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Original Research: CRITICAL CARE |

Randomized, Controlled Trials of Interventions to Improve Communication in Intensive Care: A Systematic Review FREE TO VIEW

Leslie P. Scheunemann, MD; Michelle McDevitt, RN, BSN; Shannon S. Carson, MD; Laura C. Hanson, MD, MPH
Author and Funding Information

From the Division of Geriatric Medicine and Center for Aging and Health (Drs Scheunemann and Hanson), the Medical Intensive Care Unit (Ms McDevitt and Dr Carson), and the Division of Pulmonary and Critical Care Medicine (Dr Carson), University of North Carolina Hospitals; and the Palliative Care Program (Dr Hanson), and the Cecil B. Sheps Center for Health Services Research (Dr Hanson), University of North Carolina, Chapel Hill, NC.

Correspondence to: Leslie P. Scheunemann, MD, Division of Geriatric Medicine, CB 7550, University of North Carolina, Chapel Hill, NC 27599-7550; e-mail: lscheune@unch.unc.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(3):543-554. doi:10.1378/chest.10-0595
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Background:  Communication between families and providers in the ICU affects patient and family outcomes and use of health-care resources. Recent research studies have tested interventions designed to improve communication quality and outcomes between providers and families of patients in the ICU. We conducted a systematic review of these studies.

Methods:  We searched the MEDLINE, PsychInfo, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from 1995 to July 2010. We included studies that reported controlled clinical interventions designed to improve communication between providers and families of patients in the ICU aged 18 years or older. We abstracted all selected studies to a standardized data collection instrument and completed a quality checklist based on recommendations from the Consolidated Standards for Reporting Trials (CONSORT) investigators.

Results:  In all, 2,841 articles were identified. Of those articles, 180 met the criteria for full review, and 21 articles of 16 distinct interventions met the full inclusion criteria, of which five were randomized. Interventions studied included printed information or structured family conferences, with or without additional family support. Conferences aimed to communicate the diagnosis and prognosis, elicit patient values, assess family understanding, and clarify the goals of treatment. Printed information, palliative care or ethics consultation, or regular, structured communication by the usual ICU team reduced family distress, improved comprehension, and decreased the use of intensive treatments.

Conclusions:  The evidence supports the use of printed information and structured communication by the usual ICU team, ethics consultation, or palliative care consultation to improve family emotional outcomes and to reduce ICU length of stay and treatment intensity. Evidence that these interventions reduce total costs is inconclusive. A comprehensive research agenda should ensure the future study of a full range of patient-centered outcomes.

Figures in this Article

Communication between families and providers in the ICU includes sharing information about illness and prognosis, engaging families in treatment decision making, and offering support.1 Treatment decisions are complex, and communication is essential for designing treatments that incorporate patient values. Communication also affects patient and family outcomes.1-4 Therefore, ensuring high-quality family communication is a priority for clinicians, professional societies, regulatory bodies, and third-party payers.5-7

However, communication is complicated by time constraints, lack of communication skills training, unclear goals and processes, and challenging family dynamics. Current ICU communication is often inconsistent, insufficient, and of poor quality.8,9 Families consider daily communication of clearly understandable information to be highly important, yet they rarely perceive communication as being adequate.8 As a consequence, patients’ unique values and preferences may often not be respected, and resource-intensive treatments prolong the dying process for many patients.

In response to a demonstrated need to improve communication with families,10 investigators have tested a variety of innovative approaches using the methods of health services and communication research. In order to guide clinicians in maximizing the efficiency and effectiveness of communication and to better define directions for future research, we conducted a systematic review to answer the following questions in regard to clinical trials that tested interventions to improve family communication in the adult ICU setting: (1) Are interventions effective in improving patient- or family-centered outcomes? (2) Are interventions effective in reducing costs or resource use?

Data Sources and Searches

This systematic review includes published randomized, controlled trials (RCTs) or non-RCTs reporting on interventions to improve communication between providers and family members. Because the landmark publication of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)11 in 1995 caused fundamental changes in communication about end-of-life treatment and decision making, we excluded research printed before that study. We searched the MEDLINE, PsychInfo, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from 1995 through July 19, 2010, for English-language articles reporting original data, using the search terms “intensive care unit” or “critical care,” plus “communication” or “decision making,” plus “family,” “husband,” “wife,” “son,” “daughter,” child,” “parent,” or “spouse.” We hand-searched reference lists and drew from our personal files. A research librarian at the University of North Carolina Health Sciences Library assisted with the formulation of the search strategy.

Study Selection

Two unblinded authors independently reviewed all titles and abstracts identified by the search and excluded abstracts of articles that were about populations of patients who were not adults or were not in ICUs, reported results of review or observational studies, did not address communication, or addressed communication about organ donation. All remaining articles underwent full review.

In the full review, we retained articles that met the following inclusion criteria: populations including patients in ICUs who were older than 18 years, randomized or nonrandomized controls, and reports of results of clinical interventions designed to improve communication about medical information between medical providers and patients or their families. When we identified multiple reports of different aspects of the same trial, we report them together. We allowed any outcome measures. Any disagreements about inclusion were resolved by discussion between the reviewers. We reviewed reference lists of accepted articles for additional studies.

Data Extraction and Quality Assessment

We abstracted the selected articles using a standardized data collection instrument, sorting for study design; population; sources of bias from selection, measurement, or confounding; outcome measures; and results. We created a quality checklist by adapting recommendations from the Consolidated Standards for Reporting Trials (CONSORT) groups12,13; this aligned well with the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) criteria for non-RCTs.14 The checklist included type of controls, determination of sample size, clarity of participant flow, blinding, prespecification of outcome measures, use of validated measurement tools, adherence to the intervention, and handling of missing data (Table 1). Two reviewers independently completed the quality checklist for each study; there were few disagreements, and all were resolved by consensus.

Table Graphic Jump Location
Table 1 —Quality Metrics
Data Synthesis and Analysis

For analysis purposes, we divided interventions described in these studies into those that used printed information, required an additional specialty provider or team, and those that relied on existing ICU personnel (eg, physicians, nurses, and social workers). We characterized outcome measures as patient and family centered, such as satisfaction and emotional outcomes, or as outcomes related to cost or use of health-care resources, such as use of nonbeneficial treatments or length of stay (LOS). We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist for reporting systematic reviews during manuscript preparation to ensure transparency.15

Of the initial 2,841 articles identified by the search strategy, 168 met the criteria for full review, and an additional 12 were identified from reference lists or our personal files. Of these 180 articles, 21 met all of the inclusion criteria, representing 16 distinct interventions (Fig 1). The overall methodologic quality of the studies varied (Table 1). All compared the results of patients receiving an intervention to those of a control group receiving usual care. Although two studies enrolled patients who were communicative as subjects, few patients participated, and neither study reported outcomes of these communications. Patient populations varied from inclusion of all patients in the ICU, to subsets of patients at high risk for dying based on prolonged hospitalization or mechanical ventilation, severity of illness, or diagnosis, and to the subset of patients who died.

Figure Jump LinkFigure 1. Flow diagram of article inclusion. CINAHL = Cumulative Index to Nursing and Allied Health Literature.Grahic Jump Location

Some studies used printed information, with or without family conferences. Others focused on family conferences, with or without additional practical or palliative support. Although not all studies described the conferences in detail, they generally consisted of provider-family meetings, conducted early in the ICU stay, and focused on communication of diagnosis, prognosis, and treatment options; elicitation of values and treatment decisions; and family support. Because many outcome measures for satisfaction, communication, and decision making are relatively unfamiliar, we have compiled them into tables and refer to the broad category of outcomes assessed in the text (Tables 2, 3).

Table Graphic Jump Location
Table 2 —Measurement Instruments for Satisfaction, Communication, and Decision-Making Outcomes

FAMCARE = Family Satisfaction with Advanced Cancer Care Scale; IQR = intraquartile range; PSQ = Patient Satisfaction Questionnaire; PTSD = posttraumatic stress disorder; SW = social work.

a 

The Critical Care Family Assistance Program Family Satisfaction Survey was adapted from the Family Satisfaction with Care Questionnaire used by Kaufer et al.21

b 

One point given for documentation of advance directives, do-not-resuscitate orders, orders to withhold or withdraw treatment, and limits of care; 0.5 points given for consultation regarding pastoral care, social services, or pain management service.

Table Graphic Jump Location
Table 3 —Other Methods Used to Measure Communication and Decision Making

CMO = comfort measures only; DNR = do not resuscitate.

Trials Investigating Printed Information

Three trials, two of high quality, found that printed information could improve family comprehension and emotional outcomes, but perhaps not LOS or satisfaction (Tables 4, 5). In a 34-center RCT in France,16 the simple provision of a family information leaflet improved family comprehension for patients with expected ICU LOS > 48 h (36 intervention families with good comprehension vs 10 control subjects, P < .0001). However, the provision of the leaflet failed to change satisfaction or emotional distress. A 22-center French RCT coupled a bereavement brochure with proactive family conferences for patients with high likelihood of mortality and found significantly fewer symptoms of posttraumatic stress 90 days after the patients’ deaths (P = .02).17 The secondary outcomes of depression and anxiety also improved for intervention families (P = .004). Because attending physicians had judged the included patients to be likely to die within a few days, the finding that LOS was unchanged was expected. One small prepost study25 found that a nursing intervention including a family meeting on admission, provision of an ICU booklet, and daily telephone updates did not affect overall family satisfaction, but the enrollment of only 30 participants may have limited the study’s power. (Prepost studies have a prospective usual care cohort [pre] followed by a prospective intervention cohort [post].)

Table Graphic Jump Location
Table 4 —Patient- and Family-Centered Outcomes and Resource Use by Study

APN = advance practice nurse; GCI = global cerebral ischemia; LOS = length of stay; QI = quality improvement-intervention dynamic and provider-focused. See Table 2 for expansion of the other abbreviation.

a 

Primary outcomes.

b 

Patient population defined as likely to die within a few days of enrollment.

c 

No comparison group.

Table Graphic Jump Location
Table 5 —Study Quality Characteristics

Brackets denote groups of articles treated as a single intervention because the original studies were pilots using the same intervention and methods. MOSF = multiorgan system failure; NA = not applicable; RCT = randomized, controlled trial. See Table 4 legend for expansion of the other abbreviations.

a 

Prepost studies are those with a prospective usual care cohort (pre-) followed by a prospective intervention cohort (-post). Nonrandomized controls include those subjects in studies with provider-based assignment to concurrently enrolled intervention and control groups.

b 

In reporting statistics in Table 1, we did not “double count” multiple trials testing the same intervention.

c 

Power calculations performed based on prespecified primary outcomes.

RCTs of Interventions With ICU Personnel

The 22-center French RCT17 used printed information to supplement standardized family meetings1 delivered by ICU personnel. Family meetings used the VALUE principles: value and appreciate what families said, acknowledge family members’ emotions, listen, ask questions about who the patient was as a person, and elicit questions from the family. This intervention improved the family members’ levels of posttraumatic stress, anxiety, and depression 90 days after the patients’ deaths, without changes in satisfaction or LOS. Fewer nonbeneficial treatments were provided to the intervention group. The two portions of the intervention are likely synergistic because this trial demonstrated improved emotional outcomes not seen in the study of printed information alone.

Three articles reported a communication-intensive, palliative care, quality-improvement initiative for patients who died in the ICU or within 30 h of patient transfer from the ICU.18-20 The intervention included provider training and feedback rather than direct intervention with families. In the prepost-design pilot study, the primary outcomes of family-rated communication and palliative care did not change (response rate 55%, P = .09), but outcomes for nurse-rated communication and palliative care improved (response rate 68%, P < .01), while the ICU LOS decreased (7.2 vs 5.8 days, P < .01).19 Social workers increased communication with families about spiritual needs, addressed interfamily decisional conflict, helped families know it was okay to talk to or touch a loved one, and assured families of aggressive symptom management.20 Investigators then implemented the intervention in a separate, well-conducted, 12-center, cluster-randomized RCT.18 It failed to demonstrate improved indices of family or nurse ratings of quality of communication or palliative care. Outcome ascertainment was incomplete because response rates were no more than 50%. The number of family conferences within the first 72 h actually decreased during the study (P < .001).

RCTs of Ethics Consultation

Schneiderman et al26 performed a single-site RCT followed by a seven-center RCT,27 evaluating the offer of ethics consultation for patients with value-laden treatment conflicts. In the initial study, there were 21 decedents in each group, and the patients receiving ethics consultation demonstrated significant decreases compared with those receiving usual care in the number of days in the ICU (4.2 vs 13.2, P = .03) and the number of days using artificial nutrition and hydration (4.1 vs 12.0, P = .05) and ventilator (3.7 vs 11.4, P = .05) treatments. Use of other intensive treatments did not differ between the groups. The second seven-center study showed similar results: decedents in the intervention group had decreased LOS in the hospital (8.66 vs 11.62, P = .01) and the ICU (6.42 vs 7.86, P = .03), and had fewer days receiving mechanical ventilation (6.52 vs 8.22, P = .03). There were no significant changes in the number of days of artificial nutrition and hydration. Patients surviving to hospital discharge did not have any significant differences in these outcomes. The intervention did not affect mortality.

Interventions With Nonrandomized Control Subjects
Ethics Consultation:

A non-RCT with concurrent controls tested ethics consultation for patients mechanically ventilated for > 96 h.28 Their LOS decreased by 6 days, correlating with increased documentation of advance care planning (32.0% at baseline, 38.7% of concurrent control subjects, 61.0% of intervention patients; P < .05) and increased withholding or withdrawal of life-sustaining treatments (18.9% at baseline, 22.6% of control subjects, and 48.0% of intervention patients; P < .05). Unfortunately, this study found increased hospital mortality for the intervention patients (67.7% vs 43.2% at baseline and 48.4% of control subjects; P < .05). Investigators speculated that differences in the timing of death relative to discharge might explain this difference, but analysis was limited to deaths occurring in hospital.

Palliative Care Consultation:

Three trials suggested that palliative care consultation decreases patient LOS, while a fourth showed improvements in family satisfaction. Two studies were of better quality: One demonstrated decreased ICU and hospital LOS for patients who died in a trauma ICU (P < .05),31 and the other showed decreased ICU LOS (8.89 vs 16.28 days, P = .0001) but unchanged hospital LOS for patients at high risk of dying in a medical ICU.33 Another study with small numbers of historical control subjects showed decreased ICU and hospital LOS for patients with end-stage dementia29 and global cerebral ischemia30 after cardiac arrest, but not for patients with multiorgan system failure.30 A final study found that palliative care consultation improved some domains of family satisfaction for families of patients who died, but response rates to the questionnaire were < 30%, limiting its internal validity.21

Other Specialized Personnel:

Two nonrandomized interventions found conflicting results for patient LOS and costs when specially trained nurses facilitated communication. One study used the medical director as the attending physician of the intervention group, and it demonstrated decreased hospital LOS (11.3 vs 16.4 days, P = .03), and lower direct and indirect costs ($15,559 vs $24,080 direct, P = .01; and $5,087 vs $8,035 indirect, P = .007) for patients at high risk of dying in a medical ICU.34 A second study enrolled patients expected to have > 5-day postoperative stays in a trauma ICU and showed no change in LOS or costs.23 It also had low response rates to surveys, but showed some improvements in family satisfaction with communication. Sites of practice and target patients differed, but the exploratory nature of the studies likely accounts for some of the difference in outcomes.

ICU Personnel:

One non-RCT showed no differences in family satisfaction for patients at high risk for decisional conflict in four surgical and three medical ICUs when social workers facilitated family communication, but data were missing for > 40% of patients.24 Investigators reported improved clarity of treatment goals, demonstrated by increases in decisions to forego cardiopulmonary resuscitation (OR, 1.81; P = .017), provide comfort measures only (OR, 1.94; P = .018), and treat aggressively (OR, 2.30; P = .002), without changes in LOS.24

One intervention reported positive initial32 and long-term35 effects on resource use resulting from implementation of regular, structured family meetings emphasizing clinical milestones by the medical ICU team. The median ICU LOS decreased overall from 4 to 3 days for both studies. The overall ICU mortality also decreased from 31.3% preintervention to as low as 18.0% at four-year follow-up (P < .001); investigators attributed this finding to earlier triage of the sickest patients, who eventually died, which allowed increases in ICU treatment of patients with lower-acuity illnesses. A third prepost study was built on this model but narrowed its focus to patients receiving > 72 h of mechanical ventilation without expectation of extubation in the next 48 h in five ICUs (medical, surgical, and neurosurgical).36 It failed to demonstrate differences in LOS in the hospital or ICU. Postdischarge mortality was higher for control patients.

One study investigated a formal weekday relatives’ clinic held by ICU personnel for families of patients in the ICU22; 40% of families used this clinic, and less than half of the participants completed the outcome measure survey. The study failed to demonstrate improved family satisfaction.

Our systematic review of family-provider communication interventions for patients in the ICU includes 21 articles reporting the results of 16 distinct interventions that are heterogeneous in intervention design, selection of control groups, and outcome measures. This evidence comes from five RCTs and seven non-RCTs with other methodologic strengths. Despite this heterogeneity, several consistent themes emerged. Moderate-quality evidence supports the provision of printed information to improve family comprehension. Moderate-quality evidence also supports the use of structured family conferences conducted by the usual ICU team, ethics consultation, or palliative care consultation to improve patient- and family-centered outcomes, including emotional distress, processes of communication, and the frequency and timing of decisions about major treatments.

The use of structured communication also reduced the ICU LOS and intensity of treatment use, outcomes that measure components of resource use and that may also affect patients’ experience of care. However there is debate about how much impact reductions in ICU LOS have on total hospital costs,37,38 which were not measured in most studies. More importantly, it is unclear if reduced ICU LOS leads to less-prolonged time of dying, diminishes suffering for dying patients, or has other value for patients and families. Directly measuring these patient- or family-reported outcomes represents an important focus for future research.

Interventions had greater effects for patients who died than for those who lived, but they did not increase the risk of dying itself. Ten of 11 studies reporting mortality, the primary patient-centered outcome used in these studies, showed unchanged or decreased mortality after the intervention.

Specialized providers and usual ICU personnel are both able to implement communications interventions effectively, suggesting that consistent initiatives to communicate with families may be the most important element of successful provider-family communication. The content and structure of communication varied among studies, although one tested framework has been published.39-41 The VALUE mnemonic device is one of the clearest frameworks for communication, although several other study communication protocols also provide useful conceptualizations.1,24,27,31,32,34 Although helpful, these protocols do not delineate specific elements of communication that are critical to success, such as the length of conferences, key providers to include, or content that increases comprehension or provides increased emotional support for families. Additionally, because high-quality observational studies reveal more about the ways physicians and families communicate,42-44 clinicians may be able to use such studies to strengthen specific elements of the decision-making process, such as family comprehension of prognosis and treatment pathways, elicitation of patient values, participation in deliberation over treatment choices, or communication about norms of ICU care.

It appears likely that physician involvement is necessary for successful interventions. The extent of involvement required is uncertain, but the few interventions initiated by nurses or led by social workers were less likely to be successful.20,24,25 This conclusion must be accepted cautiously because few such studies were conducted, and those studies were often characterized by low numbers of enrolled patients or the use of satisfaction instruments with low response rates as their primary outcome measures. Quality-improvement research has clearly demonstrated the importance of strong local champions for the success of interventions.45 Nurses and social workers may be able to wield these roles effectively as team approaches become more entrenched in local cultures and if families can come to expect and trust communication from nonphysicians as authoritative. Future research may explore this possibility.

Several important considerations must influence the application of our study results. First, the provision of printed information is simple and efficient, and should probably be almost universally adopted. The Society of Critical Care Medicine, the American College of Chest Physicians, and the American Thoracic Society provide pamphlets online at http://www.myicucare.org/Support_Brochures/Pages/default.aspx, https://accp.chestnet.org/storeWA/StoreAction.do?method=view&pcrNum=19, and http://patients.thoracic.org/information-series, respectively. Second, local characteristics, including the availability of consultative services or ICU personnel who champion communication initiatives, should guide the selection of any particular strategy. Third, at present, most data support the use of intensive communication for patients at high risk of dying; concentrating on these patients is an efficient use of clinician time but should not exclude other populations at risk, such as those suffering severe delirium or the chronically critically ill. Fourth, it appears uncertain that significant cost savings will be realized by any current interventions, and institutional planners must consider this when appropriating resources for ICU care.

A variety of outcome measures were tested in these studies, and in many cases, they showed that participants were responsive to intervention. The evidence is reasonably strong that we can improve family comprehension, decrease family emotional distress, reduce the use of intensive treatments, and decrease LOS. Although family satisfaction is an important aspect of quality care, response rates are low, and interventions evaluating satisfaction should also investigate other outcomes.

Many patients in the ICU are incapable of consenting to or participating in research interviews. Few studies included in this review addressed patient-centered outcomes beyond mortality. Palliative care outcomes should continue to be a focus of future research.46,47 Additional proposed measures include symptom assessment and treatment; delirium assessment and treatment; elicitation of values; assessment of and attention to the emotional, spiritual, and practical needs of patients and their families; and emotional and organizational support for ICU clinicians.46,47 Other outcomes that may be important include complicated family grief, family return to work, financial impact of illness on patients and families, and compassion fatigue among clinicians. Although improved allocation of resources in the ICU is an important goal, we believe that future communication studies should include at least one patient- or family-centered outcome and that all studies should include an assessment of mortality.

Data Limitations

The data have important limitations. Many interventions were small and followed a prepost study design; their effects were attenuated when they were reattempted in larger trials or RCTs. Secular trends could account for some effects in prepost study design. ICU culture has changed considerably with respect to end-of-life care in the past 15 years, during which these studies were conducted, and many authors commented on the changes they observed during the study period. All interventions were compared with usual care, and existing evidence does not provide for direct comparison of different forms of enhanced ICU communication. However, this research does establish an evidence base for the recommendations of critical-care professional societies, which center around early, frequent, multidisciplinary communication with the goal of shared decision making.7,48

Study Limitations

Our study may be limited by publication bias because we did not systematically attempt to find research that has not been published. However, several of the reviewed studies did not show significant effects of their interventions, indicating a willingness to publish negative studies in this field of research. Additionally, the search strategy itself may not have included all available studies; however, the same titles emerged repeatedly as we hand-searched reference lists. We did not individually communicate with the authors of included studies, so it is possible that studies did not report quality metrics that they did implement, which would lead to a falsely low impression of quality. Finally, the heterogeneity of the studies precluded attempts at meta-analysis or other types of summative analysis and complicated our attempts at transparent reporting.

We report a systematic review of interventions designed to improve provider-family communication in the ICU. Printed information can improve family comprehension and should be available in all ICUs. Regular, structured communication on the part of the usual care team or a specialized ethics or palliative-care consult service can reduce family distress, the use of intensive treatments, and ICU LOS without adversely affecting patient mortality. However, these data are insufficient to conclude that communications interventions result in meaningful total-cost reductions. Although institutional factors will influence the adoption of a particular communication strategy, physicians should provide leadership in prioritizing structured family conferences in their ICUs. A comprehensive research agenda should be developed to ensure that ICU communication strategies and other palliative-care interventions provide evidence for effectiveness across a full range of standardized, validated patient- and family-centered outcomes.

Author contributions: Dr Scheunemann is responsible for the integrity of the work as a whole, from inception to published article.

Dr Scheunemann: had primary responsibility for the conception and design of the study, development of the search strategy, choice of data collection instruments, analysis of included studies, and preparation and revision of the manuscript, and gave final approval of the version to be published.

Ms McDevitt: helped to refine the data collection instruments, performed data abstraction and analysis, assisted in drafting the manuscript, and gave final approval of the version to be published.

Dr Carson: provided assistance with data abstraction and analysis, performed revision for intellectual content, and gave final approval of the article to be published.

Dr Hanson: guided the development of the data collection instruments and data analysis, performed data abstraction, performed revision of the manuscript for intellectual content, and gave final approval of the article to be published.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The Hartford Center of Excellence in Geriatric Medicine and Training supported this work but had no role in the conception, conduct, or reporting of the study.

Other contributions: All work on this manuscript was performed at the University of North Carolina at Chapel Hill. Institutional review board approval was not obtained for this research because it did not involve human subjects.

LOS

length of stay

RCT

randomized, controlled trial

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Kaufer M, Murphy P, Barker K, Mosenthal A. Family satisfaction following the death of a loved one in an inner city MICU. Am J Hosp Palliat Care. 2008;254:318-325. [CrossRef] [PubMed]
 
Steel A, Underwood C, Notley C, Blunt M. The impact of offering a relatives’ clinic on the satisfaction of the next-of-kin of critical care patients—a prospective time-interrupted trial. Intensive Crit Care Nurs. 2008;242:122-129. [CrossRef] [PubMed]
 
Shelton W, Moore CD, Socaris S, Gao J, Dowling J. The effect of a family support intervention on family satisfaction, length-of-stay, and cost of care in the intensive care unit. Crit Care Med. 2010;385:1315-1320. [PubMed]
 
Burns JP, Mello MM, Studdert DM, Puopolo AL, Truog RD, Brennan TA. Results of a clinical trial on care improvement for the critically ill. Crit Care Med. 2003;318:2107-2117. [CrossRef] [PubMed]
 
Medland JJ, Ferrans CE. Effectiveness of a structured communication program for family members of patients in an ICU. Am J Crit Care. 1998;71:24-29. [PubMed]
 
Schneiderman LJ, Gilmer T, Teetzel HD. Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med. 2000;2812:3920-3924. [CrossRef] [PubMed]
 
Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA. 2003;2909:1166-1172. [CrossRef] [PubMed]
 
Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med. 1998;262:252-259. [CrossRef] [PubMed]
 
Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med. 2004;329:1839-1843. [CrossRef] [PubMed]
 
Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest. 2003;1231:266-271. [CrossRef] [PubMed]
 
Mosenthal AC, Murphy PA, Barker LK, Lavery R, Retano A, Livingston DH. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;646:1587-1593. [CrossRef] [PubMed]
 
Lilly CM, De Meo DL, Sonna LA, et al. An intensive communication intervention for the critically ill. Am J Med. 2000;1096:469-475. [CrossRef] [PubMed]
 
Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007;356:1530-1535. [CrossRef] [PubMed]
 
Ahrens T, Yancey V, Kollef M. Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use. Am J Crit Care. 2003;124:317-323 discussion 324.. [PubMed]
 
Lilly CM, Sonna LA, Haley KJ, Massaro AF. Intensive communication: four-year follow-up from a clinical practice study. Crit Care Med. 2003;315Suppl:S394-S399. [CrossRef] [PubMed]
 
Daly BJ, Douglas SL, O’Toole E, et al. Effectiveness trial of an intensive communication structure for families of long-stay ICU patients. Chest. 2010;1386:1340-1348. [CrossRef] [PubMed]
 
Kahn JM. Understanding economic outcomes in critical care. Curr Opin Crit Care. 2006;125:399-404. [CrossRef] [PubMed]
 
Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end of life? Am J Respir Crit Care Med. 2002;1656:750-754. [PubMed]
 
Selph RB, Shiang J, Engelberg R, Curtis JR, White DB. Empathy and life support decisions in intensive care units. J Gen Intern Med. 2008;239:1311-1317. [CrossRef] [PubMed]
 
Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med. 2005;1718:844-849. [CrossRef] [PubMed]
 
McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med. 2004;327:1484-1488. [CrossRef] [PubMed]
 
Lee Char SJ, Evans LR, Malvar GL, White DB. A randomized trial of two methods to disclose prognosis to surrogate decision makers in intensive care units. Am J Respir Crit Care Med. 2010;1827:905-909. [CrossRef] [PubMed]
 
White DB, Braddock CH III, Bereknyei S, Curtis JR. Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med. 2007;1675:461-467. [CrossRef] [PubMed]
 
White DB, Malvar G, Karr J, Lo B, Curtis JR. Expanding the paradigm of the physician’s role in surrogate decision-making: an empirically derived framework. Crit Care Med. 2010;383:743-750. [CrossRef] [PubMed]
 
Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med. 1993;32917:1271-1273. [CrossRef] [PubMed]
 
Curtis JR, Engelberg RA. Measuring success of interventions to improve the quality of end-of-life care in the intensive care unit. Crit Care Med. 2006;3411Suppl:S341-S347. [CrossRef] [PubMed]
 
Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006;154:264-271. [CrossRef] [PubMed]
 
Davidson JE, Powers K, Hedayat KM, et al; American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine 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;352:605-622. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Flow diagram of article inclusion. CINAHL = Cumulative Index to Nursing and Allied Health Literature.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Quality Metrics
Table Graphic Jump Location
Table 2 —Measurement Instruments for Satisfaction, Communication, and Decision-Making Outcomes

FAMCARE = Family Satisfaction with Advanced Cancer Care Scale; IQR = intraquartile range; PSQ = Patient Satisfaction Questionnaire; PTSD = posttraumatic stress disorder; SW = social work.

a 

The Critical Care Family Assistance Program Family Satisfaction Survey was adapted from the Family Satisfaction with Care Questionnaire used by Kaufer et al.21

b 

One point given for documentation of advance directives, do-not-resuscitate orders, orders to withhold or withdraw treatment, and limits of care; 0.5 points given for consultation regarding pastoral care, social services, or pain management service.

Table Graphic Jump Location
Table 3 —Other Methods Used to Measure Communication and Decision Making

CMO = comfort measures only; DNR = do not resuscitate.

Table Graphic Jump Location
Table 4 —Patient- and Family-Centered Outcomes and Resource Use by Study

APN = advance practice nurse; GCI = global cerebral ischemia; LOS = length of stay; QI = quality improvement-intervention dynamic and provider-focused. See Table 2 for expansion of the other abbreviation.

a 

Primary outcomes.

b 

Patient population defined as likely to die within a few days of enrollment.

c 

No comparison group.

Table Graphic Jump Location
Table 5 —Study Quality Characteristics

Brackets denote groups of articles treated as a single intervention because the original studies were pilots using the same intervention and methods. MOSF = multiorgan system failure; NA = not applicable; RCT = randomized, controlled trial. See Table 4 legend for expansion of the other abbreviations.

a 

Prepost studies are those with a prospective usual care cohort (pre-) followed by a prospective intervention cohort (-post). Nonrandomized controls include those subjects in studies with provider-based assignment to concurrently enrolled intervention and control groups.

b 

In reporting statistics in Table 1, we did not “double count” multiple trials testing the same intervention.

c 

Power calculations performed based on prespecified primary outcomes.

References

Curtis JR, Patrick DL, Shannon SE, Treece PD, Engelberg RA, Rubenfeld GD. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. Crit Care Med. 2001;292Suppl:N26-N33. [CrossRef] [PubMed]
 
Azoulay E, Pochard F, Kentish-Barnes N, et al; FAMIREA Study Group FAMIREA Study Group Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;1719:987-994. [CrossRef] [PubMed]
 
Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;1584:1163-1167. [PubMed]
 
van der Heide A, Deliens L, Faisst K, et al; EURELD Consortium EURELD Consortium End-of-life decision-making in six European countries: descriptive study. Lancet. 2003;3629381:345-350. [CrossRef] [PubMed]
 
Miller PA, Forbes S, Boyle DK. End-of-life care in the intensive care unit: a challenge for nurses. Am J Crit Care. 2001;104:230-237. [PubMed]
 
Carlet 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;305:770-784. [CrossRef] [PubMed]
 
Thompson BT, Cox PN, Antonelli M, et al; American Thoracic Society American Thoracic Society European Respiratory Society European Respiratory Society European Society of Intensive Care Medicine European Society of Intensive Care Medicine Society of Critical Care Medicine Society of Critical Care Medicine Sociètède Rèanimation de Langue Française Sociètède Rèanimation de Langue Française Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med. 2004;328:1781-1784. [CrossRef] [PubMed]
 
Azoulay E, Chevret S, Leleu G, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med. 2000;288:3044-3049. [CrossRef] [PubMed]
 
Nelson JE. Identifying and overcoming the barriers to high-quality palliative care in the intensive care unit. Crit Care Med. 2006;3411Suppl:S324-S331. [CrossRef] [PubMed]
 
Truog RD, Cist AFM, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001;2912:2332-2348. [CrossRef] [PubMed]
 
Connors AF, Dawson NV, Desbiens NA, et al; The SUPPORT Principal Investigators The SUPPORT Principal 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;27420:1591-1598. [CrossRef] [PubMed]
 
Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P. CONSORT Group CONSORT Group Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 2008;1484:295-309. [PubMed]
 
Campbell MK, Elbourne DR, Altman DG. CONSORT Group CONSORT Group CONSORT statement: extension to cluster randomised trials. BMJ. 2004;3287441:702-708. [CrossRef] [PubMed]
 
Des Jarlais DC, Lyles C, Crepaz N. TREND Group TREND Group Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health. 2004;943:361-366. [CrossRef] [PubMed]
 
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;6210:e1-e34. [CrossRef] [PubMed]
 
Azoulay E, Pochard F, Chevret S, et al. Impact of a family information leaflet on effectiveness of information provided to family members of intensive care unit patients: a multicenter, prospective, randomized, controlled trial. Am J Respir Crit Care Med. 2002;1654:438-442. [PubMed]
 
Lautrette 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;3565:469-478. [CrossRef] [PubMed]
 
Curtis JR, Nielsen EL, Treece PD, et al. Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med. In press. doi:10.1164/rccm.201006-1004OC.
 
Curtis JR, Treece PD, Nielsen EL, et al. Integrating palliative and critical care: evaluation of a quality-improvement intervention. Am J Respir Crit Care Med. 2008;1783:269-275. [CrossRef] [PubMed]
 
McCormick AJ, Curtis JR, Stowell-Weiss P, Toms C, Engelberg R. Improving social work in intensive care unit palliative care: results of a quality improvement intervention. J Palliat Med. 2010;133:297-304. [CrossRef] [PubMed]
 
Kaufer M, Murphy P, Barker K, Mosenthal A. Family satisfaction following the death of a loved one in an inner city MICU. Am J Hosp Palliat Care. 2008;254:318-325. [CrossRef] [PubMed]
 
Steel A, Underwood C, Notley C, Blunt M. The impact of offering a relatives’ clinic on the satisfaction of the next-of-kin of critical care patients—a prospective time-interrupted trial. Intensive Crit Care Nurs. 2008;242:122-129. [CrossRef] [PubMed]
 
Shelton W, Moore CD, Socaris S, Gao J, Dowling J. The effect of a family support intervention on family satisfaction, length-of-stay, and cost of care in the intensive care unit. Crit Care Med. 2010;385:1315-1320. [PubMed]
 
Burns JP, Mello MM, Studdert DM, Puopolo AL, Truog RD, Brennan TA. Results of a clinical trial on care improvement for the critically ill. Crit Care Med. 2003;318:2107-2117. [CrossRef] [PubMed]
 
Medland JJ, Ferrans CE. Effectiveness of a structured communication program for family members of patients in an ICU. Am J Crit Care. 1998;71:24-29. [PubMed]
 
Schneiderman LJ, Gilmer T, Teetzel HD. Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med. 2000;2812:3920-3924. [CrossRef] [PubMed]
 
Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA. 2003;2909:1166-1172. [CrossRef] [PubMed]
 
Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med. 1998;262:252-259. [CrossRef] [PubMed]
 
Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med. 2004;329:1839-1843. [CrossRef] [PubMed]
 
Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest. 2003;1231:266-271. [CrossRef] [PubMed]
 
Mosenthal AC, Murphy PA, Barker LK, Lavery R, Retano A, Livingston DH. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;646:1587-1593. [CrossRef] [PubMed]
 
Lilly CM, De Meo DL, Sonna LA, et al. An intensive communication intervention for the critically ill. Am J Med. 2000;1096:469-475. [CrossRef] [PubMed]
 
Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007;356:1530-1535. [CrossRef] [PubMed]
 
Ahrens T, Yancey V, Kollef M. Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use. Am J Crit Care. 2003;124:317-323 discussion 324.. [PubMed]
 
Lilly CM, Sonna LA, Haley KJ, Massaro AF. Intensive communication: four-year follow-up from a clinical practice study. Crit Care Med. 2003;315Suppl:S394-S399. [CrossRef] [PubMed]
 
Daly BJ, Douglas SL, O’Toole E, et al. Effectiveness trial of an intensive communication structure for families of long-stay ICU patients. Chest. 2010;1386:1340-1348. [CrossRef] [PubMed]
 
Kahn JM. Understanding economic outcomes in critical care. Curr Opin Crit Care. 2006;125:399-404. [CrossRef] [PubMed]
 
Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end of life? Am J Respir Crit Care Med. 2002;1656:750-754. [PubMed]
 
Selph RB, Shiang J, Engelberg R, Curtis JR, White DB. Empathy and life support decisions in intensive care units. J Gen Intern Med. 2008;239:1311-1317. [CrossRef] [PubMed]
 
Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med. 2005;1718:844-849. [CrossRef] [PubMed]
 
McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med. 2004;327:1484-1488. [CrossRef] [PubMed]
 
Lee Char SJ, Evans LR, Malvar GL, White DB. A randomized trial of two methods to disclose prognosis to surrogate decision makers in intensive care units. Am J Respir Crit Care Med. 2010;1827:905-909. [CrossRef] [PubMed]
 
White DB, Braddock CH III, Bereknyei S, Curtis JR. Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med. 2007;1675:461-467. [CrossRef] [PubMed]
 
White DB, Malvar G, Karr J, Lo B, Curtis JR. Expanding the paradigm of the physician’s role in surrogate decision-making: an empirically derived framework. Crit Care Med. 2010;383:743-750. [CrossRef] [PubMed]
 
Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med. 1993;32917:1271-1273. [CrossRef] [PubMed]
 
Curtis JR, Engelberg RA. Measuring success of interventions to improve the quality of end-of-life care in the intensive care unit. Crit Care Med. 2006;3411Suppl:S341-S347. [CrossRef] [PubMed]
 
Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006;154:264-271. [CrossRef] [PubMed]
 
Davidson JE, Powers K, Hedayat KM, et al; American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine 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;352:605-622. [CrossRef] [PubMed]
 
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