October - 2017
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The Voice of Surrogate Decision-Makers. Family Responses to Prognostic Information in Chronic Critical Illness
Am J Resp Crit Care Med, 2017, 196(7);864-872
Chronic critical illness has profound effects on patients and their families. One aspect is the challenge of acting as a surrogate decision-maker, trying to rationally interpret prognosis and make decision while dealing the with emotional burden of unfavourable prognostic information.
This qualitative study of content-guided, audio-recorded family meetings led by skilled clinician communicators (palliative care physician and nurse practitioner) was conducted at medical ICUs at 4 hospitals in 2 states from Dec 2010 to Oct 2014. Adult patients were eligible of they were ventilated for >7 days and not expected to liberate from ventilation or die in theft 3-days. The patients primary and any additional surrogate decision makers were recruited.
What did they do?
What did they find?
Content guided, communications between palliative care specialists and families of the chronically critically ill results in a spectrum of responses by surrogates to prognostic information. Recognition of these themes may help clinicians communicate with patients and families and guide development and evaluation of strategies and interventions to
support surrogates caring for a loved one in the ICU.
Rationale: Information from clinicians about the expected course of the patient’s illness is relevant and important for decision-making by surrogates for chronically critically ill patients on mechanical ventilation.
Objectives: To observe how surrogates of chronically critically ill patients respond to information about prognosis from palliative care clinicians.
Methods: This was a qualitative analysis of a consecutive sample of audio-recorded meetings from a larger, multisite, randomized trial of structured informational and supportive meetings led by a palliative care physician and nurse practitioner for surrogates of patients in medical intensive care units with chronic critical
illness (i.e., adults mechanically ventilated for >7 days and expected to remain ventilated and survive for >72 h).
Measurements and Main Results: A total of 66 audio-recorded meetings involving 51 intervention group surrogates for 43 patients were analyzed using grounded theory. Six main categories of surrogate responses to prognostic information were identified: (1) receptivity, (2) deflection/rejection, (3) emotion, (4) characterization of patient, (5) consideration of surrogate role, and (6) mobilization of support. Surrogates responded in multiple and even antithetical ways, within and across meetings.
Conclusions: Prognostic disclosure by skilled clinician communicators evokes a repertoire of responses from surrogates for the chronically critically ill. Recognition of these response patterns may help all clinicians better communicate their support to patients and families facing chronic critical illness and inform interventions to support surrogate decision-makers in intensive care units.
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