Meeting standards of high-quality intensive care unit palliative care: clinical performance and predictors.

OBJECTIVES: High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality's National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance. DESIGN: Prospective, multisite, observational study of performance of key intensive care unit palliative care processes. SETTINGS: A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital. PATIENTS: Consecutive adult patients with length of intensive care unit stay ≥5 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance. CONCLUSIONS: Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers.

Errors in identifying and expressing emotion in facial expressions, voices, and postures unique to social anxiety.

The purpose of the present study was to see if 7-10-year-old socially anxious children (n = 26) made systematic errors in identifying and sending emotions in facial expressions, paralanguage, and postures as compared with the more random errors of children who were inattentive-hyperactive (n = 21). It was found that socially anxious children made more errors in identifying anger and fear in children's facial expressions and anger in adults' postures and in expressing anger in their own facial expressions than did their inattentive-hyperactive peers. Results suggest that there may be systematic difficulties specifically in visual nonverbal emotion communication that contribute to the personal and social difficulties socially anxious children experience.

In their own words: patients and families define high-quality palliative care in the intensive care unit.

OBJECTIVE: Although the majority of hospital deaths occur in the intensive care unit and virtually all critically ill patients and their families have palliative needs, we know little about how patients and families, the most important "stakeholders," define high-quality intensive care unit palliative care. We conducted this study to obtain their views on important domains of this care. DESIGN: Qualitative study using focus groups facilitated by a single physician. SETTING: A 20-bed general intensive care unit in a 382-bed community hospital in Oklahoma; 24-bed medical-surgical intensive care unit in a 377-bed tertiary, university hospital in urban California; and eight-bed medical intensive care unit in a 311-bed Veterans' Affairs hospital in a northeastern city. PATIENTS: Randomly-selected patients with intensive care unit length of stay >=5 days in 2007 to 2008 who survived the intensive care unit, families of survivors, and families of patients who died in the intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Focus group facilitator used open-ended questions and scripted probes from a written guide. Three investigators independently coded meeting transcripts, achieving consensus on themes. From 48 subjects (15 patients, 33 family members) in nine focus groups across three sites, a shared definition of high-quality intensive care unit palliative care emerged: timely, clear, and compassionate communication by clinicians; clinical decision-making focused on patients' preferences, goals, and values; patient care maintaining comfort, dignity, and personhood; and family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Participants also endorsed specific processes to operationalize the care they considered important. CONCLUSIONS: Efforts to improve intensive care unit palliative care quality should focus on domains and processes that are most valued by critically ill patients and their families, among whom we found broad agreement in a diverse sample. Measures of quality and effective interventions exist to improve care in domains that are important to intensive care unit patients and families.

Family meetings made simpler: a toolkit for the intensive care unit.

Although a growing body of evidence has associated the intensive care unit (ICU) family meeting with important, favorable outcomes for critically ill patients, their families, and health care systems, these meetings often fail to occur in a timely, effective, and reliable way. In this article, we describe 3 specific tools that we have developed as prototypes to promote more successful implementation of family meetings in the ICU: (1) a family meeting planner, (2) a meeting guide for families, and (3) a family meeting documentation template. We describe the essential features of these tools and ways that they might be adapted to meet the local needs of individual ICUs and to maximize acceptability and use. We also discuss the role of such tools in structuring a performance improvement initiative. Just as simple tools have helped reduce bloodstream infections, our hope is that the toolkit presented here will help critical care teams to meet the important communication needs of ICU families.