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Abstract |
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 Top Abstract MethodsResultsDiscussionLimitations of Our ProjectSummaryReferences |
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• Objectives To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit.
• Methods During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician.
• Results Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15 559 vs $24 080) and variable ($5087 vs $8035) costs.
• Conclusions Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients’ families reduced lengths of stay and resource utilization.
Setting goals of care and interpreting a patient’s wishes often fall to the family members of seriously ill patients. Many of the decisions families face are unprecedented in magnitude and involve situations with which the families have no experience. Families are often stressed and confused by complex technical information while dealing with the emotional burdens of loss and grief. These families need careful explanations, time to process information, and consistent professional support to meet the challenges to their decision-making capacities. When surveyed, patients’ families rank their need for shared information, skillful communication, support, and proximity to their family member high on their list of priorities.11 They also report that being fully informed about the process of treatment withdrawal and whether or not the events unfold as predicted are important indicators of their satisfaction with their decision.12
| High levels of family stress, complex information, inadequate time, unskilled interactions, and lack of consistency make family communication difficult.
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The coordinated sharing of vital information among patients, patients’ families, and the professional care team is difficult to accomplish.13,14 Unskilled or poorly timed interactions of clinicians with families, inadequate allotment of time for processing difficult information and feelings, and placement of the responsibility for end-of-life communication solely on a patient’s physician are factors that may undermine effective communication. The frequent use of specialists and the rotation of ICU medical staff and attending physicians can also complicate interactions between patients’ families and staff members. Communication by the same provider is important when the ability of an ICU staff member to meet the needs of a patient’s family is measured,15 but often consistency is not possible.
Because of the importance of physicians’ communication with patients, patients’ families, and ICU staff members, physicians’ communication patterns require careful evaluation. Many physicians try to manage the difficult and multidimensional needs of dying patients and the patients’ families without drawing on the support of an interdisciplinary team, such as nurses (including advanced practice nurses such as clinical nurse specialists), social workers, case managers, and chaplains. Although the attending physician has final responsibility for the patient, consulting physicians can also influence the options provided to patients and patients’ families. Kollef16 reported that a strong variable in prolonged length of stay in a medical ICU was the presence of a non-ICU attending physician. Length of stay was significantly shorter for patients who relied on the ICU attending physician than for patients who did not.
Another issue to consider in the management of gravely ill patients in the ICU is economics. Research confirms that the costs of caring for dying ICU patients are considerable.17,18 Although the actual costs for groups of patients cannot be determined precisely, some data exist.
The costs of care for many patients who die are much greater than the "average" costs of care, and these patients are categorized as "outliers" in terms of resource consumption. In a typical medical ICU, outliers (about 10% of the patients) account for about 40% to 50% of the costs.19,20 In the medical ICU at Barnes-Jewish Hospital, St. Louis, Mo, the outlier group consists of less than 10% of the patients admitted in 1 year, yet this group accounts for about 45% of the costs, or $10 million of the total $22 million costs per year.21 If these figures are representative of the 8000 ICUs in the United States, costs related to caring for this group of patients in the United States are approximately $80 billion dollars per year.
Although cost is not the primary motivator for improving end-of-life care in the ICU, economic considerations are certainly relevant. Patients’ preferences for care should be elicited as clearly as possible and should be honored, especially in situations of advanced chronic disease or incurable, soon-to-be fatal illness. At Barnes-Jewish Hospital, we implemented a quality improvement project in the medical ICU, which has a 19% mortality rate, to evaluate the effect of a physician-nurse communication team on the issues just described.
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Methods |
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TopAbstractMethodsResultsDiscussionLimitations of Our ProjectSummaryReferences |
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| For patients at high mortality risk, researchers compared the length-of-stay and cost effects of daily family communication by one MD-CNS team to the usual communication process.
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Human Subjects
The project was granted exempt status by the institutional human subject committee. It was judged both difficult and inappropriate to obtain informed consent from families for clinicians’ communication patterns.
Sampling of Patients
During the time the medical director was attending physician in the ICU (approximately 30% of the year), those patients who were deemed to be at high risk for dying (by the physician and the clinical nurse specialist) or who met at least 2 of the following inclusion criteria were cared for by using the communication strategies identified by the communication team22:
All other patients who met the inclusion criteria but were cared for by a team of rotating attending physicians constituted the comparison group.
Variables Measured
All variables were prospectively measured. Demographic and clinical data were collected, and severity of illness was calculated by using the APACHE II scoring system. Data reflecting resource consumption were also collected:
Methods to Improve Communication
In order to improve the performance of the communication team, barriers to effective communication with families of seriously ill patients in our ICU were identified. Consistent with the existing literature, those barriers were as follows:
In order to address these barriers, the specific roles for the physician and clinical nurse specialist were defined. The physician provided daily medical updates to patients’ families, offered guidelines for care, and shared medical advice concerning treatment with the families. Patients, of course, were included in discussions if their condition allowed. The physician was consistent and intentionally clear and direct in his communication patterns, that is, he gave daily goals and provided options other than curative care. The physician and clinical nurse specialist spoke with patients and the patients’ families as a team whenever possible, with the goal of fostering an atmosphere of trust and collaboration. This communication occurred on a daily basis, except when patients’ families were not available.
The responsibility of the clinical nurse specialist was to provide daily information to the families and to offer them the opportunity to clarify issues that might arise. She allowed time for family members to verbalize their thoughts, their values, and their interpretation of the patient’s wishes; listened to the narrative unfolding of family decisions; and was present as a noncoercive, nonjudgmental "sounding board" as families processed their thoughts and feelings. When the situation arose, the clinical nurse specialist would also describe, if a patient’s family wanted to know, how unfamiliar events (eg, terminal weaning) would unfold. She would reinforce or discuss the plan of care as communicated by the medical treatment team and ensure that unresolved issues were addressed immediately or at the next day’s multidisciplinary rounds. This pattern of communication occurred daily, often twice in a single day (depending on the family’s needs).
As another part of this quality improvement effort in the medical ICU, all the staff nurses in the unit participated in several educational events on palliative and end-of-life care led by the nurse specialists. Individual nurses also may have been able to influence decisions made by patients and patients’ families. However, this variable was not controlled for in either group.
Data Analysis
Differences between the intervention group and the control group were analyzed by using independent t tests and 
2 tests.
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Results |
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TopAbstractMethodsResultsDiscussionLimitations of Our ProjectSummaryReferences |
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). Mean APACHE scores were significantly different in the 2 groups (28.6 in the control group vs 32.1 in the intervention group). The mean ICU length of stay was reduced from 9.5 days with standard practice to 6.1 days in the intervention group (Table 2). The mean hospital length of stay was also significantly different between the groups: 16.4 days for standard practice and 11.3 for the intervention group. In order to evaluate the effect of the physician leader on outcomes, the length of stay for his patients who met the same inclusion criteria from the prior year (1999) was compared with patients’ length of stay during his work with the clinical nurse specialist (2000). A reduction from 7.3 days for 1999 to 6.1 days in 2000 was noted.
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| When families had consistent communication with the MD-CNS team, patients had shorter hospital stays and reduced costs.
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Resource utilization, as measured by hospital charges, differed significantly between the groups. The hospital’s variable direct and indirect costs were lower in the intervention group than in the control group ($15 559 vs $24 080 for direct and $5087 vs $8035 for indirect), as were the hospital’s fixed costs ($5320 vs $8485). The total differences in charges would equal $629 262 if we subtracted the difference in mean costs per patient in each group and multiplied by 43 (the number of patients in the intervention group). In addition to the differences in resources, mortality during the ICU admission was lower in the intervention group (74%) than in the control group (93%).
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Discussion |
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TopAbstractMethodsResultsDiscussionLimitations of Our ProjectSummaryReferences |
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Several investigators have studied the effects of various interventions aimed at improving the end-of-life care for seriously ill patients. In a study by Carlson et al,26 a palliative care team achieved improved management of signs and symptoms and had a substantial reduction in the costs associated with changing the focus, when appropriate, from curative management to comfort care. In the above study, a major disadvantage was that the private physician was not a member of the palliative care team. The palliative care team needed a referral from the attending physician before interventions could begin. This policy both reduced and delayed referrals until later in patients’ ICU stays.
The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a large, randomized study with 9105 patients, was designed to describe the problems encountered by seriously ill patients in acute care settings. A second phase of the study focused on providing information to physicians about the likelihood, based on APACHE III scores, of survival of individual patients and included using skilled nurses to communicate information.27 The notion was that if physicians, nurses, and families had predictive information on the likelihood of death, goals of care could be appropriately adjusted and decision making would be enhanced. Unfortunately, this intervention did not yield any changes in behavior or decision making among physicians, patients, or patients’ families. This finding reinforces the fact that information alone does not change behavior. It was thought that if physicians and patients’ families had more "data" about the likelihood of death, they would automatically opt for less aggressive care. Because information alone does not seem to change behavior, it becomes more apparent that devising more effective communication strategies is necessary.
| Early, frequent, and consistent communication by attending physician and advanced practice nurse teams can support families’ end-of-life decisions. Future studies should address families’ satisfaction with the level of communication and decision-making support they received.
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The quality improvement project described here addressed issues uncovered in previous studies.26,27 Unlike previous investigators, we found that using a team consisting of a physician and a clinical nurse specialist to coordinate communication affected end-of-life resource utilization. On the basis of the limitations of the program used by Carlson et al and the SUPPORT study, our strategies for improvement were designed with the following understandings:
This intervention produced a significant change in ICU length of stay and resource utilization. Length of stay in the ICU was significantly shorter for patients in the intervention group (6.1 days) than for patients of other physicians (9.5 days). This reduction in length of stay could not be attributed to the intervention group having less critically ill patients. APACHE scores (Table 1
) indicated that the patients in the intervention group were at least as sick as the patients in the control group.
ICU costs decreased in all areas, from fixed and variable costs to total costs per case. The total savings in the 1 year of this program are difficult to interpret on the basis of variables such as rate of reimbursement, cost of the advance practice nurse’s time, and difficulty in measuring real hospital costs. However, from the decreases in costs per case, resource utilization appears to have differed significantly between the 2 groups. The charges in the measured variables were $629 262 less for patients and families cared for by the physician and the clinical nurse specialist.
The decrease in costs were not simply a function of encouraging patients to choose comfort care and death rather than traditional care; the mortality rate was lower in the intervention group (74%) than in the control group (93%). The reasons for the lower mortality rates are not clear. However, they may be due to patients being discharged from the ICU rather than continuing to receive traditional care.
When implementing a program to improve the quality of conversations between ICU staff and patients’ families facing end-of-life decisions, the primary goal is not financial gain. It is, rather, to meet the needs of patients and their families, to ensure that the wishes of seriously ill patients are honored, and to give expert care. The hope is that these efforts result in as peaceful and dignified a death as possible if death must be the outcome of a patient’s ICU stay. As a factor for analysis, however, financial matters remain relevant. Demonstration of a beneficial financial effect increases the likelihood of administrative support for a program. Allocation of monies to support the salary of the clinical nurse specialist and the continuing education of physicians and nurses in end-of-life care is crucial if these interventions are to be successful.
Last, a close look at data for the intervention group reveals 2 more findings. First, in 42 of the 43 cases, the patients’ families made some kind of decision to either withhold or withdraw care at the end of life. This finding underscores the importance of intentionally and well-designed communication and support systems for families making medical and moral decisions. For most families, this territory is unfamiliar. They benefit from consistent, supportive, non-coercive, engaged professional partners in making decisions. Second, a comparison of the length of mechanical ventilation between the 2 groups reveals that all patients who met the inclusion criteria and who were managed according to standard practice spent some time receiving mechanical ventilation. In the intervention group, 5 patients who met the inclusion criteria did not receive mechanical ventilation. This finding might indicate that with early discussion of options and support, more patients and their families elected to withhold life-prolonging treatments. Empowering others to make the best decisions for their own care in the face of serious, life-threatening illness remains an important goal in ICU care.
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Limitations of Our Project |
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TopAbstractMethodsResultsDiscussionLimitations of Our ProjectSummaryReferences |
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The program used a clinical nurse specialist as the main nursing leader. Whether another nurse with skill in communication could have had the same effect was not studied. It seemed helpful that the clinical nurse specialist was educated in palliative care and ethics. Although the cost-analysis data suggest that retaining a palliative care specialist in ICUs benefits patients and patients’ families and is cost-effective, in this era of cost containment, other strategies for use of personnel may be necessary. In some settings, this role might be filled by staff or "charge" nurses who hold special interest in end-of-life care. However, adequate time must be allotted for such a role to be effectively accomplished.
This quality improvement intervention did not use standard randomization of patients to treatment and control groups. For this initial study, we looked at existing records and data that had implications for our standard ICU care and the innovative improvement efforts of a single team. For studies of perceptions and satisfaction among patients’ families, a most important variable, informed consent and different study designs would be required.
The results of this program require further investigation with larger samples and comparison of other techniques. This program is one of potentially many successful programs that could be developed.
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Summary |
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TopAbstractMethodsResultsDiscussionLimitations of Our ProjectSummaryReferences |
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Our results indicate the beneficial financial effect a focused approach to improving communication with patients and their families at the end of life can have. Priority must be given to discussing values and plans of care with families and patients as diligently as communicating technical aspects of a patient’s care. Sharing and, more importantly, processing important information about care options for patients facing life-limiting illness and death must become expected and routine.
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ACKNOWLEDGMENT |
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To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
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REFERENCES |
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TopAbstractMethodsResultsDiscussionLimitations of Our ProjectSummaryReferences |
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When critically appraising the AJCC journal club article, Improving Family Communications at the End of Life, that you have just read, consider the questions and discussion points listed below.
Study Synopsis: This study was conducted to evaluate the impact of an MD-CNS communication team in the ICU on length of stay and costs for seriously ill ICU patients near the end of life. Of 151 patients at high risk for death during more than a 1-year period, 43 patients received care provided by the ICU medical director teamed with a CNS, and 108 received standard care, provided by 1 of 5 ICU attending physicians. The MD-CNS group provided daily medical updates to family members, discussed guidelines and goals for care, and provided information on treatment options other than curative care. The CNS spent additional time with families clarifying issues and reinforcing the plan of care.
Information From the Authors: Lead author Tom Ahrens, RN, DNS, CS, provided additional information about the study. The communication strategies employed in the study were aimed at providing information and clarifying treatment goals. Ahrens relates, "Communication was done in the ICU or the waiting room, wherever appropriate, including phone calls at home."
Patients were chosen for the study based on the nurses’ evaluations of patients at a high risk of death. Ahrens explains, "We actually thought of the high risk of death guideline but in the end it was simply the nurse’s gestalt of a high risk of death that was our best indicator of who should be targeted—for example, diagnosis, physical appearance, number of drips."
Along with resulting in a decreased length of stay and resouce use, observations of the ffect of the intervention revealed a treatment-related difference in that 5 patients in the MD-CNS group did not go on to receive mechanical ventilation. Another treatment-related difference was to not start dialysis. Ahrens explains, "One of our best examples was the withholding of dialysis in a patient with end-stage HIV."
Concurrent with the study, ICU nurses participated in education events on palliative and end-of-life care. This variable was not controlled in either group; however, Ahrens explains that there was no additional effect of that effort on the current study results.
When asked how AJCC’s readership could best use information from the study, Ahrens said, "ICUs in particular need a nurse with excellent communication skills to focus just on family communication. This would not only be a cost-effective position, but one that would greatly enhance patient and family satisfaction. This could go a long way to reducing ‘futile’ care and better meeting patients’ and families’ wishes. Anyone can introduce this practice by targeting patients who seem to have a high likelihood of a poor outcome."
Implications for Practice: The findings of the study demonstrate that the use of an MD-CNS team focused on improving communication with ICU patients and families was effective at reducing ICU and hospital lengths of stay and resource utilization. This is consistent with what nurses inherently know in terms of the benefits of providing information to families of critically ill patients. However, the study specifically demonstrated an impact on end-of-life resource utilization, something that has not been reported previously. The implications for clinical practice are important, as improved communication can enhance patient and family care as well as aid the decision-making process regarding medical treatments and aggressiveness of care. Furthermore, improved communication may lead to other benefits for palliative care strategies for ICU patients near the end of life.
Journal Club feature commentary is provided by Ruth Kleinpell.
This article has been cited by other articles:
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  K. A. Lorenz, J. Lynn, S. M. Dy, L. R. Shugarman, A. Wilkinson, R. A. Mularski, S. C. Morton, R. G. Hughes, L. K. Hilton, M. Maglione, et al. Evidence for Improving Palliative Care at the End of Life: A Systematic Review Ann Intern Med, January 15, 2008; 148(2): 147 - 159. [Abstract] [Full Text] [PDF]
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 D. A. Gruenberg, W. Shelton, S. L. Rose, A. E. Rutter, S. Socaris, and G. McGee Factors influencing length of stay in the intensive care unit. Am. J. Crit. Care., September 1, 2006; 15(5): 502 - 509. [Abstract] [Full Text] [PDF]
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 M. Thiers End-of-life decision making in ICU Crit. Care Nurse, April 1, 2006; 26(2): 16 - 17. [Full Text] [PDF]
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M. Narasimhan, L. A. Eisen, C. D. Mahoney, F. L. Acerra, and M. J. Rosen Improving Nurse-Physician Communication and Satisfaction in the Intensive Care Unit With a Daily Goals Worksheet Am. J. Crit. Care., March 1, 2006; 15(2): 217 - 222. [Abstract] [Full Text] [PDF]
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M. Thelen End-of-Life Decision Making in Intensive Care Crit. Care Nurse, December 1, 2005; 25(6): 28 - 37. [Full Text] [PDF]
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R. L. Beckstrand and K. T. Kirchhoff Providing End-of-Life Care to Patients: Critical Care Nurses' Perceived Obstacles and Supportive Behaviors Am. J. Crit. Care., September 1, 2005; 14(5): 395 - 403. [Abstract] [Full Text] [PDF]
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 J-L Vincent, J Berre, and J Creteur Withholding and withdrawing life prolonging treatment in the intensive care unit: a current European perspective Chronic Respiratory Disease, April 1, 2004; 1(2): 115 - 120. [Abstract] [PDF]
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