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.

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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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