An intensive communication intervention for the critically ill.
OBJECTIVE
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.


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.
Lilly
C M
CM
Combined Program in Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
De Meo
D L
DL
Sonna
L A
LA
Haley
K J
KJ
Massaro
A F
AF
Wallace
R F
RF
Cody
S
S
D018806:APACHE; D000368:Aged; D001900:Boston / Q000453:epidemiology; D019090:Case Management; D003142:Communication; D003422:Critical Care / Q000379:methods* / Q000592:standards*; D005260:Female; D006302:Health Services Research; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D013677:Medical Laboratory Science; D008875:Middle Aged; D016017:Odds Ratio; D010166:Palliative Care; D010347:Patient Care Planning; D010348:Patient Care Team; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis