An intensive communication intervention for the critically ill


      PURPOSE: We sought to determine the effects of a communication process that was designed to encourage the use of advanced supportive technology when it is of benefit, but to limit its burdens when it is ineffective. We compared usual care with a proactive, multidisciplinary method of communicating that prospectively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient. This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death.
      MATERIALS AND METHODS: We performed a before-and-after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care. Multidisciplinary meetings were held within 72 hours of critical care admission. Patients, families, and the critical care team discussed the care plan and the patients’ goals and expectations for the outcome of critical care. Clinical “milestones” indicative of recovery were identified with time frames for their occurrence. Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient’s goals. We measured length of stay, mortality, and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention.
      RESULTS: Intensive communication significantly reduced the median length of stay from 4 days (interquartile range, 2 to 11 days) to 3 days (2 to 6 days, P = 0.01 by survival analysis). This reduction remained significant after adjustment for acute physiology and chronic health evaluation (APACHE) 3 score [risk ratio (RR) = 0.81; 95% confidence interval (CI), 0.66 to 0.99; P = 0.04). Subgroup analysis revealed that this reduction occurred in our target group, patients with acuity scores in the highest quartile who died (RR = 0.60; 95% CI, 0.38 to 0.92; P = 0.02). The intervention, which allowed dying patients earlier access to palliative care, was not associated with increased mortality.
      CONCLUSIONS: Intensive communication was associated with a reduction in critical care use by patients who died. Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective.
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        • Halpern N.A
        • Bettes L
        • Greenstein R
        Federal and nationwide intensive care units and healthcare costs.
        Crit Care Med. 1994; 22: 2001-2007
        • Danis M
        • Patrick D.L
        • Southerland L.I
        • Green M.L
        Patients’ and families’ preferences for medical intensive care.
        JAMA. 1988; 260: 797-802
        • Danis M
        • Southerland L.I
        • Garrett J.M
        • et al.
        A prospective study of advance directives for life-sustaining care.
        N Engl J Med. 1991; 324: 882-888
        • Prendergast T.J
        • Claessens M.T
        • Luce J.M
        A national survey of end-of-life care for critically ill patients.
        Am J Respir Crit Care Med. 1998; 158: 1163-1167
        • Wong D.T
        • Gomez M
        • McGuire G.P
        • Kavanagh B
        Utilization of intensive care unit days in a Canadian medical-surgical intensive care unit.
        Crit Care Med. 1999; 27: 1319-1324
        • Oye R.K
        • Bellamy P.E
        Patterns of resource consumption in medical intensive care.
        Chest. 1991; 99: 685-689
        • Esserman L
        • Belkora J
        • Lenert L
        Potentially ineffective care. A new outcome to assess the limits of critical care.
        JAMA. 1995; 274: 1544-1551
        • Prendergast T.J
        • Luce J.M
        Increasing incidence of withholding and withdrawal of life support from the critically ill.
        Am J Respir Crit Care Med. 1997; 155: 15-20
        • Brody H
        • Campbell M.L
        • Faber-Langendoen K
        • Ogle K.S
        Withdrawing intensive life-sustaining treatment—recommendations for compassionate clinical management.
        N Engl J Med. 1997; 336: 652-657
        • Campbell M.L
        • Carlson R.W
        Terminal weaning from mechanical ventilation.
        Am J Crit Care. 1992; 1: 52-56
        • Gilligan T
        • Raffin T.A
        Withdrawing life support.
        Crit Care Med. 1996; 24: 352-353
        • Wilson W.C
        • Smedira N.G
        • Fink C
        • McDowell J.A
        • Luce J.M
        Ordering and administration of sedatives and analgesics during the withholding and withdrawal of life support from critically ill patients.
        JAMA. 1992; 267: 949-953
        • SUPPORT group of investigators
        A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT).
        JAMA. 1995; 274: 1591-1598
        • Dowdy M.D
        • Robertson C
        • Bander J.A
        A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay.
        Crit Care Med. 1998; 26: 252-259
        • Kruse J.A
        • Thill-Baharozian M.C
        • Carlson R.W
        Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit.
        JAMA. 1988; 260: 1739-1742
        • Meyer A.A
        • Messick W.J
        • Young P
        • et al.
        Prospective comparison of clinical judgment and APACHE II score in predicting the outcome in critically ill surgical patients.
        J Trauma. 1992; 32: 747-754
        • Marks R.J
        • Simons R.S
        • Blizzard R.A
        • Browne D.R
        Predicting outcome in intensive therapy units—a comparison of Apache II with subjective assessments.
        Intensive Care Med. 1991; 17: 159-163
        • Castella X
        • Artigas A
        • Bion J
        • Kari A
        A comparison of severity of illness scoring systems for intensive care unit patients.
        Crit Care Med. 1995; 23: 1327-1335
        • Lee D.K
        • Swinburne A.J
        • Fedullo A.J
        • Wahl G.W
        Withdrawing care. Experience in a medical intensive care unit.
        JAMA. 1994; 271: 1358-1361