PURPOSE: The determinants of quality evaluation for end-of-life care are not well elucidated in the ICU. Qualitative analysis can explore factors that may affect quality ratings of end-of life ICU experiences.
METHODS: We categorized responses to an open-ended question in interviews with family members of patients who died in an ICU using modified constant comparative content analysis. We explored associations between expressed themes and quality ratings on the ICU-Quality of Death and Dying (ICU-QODD) instrument using a previously reported structured multivariate linear analysis.
RESULTS: Although most family member comments (54% of 194) offered from 77 subjects (82% of participants in the study) were classified as positive regarding the ICU dying experience, 71% of comments related to communication (75 of 105) expressed poor experiences. Rating of the quality of the last seven days of life (0-10 scale) was strongly (linear coefficient -1.5) and negatively associated with reports of poor communication (p=0.007) Other associations were saying goodbye (1.92, p=0.003), control over what was going on around in ICU (0.74, p<0.0001), patient's pain under control (0.56, p=0.007), and witnessing any treatments that upset the family rater(-1.03, p=0.05). Similarly, the rating of ICU as place of death was negatively associated with poor communication (-1.8, p=0.004); other associations include pain under control (0.73, p=0.003), control over what was going on (0.49, p=0.01), and witnessing any upsetting treatments (-2.3, p=0.0003) The cumulative ICU-QODD rating was not associated with negative communication.
CONCLUSION: Our qualitative analysis identified communication as a problematic area in end-of-life ICU experiences. Modeling further suggests a substantial association between experiencing poor communication and family ratings of the end-of-life ICU experience. Amongst themes reported by family members, targets for improvement in ICU communication include helping the patient and family understand disease processes and prognoses and engaging in earlier end-of-life discussions.
CLINICAL IMPLICATIONS: Quality of care in the ICU may be enhanced by improving communication and should be an immediate focus of innovative ICU quality of care initiatives.
DISCLOSURE: Wayneinder Anand, None.