Half the families of intensive care unit patients experience inadequate communication with physicians

1. Half the families of intensive care unit patients experience inadequate communication with physicians Critical Care Medicine August 2000

3. Introduction Providing care : priority for critical care physicians and nurses. Providing the family with a realistic understanding of the ICU patient's condition is also an important goal. Many ICU patients are unable to understand their condition or to impart information to their families because they are sedated or unable to communicate . Physicians should meet with families to provide them with accurate, easy-to-understand information about the patient's diagnosis, prognosis, and treatment .

4. In 1993, the Society of Critical Care Medicine issued a "needs assessment questionnaire� Johnson et al. found that overall questionnaire scores were correlated with family satisfaction. Comprehension by families of the condition of ICU patients may not correlate consistently with family satisfaction and may require specific evaluation. A prospective 6-month study to evaluate how often families demonstrated adequate comprehension of the diagnosis, prognosis, and treatment of medical ICU patients Evaluate patient-, family-, and caregiver-related factors that may increase the risk of poor comprehension by families.

5. METHODS the Saint-Louis Teaching Hospital Medical ICU 12-bed medical ICU ; 650-bed teaching hospital in downtown Paris Approximately 500 patients per year, of whom 20% have immune deficiencies, generally attributable to hematologic diseases. The nurse-to-patient ratio is 1:3. Four senior and two junior physicians are in the ICU during the day (8 am to 7 pm) and one senior and one junior physician during the night (7 pm to 8am). A physician and nurse meet with family members at admission of each patient to the ICU. Information about the patient's condition generally is given by the physician in a room used only for this purpose. An interpreter is present if the family does not speak French. An information brochure : to families at admission; it contains information about ICU management, four phone numbers , and family visiting hours (1:30-3 pm and 6:30-8 pm). The physician in charge of the patient writes his or her name on the brochure before handing it to the family.

6. Conduct of the Study Patients and families were enrolled prospectively 2 days after ICU admission. The same investigator collected all the study data and conducted all the interviews with the physicians who first met the family, with the nurses who knew most about the patient and family, and with the patients' representatives. Patients All consecutive patients who were admitted to the medical ICU for >48 hrs Between June 1 and November 30, 1997. Recorded: age, gender, occupation, address, marital situation, comorbidities, prior ICU admission, reasons for ICU admission, severity score on admission (SAPS II) , and treatments.

7. Representatives The relative or friend of the patient or specifically designated by the patient . Before the beginning of the study, the ICU physicians and nurses received information on the study objectives and design; similar information was given to each patient and representative before study inclusion. Each representative was interviewed by the same investigator (E.A.). The representative�s data were collected at the beginning of the interview: - age, gender, occupation, comorbidities, prior ICU admission, relationship with the patient, geographic origin, languages spoken fluently, and whether there was a healthcare professional in the family. The rest of the interview focused on evaluating comprehension by the representative of the diagnosis, prognosis, and treatment in the patient as detailed subsequently. Patients with no visitors during the first 5 days of the ICU stay were considered to have no representative.

8. Caregivers Nurses. Nurses who cared for the patient for >2 days were interviewed to collect the following information: telephone calls from the family, number of visits, questions asked by the representative, nature of contact between the representative and patient during visits (eye contact, speech, touching), perception by the nurses of global comprehension by the representative. Physicians. Met with the family at admission and provided the representative with information on the condition of the patient was interviewed. The following were recorded: junior or senior physician status, time of admission (day or night), duration of the first verbal exchange with the representative (in minutes), perception by the physician of comprehension by the representative, the diagnosis given to the representative, use of ten major treatment interventions (sedation, mechanical ventilation, vasopressor agents, dialysis, surgery, antibiotics, blood transfusion, cancer chemotherapy, immunosuppressive agents, chest drainage), and whether the physician considered the prognosis grave (i.e., anticipated a fatal outcome) based on his or her clinical judgment within 24 or 48 hrs of ICU admission. Finally, we also noted whether a family information brochure was given to the representative.

9. Comprehension Assessment Interview Based on an interview with one of the investigators (E.A.). Every tenth representative (10/102, n =10) was also interviewed by two other investigators (G.L., M.B.), who described their perception of the representative's comprehension to the main investigator (E.A.). Comprehension was assessed : satisfactory comprehension of the diagnosis knowledge of which organ was primarily involved in the disease process; satisfactory comprehension of the prognosis, defined as knowledge of whether the patient was expected to survive or not satisfactory comprehension of the treatment, defined as knowledge of at least one of the major treatments used among the list of ten given in the preceding "Physicians" section. "I do not know" answers were taken as indicating poor comprehension.

10. Statistical Analysis Results are expressed as mean +/- sd. Fisher's exact test and the nonparametric Wilcoxon test. Univariate and multivariate logistic models were constructed to summarize predictive information. Estimated odds ratios (ORs) were computed, with their 95% confidence intervals (95% CIs) . Of the 200 patients admitted during the study period, 109 spent >=2 days in our ICU. We were able to contact a family member of 102 patients. Of these 102 patients, 76 did and 26 did not receive visits from their representative during their ICU stay;. All representatives agreed to participate in the study. The results reported next are based on the 76 patients whose representatives were interviewed at the ICU.

11. Characteristics of Patients, Representatives, Nurses, and Physicians Patients. Mean patient age : 54 +/- 17 yrs, 67% of patients were men, mean SAPS II at admission was 41 +/- 20, mean length of ICU stay : 6.5 +/- 4 days, and mortality was 30%. 29 patients (38%) were admitted directly to the ICU, 16 (21%) were referred from hematology or oncology wards in our hospital, 31 (41%) were referred from other wards in our hospital or from other hospitals. 50 patients were living with a spouse or companion. In 15 patients (20%), there was no previous history of disease or medical treatment. 22 patients (29%) were unemployed. Reasons for admission were acute respiratory failure in 35 patients(45%) acute respiratory failure with shock in 15 patients (20%), shock only in 13 patients (17%), coma in 10 patients (13%), and acute renal failure in 3 patients. Forty-two patients (55%) were admitted to the ICU at night. 38 patients (50%) were sedated, 50 (66%) were on mechanical ventilation, 11 (14%) were on dialysis, 34 (45%) received vasopressor agents, and nine (12%) had recently undergone surgery. 18 patients (23%) were awake and able to communicate.

12. Representatives. Forty-seven (62%) of the 76 representatives were spouses, and the remainder were parents, children, or friends. Mean age of representatives was 50 +/- 15 yrs; 25 representatives (33%) were male and 18 (24%) were unemployed. Eighteen representatives (24%) had a healthcare professional among their close relatives, Four had been hospitalized in an ICU. Only 35 (46%) representatives asked the physician for information. Twenty-five representatives (33%) were of foreign descent, and 12 (16%) did not speak French. Comprehension by the Representatives. Failure to comprehend the diagnosis, prognosis, or treatment was noted in 41 representatives (54%); 15 (20%) representatives did not understand the diagnosis, 33 (43%) the prognosis, and 30 (40%) the treatment. Ten representatives were each assessed by three investigators, who obtained concordant results regarding comprehension.

13. Nurses. The ICU nurses reported that the number of daily visits from representatives was one per day for 25 patients, two per day for 22 patients, and three or more per day for 28 patients. 26 representatives did not phone to request information from the nurses, 22 phoned once a day, 13 twice a day, and 14 three times a day or more. Twenty-four representatives (32%) asked questions of the nurses, usually about the treatments received by the patient. Some representatives used only one modality (eye contact, speech,or touching) for communicating with the patient and that only 38 (50%) used all three modalities. The nurses believed that 34 representatives (44.7%) had poor comprehension of the patient's diagnosis, prognosis, or treatment.

14. Physicians. - The first physician to speak with the representative was a junior physician in 38 cases (50%). . - Duration of the first interview was 10 +/- 6 mins (range 2-30). The interval between patient admission and the comprehension assessment interview was 66 +/- 33 hrs (50-132). - The number and total duration of physician-representative interviews in the first 48 hrs were 2 +/- 2 and 57 +/- 41 mins, respectively. Immediately after the first interview, the physician rated comprehension by the representative as poor in 32 (46%) cases. The family information brochure was given to only 45 (60%) representatives. Whether or not a brochure was given was not related to the severity of the acute illness as reflected by the SAPS II, to where the patient was before ICU admission, or to the geographic origin of the representative. Mean duration of the first interview was significantly longer for the representatives who were given than for those who were not given the brochure (12 mins vs. 8 mins, p = .01).

17. Factors Associated With Poor Comprehension Table 1, the likelihood of poor comprehension was greater for - representatives of younger, - unemployed patients , - referred to the ICU from hematology or oncology wards , - because of acute respiratory failure - coma Representatives who were of -foreign descent and/or did not speak French, -no personal experience of ICUs, -no health- care professionals among their relatives, and were -not the spouse of the patient also demonstrated poorer comprehension.

18. Comprehension was poorer for representatives who asked questions and for those who communicated with the patient using a combination of eye contact, speech, and touching.

19. Factors associated with poor comprehension by representatives Patient-related factors included age (p = .03), unemployment (p = .01), referral from a hematology or oncology ward (p = .006), admission for acute respiratory failure (p = .005) or coma (p = .01), and a relatively favorable prognosis (p = .04). Family-related factors were foreign descent (p = .007), no knowledge of French (p = .03), representative not the spouse (p = .03), and no healthcare professional in the family (p = .01). Physician-related factors were first meeting with representative p = .03) and failure to give the representative an information brochure (p = .02). Moreover, after the first meeting, caregivers accurately predicted poor comprehension by representatives (p = .03).

20. DISCUSSION Poor comprehension - an inability to understand information, an inability to recall information that was received and understood at some point, or failure to receive information. 54% of representatives of ICU patients had poor comprehension of the patient's diagnosis, prognosis, or treatment.

21. Comprehension of each of the three facets of the patient's condition (diagnosis, prognosis, and treatment) was correlated with comprehension of the other two facets. Prognosis was the facet most likely to be poorly comprehended (43%). Prognosis was less likely to be understood by representatives of patients with a>=40% likelihood of survival as predicted based on the SAPS II at admission ICU environment and visiting rules were perceived by representatives as indicating a poor prognosis; alternatively, physicians may have spent more time with representatives of patients with a grave prognosis. Diagnosis was more likely to be understood than prognosis; however, comprehension was poorer for coma and for acute respiratory failure with or without mechanical ventilation than for other diagnoses.

22. The poor comprehension of coma may be ascribable to the additional stress and anxiety generated by the inability of coma patients to communicate with their family; the situation may be similar in patients sedated for mechanical ventilation and in nonintubated patients with dyspnea so severe as to impair oral communication. Representatives of younger patients were at increased risk of poor comprehension, the reality of a life-threatening illness may be easier to grasp for families of older patients. In families with at least one healthcare professional, poor comprehension was significantly less common

23. Representatives of hematology and oncology patients had significantly poorer comprehension, indicating that they may have experienced difficulty in dealing with the change in ward, caregivers, visiting rules, and style of physician-family communication. Perhaps the possibility of ICU admission should be discussed with the patient and family at the time of the diagnosis and initial treatment of hematologic or other malignant diseases. Representatives of foreign descent, particularly those who did not speak French, demonstrated poor comprehension despite the involvement of an interpreter. Cross-cultural interactions in ICUs have been reported ; physicians also should seek to determine how well the information is understood despite cultural differences in values, perceptions, expectations regarding health care, and styles of expression and behavior

24. Even when the family members speak the same language as the physician, there may be gaps in the comprehension of shades of meaning, etiquette, and styles of expression that, combined with unfamiliar medical and technical terms, may impair communication severely. Also, the role of cultural differences should be viewed in relation to that of other factors such as financial resources; for instance, in this study, unemployment was associated with poorer comprehension.

25. The nature of the ties between the patient and representative influenced comprehension. Spouses were most likely to demonstrate good comprehension, Perhaps because they had to bear the impact of the absence of their companion and/or because they received information from their general practitioner or other professionals providing health care to the family .

26. Nurses' observations such as modalities of patient-representative communication and questions asked by representatives were correlated with comprehension in this study and may be useful for identifying families with special informational needs. The correlation between communication modalities and comprehension is difficult to explain; cultural factors may be involved or that touching may reflect an attempt by severely distressed family members to make sure that the patient is still alive and has not been harmed by treatments initiated . Conversely, absence of physical contact may indicate acceptance by family members, rightly or wrongly, that the patient soon may be separated from them through death.

27. Only the duration of the first meeting was associated with comprehension Physicians must take enough time to talk to family members and listen to their wishes at admission of ICU patients. Spending "sufficient" time with the family is recommended in some guidelines for family meetings, In a study of eight family members of trauma patients, Atkinson et al. recommended that enough time should be devoted to family meetings but failed to specify how much time was enough. They emphasized that families need time to adjust to the emotional distress produced by a critical illness in a relative.

28. > 50% of family members of ICU patients with severe injuries showed symptoms of depression. Strategies for improving communication between physicians and families would fail in families with depression or other factors impeding their ability to acknowledge distressing information. ICU physicians should be on the alert for symptoms of anxiety and depression in family members

29. ICU physicians should - identify patients and families at high risk of poor comprehension, - to better explain misunderstood diagnoses, and to point out the usefulness of intensive care for patients whose prognosis is relatively good. Information should be given by a junior or senior physician who should meet with the family for a sufficiently long period of time and should give the family an information brochure. The physicians and nursing staff should constantly strive to satisfy families' informational needs. Meetings should be offered to families by the physicians, because many families (in this study,half) fail to ask to see a physician.

30. Conclusions Patient information is frequently not communicated effectively to family members by ICU physicians. Physicians should strive to identify patients and families who require special attention and to determine how their personal style of interrelating with family members may impair communication.

32. Thank You for Your Attension