Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help?
OBJECTIVE
Determine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients' symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters.


METHODS
Prospective study of proxy reporters of symptoms in seriously ill patients.


METHODS
Two intensive care units in a tertiary medical center in the Western United States.


METHODS
Two hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians.


METHODS
None.


RESULTS
On the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients' and family members' ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients' and physicians' ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients' and nurses' ratings. Two symptoms had symptom-distress correlation coefficients between patients' and physicians' ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively.


CONCLUSIONS
Patient-family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients' symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians' and patients' symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients' symptoms. Proxy overestimation of patients' symptom scores warrants further study because this may influence decisions about treating patients' symptoms.
Department of Physiological Nursing, University of California, San Francisco, CA, USA. kathleen.puntillo@nursing.ucsf.edu
Kathleen A
KA
Puntillo
John
J
Neuhaus
Shoshana
S
Arai
Steven M
SM
Paul
Michael A
MA
Gropper
Neal H
NH
Cohen
Christine
C
Miaskowski
D000328:Adult; D000368:Aged; D016638:Critical Illness; D005190:Family; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009741:Nursing Staff, Hospital; D011446:Prospective Studies; D019727:Proxy