title: Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness.
abstract: BACKGROUND
  Problems persist with surrogate decision making in intensive care units, leading to distress for surrogates and treatment that may not reflect patients' values.
  
  
  OBJECTIVE
  To assess the feasibility, acceptability, and perceived effectiveness of a multifaceted, nurse-led intervention to improve surrogate decision making in intensive care units.
  
  
  METHODS
  A single-center, single-arm, interventional study in which 35 surrogates and 15 physicians received the Four Supports Intervention, which involved incorporating a family support specialist into the intensive care team. That specialist maintained a longitudinal relationship with surrogates and provided emotional support, communication support, decision support, and anticipatory grief support. A mixed-methods approach was used to evaluate the intervention.
  
  
  RESULTS
  The intervention was implemented successfully in all 15 patients, with a high level of completion of each component of the intervention. The family support specialist devoted a mean of 48 (SD 36) minutes per day to each clinician-patient-family triad. All participants reported that they would recommend the intervention to others. At least 90% of physicians and surrogates reported that the intervention (1) improved the quality and timeliness of communication, (2) facilitated discussion of the patient's values and treatment preferences, and (3) improved the patient-centeredness of care.
  
  
  CONCLUSIONS
  The Four Supports Intervention is feasible, acceptable, and was perceived by physicians and surrogates to improve the quality of decision making and the patient-centeredness of care. A randomized trial is warranted to determine whether the intervention improves patient, family, and health system outcomes.
authors.affiliation: Program of Ethics and Decision Making, Department of Critical Care Medicine at University of Pittsburgh School of Medicine, PA 15261, USA. whitedb@upmc.edu
authors.forename: Douglas B
authors.initials: DB
authors.lastname: White
authors.forename: Sarah Martin
authors.initials: SM
authors.lastname: Cua
authors.forename: Roberta
authors.initials: R
authors.lastname: Walk
authors.forename: Laura
authors.initials: L
authors.lastname: Pollice
authors.forename: Lisa
authors.initials: L
authors.lastname: Weissfeld
authors.forename: Seoyeon
authors.initials: S
authors.lastname: Hong
authors.forename: C Seth
authors.initials: CS
authors.lastname: Landefeld
authors.forename: Robert M
authors.initials: RM
authors.lastname: Arnold
mesh_terms: D000368:Aged; D003142:Communication; D016638:Critical Illness; D003657:Decision Making; D005190:Family / Q000523:psychology*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital; D010348:Patient Care Team; D010414:Pennsylvania; D011368:Professional-Family Relations; D019727:Proxy / Q000523:psychology; D012944:Social Support; D020458:Third-Party Consent