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.

Objectives: To assess the feasibility, acceptability, and perceived effectiveness of a multifaceted, nurse-led intervention to improve surrogate decision making in intensive care units.

Study design: 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.

Figures

Figure

The Four Supports Intervention: timeline of procedures. Abbreviations: FSS, family support specialist; ICU, intensive care unit; LST, life-sustaining treatment.