Communication of prognostic information in an ICU at end of life: Practices among and between nurses, physicians and family members

Design. Ethnographic study analyzing prognostic communication at end of life in ICU between/among family members of patients at high risk for death and critical care physicians and nurses.Study questions. (1) What are the communication practices of prognostic information at end of life between and among critical care nurses, physicians, and family members in ICU throughout patients' trajectories? (2) "What are the social, institutional, professional, and political influences which shape these practices?"Setting. A 22 bed adult medical/surgical ICU in an urban, non-teaching hospital in mid-west USASampling. Purposive.Data collection. Observation 12-16 hours per week for 9 months including following medical rounds attending family care conferences informal and formal (audiotaped) interviews with key nurse, physician, and family member informants. Field notes recorded.Data analysis. Patterns in prognostic communication and influences identified, analyzed over time while comparing cases. Patterns compared/contrasted to study's theoretical framework which was altered to fit data.Findings. Physicians "paint" initial prognostic picture nurses "fill in the details," including quality of life, long term outcomes, and physical implications of treatments. Communication of prognosis closely associated with certainty level and time, structured within a 2 week timeframe of aggressive treatment, and. prompted by need for a medical decision and/or nurse perception of lack of provider/family alignment of understandings. Critical importance of temporality in critical illness and ICU identified, especially in relation to treatment limitation. Layers of tensions described which influence "what is said" and "what is not said" by providers to families management of tensions usually revolving around negotiation of meaning. Family communication needs described and theory of prognostic communication delineated.Recommendations include. (1) Communicate honest/realistic prognostic information, including possibility of death, with compassion early in patient's trajectory. The "style" of communication is most important in supporting families, not avoiding giving bad news until there is "certainty." (2) Question assumption that all patients want "full" ICU care. (3) Share responsibility of decision making/outcomes with families by using the word "we" in relation to decision making, rather than "you." (4) Explain temporal nature of ICU to families. (5) Assess family members' need for privacy/information content/emotional support structured into formal care conferences and lacking in informal bedside care conferences. (6) Prioritize nurse continuity. (7) Continually assess understandings/perceptions by asking family members to describe their understandings. (8) Encourage/listen to family members' "narration" regarding experiences of patient's previous quality of life/health and their concerns/ hopes/goals regarding the patient. (9) Upon ICU admission, discuss with families the uncertainty of treatment outcomes and difference between survival and quality of life. (10) Physicians should recognize patient code status is a significant stressor for nurses and strive for timely follow up on code status issues.