Palliative care in the intensive care unit (ICU) is an important focus for quality improvement.
To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative ...care in the ICU.
We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results.
There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01).
We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.
OBJECTIVE:Family members of critically ill patients report dissatisfaction with family-clinician communication about withdrawing life support, yet limited data exist to guide clinicians in this ...communication. The hypothesis of this analysis was that increased proportion of family speech during ICU family conferences would be associated with increased family satisfaction.
DESIGN:Cross-sectional study.
SETTING:We identified family conferences in intensive care units of four Seattle hospitals during which discussions about withdrawing life support were likely to occur.
PARTICIPANTS:Participants were 214 family members from 51 different families. There were 36 different physicians leading the conferences, as some physicians led more than one conference.
INTERVENTIONS:Fifty-one conferences were audiotaped.
MEASUREMENTS:We measured the duration of time that families and clinicians spoke during the conference. All participants were given a survey assessing satisfaction with communication.
RESULTS:The mean conference time was 32.0 mins with an sd of 14.8 mins and a range from 7 to 74 mins. On average, family members spoke 29% and clinicians spoke 71% of the time. Increased proportion of family speech was significantly associated with increased family satisfaction with physician communication. Increased proportion of family speech was also associated with decreased family ratings of conflict with the physician. There was no association between the duration of the conference and family satisfaction.
CONCLUSIONS:This study suggests that allowing family members more opportunity to speak during conferences may improve family satisfaction. Future studies should assess the effect of interventions to increase listening by critical care clinicians on the quality of communication and the family experience.
One in fi ve deaths in the United States occurs in the ICU, and many of these deaths are experienced as less than optimal by families of dying people. The current study investigated the relationship ...between family satisfaction with ICU care and overall ratings of the quality of dying as a means of identifying targets for improving end-of-life experiences for patients and families.
This multisite cross-sectional study surveyed families of patients who died in the ICU in one of 15 hospitals in western Washington State. Measures included the Family Satisfaction in the ICU (FS-ICU) and the Single-Item Quality of Dying (QOD-1) questionnaires. Associations between FS-ICU items and the QOD-1 were examined using multivariate linear regression controlling for patient and family demographics and hospital site.
Questionnaires were returned for 1,290 of 2,850 decedents (45%). Higher QOD-1 scores were significantly associated (all P < .05) with (1) perceived nursing skill and competence (β= 0.15), (2) support for family as decision-makers ( β= 0.10), (3) family control over the patient’s care( β= 0.18), and (4) ICU atmosphere (β= 0.12). FS-ICU items that received low ratings and correlated with higher QOD-1 scores (ie, important items with room for improvement) were (1) support of family as decision-maker, (2) family control over patient’s care, and (3) ICU atmosphere.
Increased support for families as decision-makers and for their desired level of control over patient care along with improvements in the ICU atmosphere were identified as aspects of the ICU experience that may be important targets for quality improvement.
ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.
Communication with patients and families is an essential component of high-quality care in serious illness. Small-group skills training can result in new communication behaviors, but past studies ...have used facilitators with extensive experience, raising concerns this is not scalable.
The objective was to investigate the effect of an experiential communication skills building workshop (Codetalk), led by newly trained facilitators, on internal medicine trainees' and nurse practitioner students' ability to communicate bad news and express empathy.
Trainees participated in Codetalk; skill improvement was evaluated through pre- and post- standardized patient (SP) encounters.
The subjects were internal medicine residents and nurse practitioner students at two universities.
The study was carried out in anywhere from five to eight half-day sessions over a month. The first and last sessions included audiotaped trainee SP encounters coded for effective communication behaviors. The primary outcome was change in communication scores from pre-intervention to post-intervention. We also measured trainee characteristics to identify predictors of performance and change in performance over time.
We enrolled 145 trainees who completed pre- and post-intervention SP interviews-with participation rates of 52% for physicians and 14% for nurse practitioners. Trainees' scores improved in 8 of 11 coded behaviors (p<0.05). The only significant predictors of performance were having participated in the intervention (p<0.001) and study site (p<0.003). The only predictor of improvement in performance over time was participating in the intervention (p<0.001).
A communication skills intervention using newly trained facilitators was associated with improvement in trainees' skills in giving bad news and expressing empathy. Improvement in communication skills did not vary by trainee characteristics.
The U.S. social safety net for the very poor has been shrinking for several decades. Two factors stand out as potential drivers of this transformation: a neoliberal turn in poverty governance that ...favors incarceration and other punitive policies and “religious neoliberalism,” which melds neoliberal, anti-statist political ideology with conservative Christian ideals of compassionate assistance administered not by government but through local congregations. Yet these two streams have not been studied simultaneously in relation to welfare retrenchment. Analysis of the demise of state General Assistance (GA) programs using Cox regression models and a unique longitudinal data set shows that higher incarceration rates and higher church density both contribute to the decline of public assistance over time. Findings support the theoretical perspective of religious neoliberalism.
The U.S. Department of Agriculture's Supplemental Nutrition Assistance Program (SNAP) decreases poverty and food insecurity for millions of Americans. Yet not all eligible households participate, and ...disparities in participation exist by household size, race, ethnicity, and place. We examine the county-level associations between maximum benefit levels and SNAP enrollment by household size, race, ethnicity, and metropolitan status from 2007 to 2013 in the state of Georgia. National county-level data on participation in SNAP by racial or ethnic group are not available, but Georgia features substantial variation by race and ethnicity as well as metropolitan status at the county level that make it well suited for our analysis. Maximum SNAP benefit levels were associated with increases in county-level SNAP enrollment across the board but especially for single-person households, Hispanics, and rural Whites. These findings have implications for future changes to SNAP benefits.
We examined health care conflicts through interviews with health care leaders, providers, and patients. Ninety-two medical providers, nurses, technologists, hospital leaders, and patients/families ...shared 156 conflict stories. We identified individual, interpersonal, and organizational factors contributing to interprofessional conflicts. Individual contributors included resource depletion (i.e., stress and fatigue), perceptions of others' seemingly selfish motives, and judgment toward colleagues' competence. Interpersonal conflicts involved prior unresolved conflicts, dehumanization, power differentials, or communication breakdown. Organizational factors included navigating within complex organizational structures and noncompliance with group norms. Conflicts resulted in negative consequences for patients (safety, satisfaction), providers (career, relationships, satisfaction, morale), and organizations (performance, staff turnover).
Allelopathic effects of invasive plants on native flora may be mitigated by the abiotic and biotic environment into which the allelochemicals are released. Lonicera maackii (Amur honeysuckle), an ...invasive plant of the eastern deciduous forest, suppresses seed germination in laboratory assays. We investigated how L. maackii leachate interacts with abiotic conditions and with the soil microbial community. First, we tested the effects of leaf extract from L. maackii on germination of the native woodland herb, Blephilia hirsuta, under different light and soil conditions. We found that germination of Blephilia hirsuta was reduced by L. maackii extract, but abiotic conditions did not interact with this effect. We also tested the effects of leaf extract on germination of five native woodland species and L. maackii placed in sterile or live soil. There was an overall suppressive effect of L. maackii extract on itself and the other five native species tested. However, L. maackii extract interacted with live soil in ways that differed with the species being tested and, in some cases, changed over time. Our results indicate that allelopathic potential of L. maackii shows context dependency with respect to soil microorganisms and native species identity but not to light conditions or soil type. Our results imply that restoration of invaded areas may require active reintroduction of species sensitive to allelopathy in live soil. Further, laboratory assays of allelopathy should consider the interaction of allelochemicals with biotic and abiotic conditions to more accurately predict the impacts of allelopathy on plant communities.
Background: After-death surveys are an important source of information about the quality of end-of-life care, but response rates generally
are low. Our goal was to understand the potential for ...nonresponse bias in survey studies of family members after a patient's
death in the hospital ICU by identifying differences in patient demographics and delivery of palliative care between patients
whose families respond to a survey about end-of-life care and those whose families do not.
Methods: We performed a cohort study of patients who died in the ICU at 14 hospitals. Surveys were mailed to family members 1 to 2
months after the patient's death. Chart abstraction was completed on all patients, assessing demographic characteristics and
previously validated indicators of palliative care.
Results: Of the 2,016 surveys sent to families, 760 were returned, for a response rate of 38%. Patients whose family members returned
the surveys were more likely to be white (88% vs 74%, respectively; p < 0.001); to be older (71 years vs 69 years, respectively;
p = 0.015); and to have received more indicators of palliative care, including medical record documentation of family present
at death, involvement of spiritual care, and dying after a decision to limit life-sustaining therapies (p < 0.05).
Conclusions: Patients whose family members responded to a survey about end-of-life care were more likely to be white, older, and have
indicators of palliative care documented in the medical record. Because these patients likely received higher quality palliative
care, these findings suggest that the response bias in end-of-life care research is toward overestimating the quality of palliative
care.
Trial registration: ClinicalTrials.gov Identifier: NCT00685893
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