Systematic Review: Controlled Trials of Interventions to Improve Communication in Intensive Care

Background: Communication between families and providers in the intensive care unit (ICU) affects patient and family outcomes, and healthcare utilization. Recent research has tested interventions designed to improve communication quality and outcomes between providers and families of ICU patients. We conducted a systematic review of these studies. Methods: We searched MEDLINE, PsychInfo, Cochrane, and CINAHL from 1995 to July 2010. Included studies reported controlled clinical interventions designed to improve communication between providers and families of ICU patients aged 18 years or older. Investigators abstracted all selected studies to a standardized data collection instrument and completed a quality checklist based on recommendations from the CONSORT investigators. Results: 2841 titles were identified. 180 met criteria for full review and 21 articles of 16 distinct interventions met full inclusion criteria, of which 5 were randomized. Interventions studied included printed information, or structured family conferences with or without additional family support. Conferences aimed to communicate diagnosis and prognosis, elicit patient values, assess family understanding, and clarify goals of treatment. Printed information, palliative care or ethics consultation, or regular, structured communication by the usual ICU team reduced family distress, improved comprehension, and decreased use of intensive treatments. Conclusions: Moderate quality evidence supports printed information and structured communication by the usual ICU team, ethics consultation, or palliative care consultation to improve family emotional outcomes, and reduce ICU lengths of stay and treatment intensity. Evidence that these interventions reduce total costs is inconclusive. A comprehensive research agenda should ensure future study of a full range of patient-centered outcomes.Master of Public Healt

Delayed Hemolytic Transfusion Reaction in Sickle Cell Disease

Delayed hemolytic transfusion reactions (DHTR) are potentially life-threatening complications observed in patients with sickle cell disease. We review the clinical features, pathophysiology, laboratory evaluation, and management of this complication. It is important that DHTR be included in the differential diagnosis of acute pain episodes following a red blood cell transfusion in a patient with sickle cell disease

Aging and Post-Intensive Care Syndrome–Family (PICS-F): A Critical Need for Geriatric Psychiatry

Postintensive care syndrome–family (PICS-F) describes the psychological symptoms that affect the family members of patients hospitalized in the intensive care unit (ICU) or recently discharged from the ICU. Geriatric psychiatrists should be concerned about PICS-F for several reasons. First, ICU hospitalization in older adults is associated with higher rates of cognitive and physical impairment compared with older adults hospitalized in non-ICU settings or dwelling in the community. This confers a special burden on the caregivers of these older ICU survivors compared with other geriatric populations. Second, as caregivers themselves age, caring for this unique burden can be more challenging compared with other geriatric populations. Third, evidence for models of care centered on patients with multimorbidity and their caregivers is limited. A deeper understanding of how to care for PICS and PICS-F may inform clinical practice for other geriatric populations with multimorbidity and their caregivers. Geriatric psychiatrists may play a key role in delivering coordinated care for PICS-F by facilitating timely diagnosis and interdisciplinary collaboration, advocating for the healthcare needs of family members suffering from PICS-F, and leading efforts within healthcare systems to increase awareness and treatment of PICS-F. This clinical review will appraise the current literature about the impact of critical illness on the family members of ICU survivors and identify crucial gaps in our knowledge about PICS-F among aging patients and caregivers

The Facilitated Values History: Helping Surrogates Make Authentic Decisions for Incapacitated Patients with Advanced Illness

Many patients who develop incapacitating illness have not expressed clear treatment preferences. Therefore, surrogate decision makers are asked to make judgments about what treatment pathway is most consistent with the patient’s values. Surrogates often struggle with such decisions. The difficulty arises because answering the seemingly straightforward question, “What do you think the patient would choose?” is emotionally, cognitively, and morally complex. There is little guidance for clinicians to assist families in constructing an authentic picture of the patient’s values and applying them to medical decisions, in part because current models of medical decision making treat the surrogate as the expert on the patient’s values and the physician as the expert on technical medical considerations. However, many surrogates need assistance in identifying and working through the sometimes conflicting values relevant to medical decisions near the end of life. We present a framework for clinicians to help surrogates overcome the emotional, cognitive, and moral barriers to high-quality surrogate decision making for incapacitated patients

Development and validation of a printed information brochure for families of chronically critically ill patients*

Families and other surrogate decision-makers for chronically critically ill patients often lack information about patient prognosis or options for care. This study describes an approach to develop and validate a printed information brochure about chronic critical illness aimed at improving comprehension of the disease process and outcomes for patients’ families and other surrogate decision-makers

Barriers and facilitators to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis

Objective To identify critical illness survivors’ perceived barriers and facilitators to resuming performance of meaningful activities when transitioning from hospital to home. Design Secondary content analysis of semistructured interviews about patients’ experiences of intensive care (primary analysis disseminated on the patient-facing website www.healthtalk.org). Two coders characterised patient-perceived barriers and facilitators to resuming meaningful activities. To facilitate clinical application, we mapped the codes onto the Person-Task-Environment model of performance, a patient-centred rehabilitation model that characterises complex interactions among the person, task and environment when performing activities. Setting United Kingdom, 2005–2006. Participants 39 adult critical illness survivors, sampled for variation among demographics and illness experiences. Results Person-related barriers included negative mood or affect, perceived setbacks; weakness or limited endurance; pain or discomfort; inadequate nutrition or hydration; poor concentration/confusion; disordered sleep/hallucinations/nightmares; mistrust of people or information; and altered appearance. Task-related barriers included miscommunication and managing conflicting priorities. Environment-related barriers included non-supportive health services and policies; challenging social attitudes; incompatible patient–family coping (emotional trauma and physical disability); equipment problems; overstimulation; understimulation; and environmental inaccessibility. Person-related facilitators included motivation or attitude; experiencing progress; and religion or spirituality. Task-related facilitators included communication. Environment-related facilitators included support from family, friends or healthcare providers; supportive health services and policies; equipment; community resources; medications; and accessible housing. Barriers decreased and facilitators increased over time. Six barrier–facilitator domains dominated based on frequency and emphasis across all performance goals: mood/motivation, setbacks/progress, fatiguability/strength; mis/communication; lack/community support; lack/health services and policies. Conclusions Critical illness survivors described a comprehensive inventory of 18 barriers and 11 facilitators that align with the Person-Task-Environment model of performance. Six dominant barrier–facilitator domains seem strong targets for impactful interventions. These results verify previous knowledge and offer novel opportunities for optimising patient-centred care and reducing disability after critical illness.</p