376(9749):1347-53. doi: 10.1016/S0140-6736(10)60143-2. Epub 2010 Oct 11. Review.  PMID: 20934213.
• LeClaire MM, Oakes JM, Weinert CR. Communication of prognostic information for critically ill patients. Chest. 128(3):1728-35. 2005. [pubmed]
• Teno JM, Fisher E, Hamel MB. Decision-making and outcomes of prolonged ICU stays in seriously ill patients. Journal of the American Geriatrics Society. 48(5 Suppl):S70-4. 2000. [pubmed]
• Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008 Mar;36(3):953-63. Erratum in: Crit Care Med. 2008 May;36(5):1699. PMID: 18431285.