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Ann Am Thorac Soc. 2016 Sep;13(9):1546-52. doi: 10.1513/AnnalsATS.201603-212OC.

Intensivist-reported Facilitators and Barriers to Discussing Post-Discharge Outcomes with Intensive Care Unit Surrogates. A Qualitative Study.

Turnbull AE1,2,3, Davis WE1,2, Needham DM1,2,4, White DB5,6,7, Eakin MN1,2.

Author information

1
1 Outcomes after Critical Illness and Surgery Group.
2
2 Division of Pulmonary and Critical Care Medicine, School of Medicine.
3
3 Department of Epidemiology, Bloomberg School of Public Health, and.
4
4 Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
5
5 Center for Bioethics and Health Law, Department of Critical Care Medicine.
6
6 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, and.
7
7 Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

Abstract

RATIONALE:

Intensive care unit (ICU) patients' expected post-discharge outcomes are rarely discussed in family meetings despite this information being centrally important to patients and their families.

OBJECTIVES:

To characterize intensivist-identified barriers and facilitators to discussing post-discharge outcomes with surrogates of ICU patients.

METHODS:

Qualitative study conducted via one-on-one, semistructured telephone interviews with 23 intensivists from 20 hospitals with accreditation council for graduate medical education-accredited critical care medicine programs in 16 states. A limited application of grounded theory methods was used to code transcribed interviews and identify themes and illustrative quotes.

MEASUREMENTS AND MAIN RESULTS:

Intensivists reported tension between their professional responsibility to discuss likely functional outcomes versus uncertainty about their ability to predict those outcomes for an individual patient. They cited three main barriers as limiting their ability to conduct conversations about post-discharge outcomes with ICU surrogates: (1) incorrectly optimistic expectations for recovery among ICU surrogates, (2) having little or no contact with their patients after ICU discharge, and (3) minimal confidence applying existing outcomes research to individual patients. Despite these barriers, experience talking to ICU surrogates, seeing ICU survivors in the outpatient setting, and trusted research on functional outcomes were identified as important facilitators to discussing likely patient outcomes with surrogates. Intensivists generally welcomed questions from surrogates about post-discharge outcomes as opportunities to initiate conversations about prognosis and patient values.

CONCLUSIONS:

In this sample of intensivists from 20 academic hospitals, experience conducting conversations with surrogates and interactions with ICU survivors as outpatients were identified as facilitating discussion of expected post-discharge outcomes while optimistic surrogate expectations and prognostic uncertainty were barriers. There was tension between self-perceived ability to prognosticate and belief in a professional obligation to discuss patient outcomes.

KEYWORDS:

communication barriers; critical care; patient-centered care; prognosis; surrogate decision-making

PMID:
27294981
PMCID:
PMC5059504
DOI:
10.1513/AnnalsATS.201603-212OC
[Indexed for MEDLINE]
Free PMC Article

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