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I applaud Mary Thelan for the excellent article, End-of-Life Decision Making in Intensive Care (December 2005:28–37). As she noted, because of the ability of medicine and nursing to offer extraordinary support that extends life, families need more help to understand complex medical treatments and to support decision making regarding patient care. My experience with an interdisciplinary model supports the author’s acknowledgment of this being an effective model for decision making in the intensive care unit (ICU). As the manager of an ICU, I established a protocol for an interdisciplinary family conference to improve communication and the quality of care in the ICU. My experience has been that fine-tuning the plan of care by this method does indeed clarify end-of-life (EOL) goals.
Evidence suggests that providing family guidance correlates to the clarification of goals at the EOL. Ahrens et al1 developed a team to improve communication with families who had relatives in ICU who were at high risk of dying. The team consisted of a clinical nurse specialist and the medical director. The purpose of their study was to evaluate the team’s effect on length of stay in the ICU and the overall cost for patient care near EOL in ICU. The study showed a positive correlation between the intervention and decreased costs. The length of stay in ICU and in the hospital was significantly decreased in the intervention group. These investigators found that in 42 of the 43 cases that received the intervention, patients’ families decided to either withhold or withdraw treatments. A nonequivalent control group pretest-posttest study by Burns et al2 included 7 ICUs at 4 Boston teaching hospitals. Patients were selected when a 4-question screening tool determined a conflict with care. The intervention was not associated with a statistically significant change in the satisfaction with ICU care but significantly increased the probability of limiting resuscitation, to decide on comfort care, or to treat the patient aggressively.
The Patient Conference protocol at my hospital initiates dialogue important to decision making in the ICU. Ideally, each Monday the charge nurse selects a patient with the help of the bedside nurses. Selection is based on the criterion of 1-week stay in ICU. The selected patient’s room is flagged with a conference sign-up sheet. The charge nurse or bedside nurse coordinates the time and place of the meeting and notifies the family and other members of the patient’s team. The nurse records team members who will attend the conference on the sign-up sheet. The bedside nurse is expected to attend the conference.
The conference leader is usually the physician but when a physician is not present, the bedside nurse assumes this role. The goal of the conference is to clarify the plan of care. The conference agenda follows a nursing shift report, that is, a head-to-toe assessment of each system, ending with review of skin assessment and pain management. This format provides information to the family and team members and functions as the framework necessary to elicit discussion about prognostic issues and other family concerns. When a physician is not present, prognostic issues are deferred. Prognostic concerns are then addressed in a summary of the conference documented by the bedside nurse. Copies of the summary are placed in the patient’s bedside and progress notes.
There are some potential limitations to implementing these family conferences. Coordination of the team and family may require multiple phone calls, especially when the patient’s situation is complicated and involves many services. The time it takes to participate in the conference may be a deterrent to a nurse with a 2-patient assignment. Many physicians have other commitments that interfere with the conference time. Lack of financial incentive provides little motivation for physicians to participate. Physicians, nurses, and other disciplines attending the conference may not have the skills to address palliative care needs.
To date, our interdisciplinary conference occurs in a more reactive than proactive way. Sometimes it takes my action to initiate the process, and other times the bedside nurse takes the initiative. Less often, a physician asks for a conference. The conference may consist of the family, the patient’s physician, and bedside nurse. Or it may include the family, multiple physicians, nurse, physical therapist, dietician, occupational therapy, social services, and respiratory therapist. Patients are included when feasible. Some conferences are planned in advance, and others are spontaneous. One very important criterion is that, during the conference, all participants are seated in order to "level the playing field."
I have been mentoring staff in this protocol for the past 4 years and have experienced the positive results described by Thelan. Thelan’s article on EOL decision making reinforces the need for nurses to plan interdisciplinary meetings. Nurses can be instrumental in directing EOL care of critically ill patients toward a more collaborative, compassionate practice.
References
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