Translating and Implementing Evidence-Based Care in the ICU: It's Time to Value Family Communication

Abstract

One of the greatest challenges for modern medicine is translating the vast and ever-growing evidence base from efficacy studies into clinical practice. For complex clinical interventions, such as enhancing family communication or decision making, the journey from evidence to better care delivery is even more difficult. Guidelines and statements over the past few years from critical care professional societies1Carlet J Thijs LG Antonelli M et al.Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care; Brussels, Belgium, April 2003.Intensive Care Med. 2004; 30: 770-784Crossref PubMed Scopus (390) Google Scholar, 2Davidson JE Powers K Hedayat KM et al.Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005.Crit Care Med. 2007; 35: 605-622Crossref PubMed Scopus (816) Google Scholar, 3Lanken PN Terry PB Delisser HM et al.An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.Am J Respir Crit Care Med. 2008; 177: 912-927Crossref PubMed Scopus (545) Google Scholar, 4Selecky PA Eliasson CA Hall RI et al.Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement.Chest. 2005; 128: 3599-3610Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Truog RD Campbell ML Curtis JR et al.Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine.Crit Care Med. 2008; 36: 953-963Crossref PubMed Scopus (713) Google Scholar have strongly emphasized communication with families, citing emerging data that improved family communication benefits care and family outcomes. However, provider-family communication has been shown to be deficient, as the authors of a concise clinical review in this issue of CHEST (see page 835)6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar expertly summarize.7Mularski RA Curtis JR Billings JA et al.Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup.Crit Care Med. 2006; 34: S404-S411Crossref PubMed Scopus (129) Google Scholar, 8Mularski RA Defining and measuring quality palliative and end-of-life care in the intensive care unit.Crit Care Med. 2006; 34: S309-S316Crossref PubMed Scopus (36) Google Scholar, 9National Consensus Project Clinical practice guidelines for palliative care.Available at: http://www.nationalconsensusproject.org/Guideline.pdfGoogle Scholar, 10Nelson JE Mulkerin CM Adams LL et al.Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback.Qual Saf Health Care. 2006; 15: 264-271Crossref PubMed Scopus (144) Google Scholar Curtis and White6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar further review the emerging evidence base for clinician-family communication in the ICU, and present novel strategies and tools to implement best practices.6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar The sorely needed synopsis of the ICU communication evidence base in this issue of CHEST6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar aids the field in understanding why family participation and communication has been increasingly emphasized as an important part of medical management for the millions of people cared for each year in an ICU and is being proposed as belonging among the key quality indicators for ICU care.6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 7Mularski RA Curtis JR Billings JA et al.Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup.Crit Care Med. 2006; 34: S404-S411Crossref PubMed Scopus (129) Google Scholar, 8Mularski RA Defining and measuring quality palliative and end-of-life care in the intensive care unit.Crit Care Med. 2006; 34: S309-S316Crossref PubMed Scopus (36) Google Scholar, 9National Consensus Project Clinical practice guidelines for palliative care.Available at: http://www.nationalconsensusproject.org/Guideline.pdfGoogle Scholar, 10Nelson JE Mulkerin CM Adams LL et al.Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback.Qual Saf Health Care. 2006; 15: 264-271Crossref PubMed Scopus (144) Google Scholar Much of the reason for involving families in ICU care stems from the inability of critically ill patients to participate in decision making, and the need for insight into patient preferences and goals.1Carlet J Thijs LG Antonelli M et al.Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care; Brussels, Belgium, April 2003.Intensive Care Med. 2004; 30: 770-784Crossref PubMed Scopus (390) Google Scholar, 2Davidson JE Powers K Hedayat KM et al.Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005.Crit Care Med. 2007; 35: 605-622Crossref PubMed Scopus (816) Google Scholar, 3Lanken PN Terry PB Delisser HM et al.An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.Am J Respir Crit Care Med. 2008; 177: 912-927Crossref PubMed Scopus (545) Google Scholar, 4Selecky PA Eliasson CA Hall RI et al.Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement.Chest. 2005; 128: 3599-3610Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Truog RD Campbell ML Curtis JR et al.Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine.Crit Care Med. 2008; 36: 953-963Crossref PubMed Scopus (713) Google Scholar, 6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 8Mularski RA Defining and measuring quality palliative and end-of-life care in the intensive care unit.Crit Care Med. 2006; 34: S309-S316Crossref PubMed Scopus (36) Google Scholar, 9National Consensus Project Clinical practice guidelines for palliative care.Available at: http://www.nationalconsensusproject.org/Guideline.pdfGoogle Scholar Additionally, for the 20% or so of ICU patients who experience the end of life in the critical care setting, family members are both partners and recipients of care, many experiencing profound mental, physical, and economic suffering.1Carlet J Thijs LG Antonelli M et al.Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care; Brussels, Belgium, April 2003.Intensive Care Med. 2004; 30: 770-784Crossref PubMed Scopus (390) Google Scholar, 2Davidson JE Powers K Hedayat KM et al.Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005.Crit Care Med. 2007; 35: 605-622Crossref PubMed Scopus (816) Google Scholar, 3Lanken PN Terry PB Delisser HM et al.An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.Am J Respir Crit Care Med. 2008; 177: 912-927Crossref PubMed Scopus (545) Google Scholar, 4Selecky PA Eliasson CA Hall RI et al.Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement.Chest. 2005; 128: 3599-3610Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Truog RD Campbell ML Curtis JR et al.Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine.Crit Care Med. 2008; 36: 953-963Crossref PubMed Scopus (713) Google Scholar, 6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 8Mularski RA Defining and measuring quality palliative and end-of-life care in the intensive care unit.Crit Care Med. 2006; 34: S309-S316Crossref PubMed Scopus (36) Google Scholar, 11Lautrette A Darmon M Megarbane B et al.A communication strategy and brochure for relatives of patients dying in the ICU.N Engl J Med. 2007; 356: 23-32Crossref Scopus (865) Google Scholar In the last decade, a number of domains, target processes, and exemplary behaviors have been identified that contribute to high-quality communication in the critical care setting.1Carlet J Thijs LG Antonelli M et al.Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care; Brussels, Belgium, April 2003.Intensive Care Med. 2004; 30: 770-784Crossref PubMed Scopus (390) Google Scholar, 2Davidson JE Powers K Hedayat KM et al.Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005.Crit Care Med. 2007; 35: 605-622Crossref PubMed Scopus (816) Google Scholar, 3Lanken PN Terry PB Delisser HM et al.An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.Am J Respir Crit Care Med. 2008; 177: 912-927Crossref PubMed Scopus (545) Google Scholar, 4Selecky PA Eliasson CA Hall RI et al.Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement.Chest. 2005; 128: 3599-3610Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Truog RD Campbell ML Curtis JR et al.Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine.Crit Care Med. 2008; 36: 953-963Crossref PubMed Scopus (713) Google Scholar, 6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 8Mularski RA Defining and measuring quality palliative and end-of-life care in the intensive care unit.Crit Care Med. 2006; 34: S309-S316Crossref PubMed Scopus (36) Google Scholar, 11Lautrette A Darmon M Megarbane B et al.A communication strategy and brochure for relatives of patients dying in the ICU.N Engl J Med. 2007; 356: 23-32Crossref Scopus (865) Google Scholar, 12Lilly CM De Meo DL Sonna LA et al.An intensive communication intervention for the critically ill.Am J Med. 2000; 109: 469-475Abstract Full Text Full Text PDF PubMed Scopus (402) Google Scholar Applying and improving ICU communication outside of trials requires local innovation to translate interventions from controlled protocols. Curtis and White6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar succeed in doing what a “Topics in Practice Management” review should do: they propose adaptable strategies for implementation and quality-of-care enhancement, and introduce two novel tools to achieve these aims. One tool outlined is the VALUE mnemonic (Value family statements, Acknowledge family emotions, Listen to the family, Understand the patient as a person, Elicit family questions) that combines evidence-based approaches for quality family communication in the ICU (see Fig 2 in the article by Curtis and White6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar), which emphasizes the opportunity to listen and respond when talking with family members. In a randomized-controlled trial11Lautrette A Darmon M Megarbane B et al.A communication strategy and brochure for relatives of patients dying in the ICU.N Engl J Med. 2007; 356: 23-32Crossref Scopus (865) Google Scholar across 22 French ICUs, which was designed in part to address earlier data from that same consortium showing that only half of families understood even the most basic of information about their loved one's illness, researchers attained significant improvements in the process of communication about care and in family outcomes. Using an informational brochure and a simple communication enhancement strategy grounded by VALUE, the investigators demonstrated reductions in anxiety, depression, and posttraumatic stress disorder-related symptoms for the surviving family members of patients who died in the ICU.11Lautrette A Darmon M Megarbane B et al.A communication strategy and brochure for relatives of patients dying in the ICU.N Engl J Med. 2007; 356: 23-32Crossref Scopus (865) Google Scholar The VALUE mnemonic may be useful for education, as a clinical reminder or point-of-care tool, or in more complex practice enhancement efforts. For example, we recently employed VALUE in our ICU in a rapid cycle quality improvement effort, achieving gains in the processes of care and family satisfaction (unpublished data). Another particularly vexing aspect of ICU communication involves decisions. Ethical principles and evolving research advocate shared decision making (ie, joint decisional processes between the treating providers and the patient's family).1Carlet J Thijs LG Antonelli M et al.Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care; Brussels, Belgium, April 2003.Intensive Care Med. 2004; 30: 770-784Crossref PubMed Scopus (390) Google Scholar, 2Davidson JE Powers K Hedayat KM et al.Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005.Crit Care Med. 2007; 35: 605-622Crossref PubMed Scopus (816) Google Scholar, 3Lanken PN Terry PB Delisser HM et al.An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.Am J Respir Crit Care Med. 2008; 177: 912-927Crossref PubMed Scopus (545) Google Scholar, 4Selecky PA Eliasson CA Hall RI et al.Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement.Chest. 2005; 128: 3599-3610Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Truog RD Campbell ML Curtis JR et al.Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine.Crit Care Med. 2008; 36: 953-963Crossref PubMed Scopus (713) Google Scholar, 6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar A significant contribution of the work by Curtis and White6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar is an illustrative practical framework of the spectrum of decision making with an iterative approach to optimize the process of involving families (see Fig 1 in Curtis and White6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar). The method operates on a presumption of shared decision making for family interactions (as a compromise between parentalism and solely informed autonomous choice), but then requires practitioners to further assess and adapt communication based on preferences of the family. The algorithm avoids a one-size-fits-all approach by advocating that providers facilitate discussions in response to inquiry about how the families prefer to interact with health professionals and suggests that providers reframe difficult medical and life decisions based on expressions of patients' values and concerns. With goals of minimizing the stress on the family, improving family outcomes, and individualizing care, a functional strategy is proposed to guide clinicians to an adaptable and individualized decisional approach for family communication. The responsive process requires providers to ask open-ended questions and listen actively. The approach is further modified by survival and/or functional outcome possibilities, tending toward an increased decisional role for physicians when patients have poorer and more certain prognoses. Curtis and White6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar have advanced the application of the science of ICU communication with their work, primarily by providing locally adaptable implementation strategies and practical tools. As prior efficacy studies have demonstrated that communication interventions can improve outcomes and reduce length of stay, this practice management article6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar should encourage and empower ICU providers to target and innovate aspects of ICU care relating to communication. Appropriately, the authors stress that approaches to improve communication in the ICU must be proactive, collaborative within interdisciplinary teams, culturally competent, and adaptable. Gaps in knowledge are acknowledged, and future study is suggested. Finally, Curtis and White6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar review reimbursement and payment issues that lag behind the demonstrated importance of relatively time-consuming family communication activities. Critical care practice has evolved as an evidence-based field with highly technical and specialized skills that require care coordination and responsive care delivery. Optimizing ICU care requires teams to facilitate effective patient-family-centered communication and palliative care, concomitantly with life-preserving therapy. To achieve the implementation of emerging evidence, locally adaptable strategies, such as the practice aids put forward by Curtis and White,6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar are needed to innovate and continuously improve care. These techniques are ready for clinical practice, repeated cycles of performance measurement, and further study of their effectiveness across delivery settings and systems.6Curtis JR White DB Practical guidance for evidence-based ICU family conferences.Chest. 2008; 134: 835-843Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 7Mularski RA Curtis JR Billings JA et al.Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup.Crit Care Med. 2006; 34: S404-S411Crossref PubMed Scopus (129) Google Scholar, 8Mularski RA Defining and measuring quality palliative and end-of-life care in the intensive care unit.Crit Care Med. 2006; 34: S309-S316Crossref PubMed Scopus (36) Google Scholar, 9National Consensus Project Clinical practice guidelines for palliative care.Available at: http://www.nationalconsensusproject.org/Guideline.pdfGoogle Scholar, 10Nelson JE Mulkerin CM Adams LL et al.Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback.Qual Saf Health Care. 2006; 15: 264-271Crossref PubMed Scopus (144) Google Scholar By moving research with these types of end-of-the-pipeline strategies, we may finally start to achieve the goals of the National Institutes of Health Roadmap: improved translation from scientific discovery into valued health outcomes for society.