Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care

Abstract

Rationale: Communication with family of critically ill patients is often poor and associated with family distress.

Objectives: To determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care.

Methods: We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict.

Measurements and main results: Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001).

Conclusions: Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. Clinical trial registered with www.clinicaltrials.gov (NCT 00720200).

Trial registration: ClinicalTrials.gov NCT00720200.

Keywords: communication; critical care; family; palliative care; randomized trial.

Figures

Figure 1.

Flow diagram of patient and family sample development. *Baseline data were too late if the questionnaire was completed more than 14 days after distribution; follow-up data were too late if the questionnaire was completed more than 60 days after distribution. LNOK = legal next of kin.

Figure 2.

Proportion of family members with a minimal clinically important change in symptoms of depression between baseline and 3- or 6-month follow-up.