That's the conclusion of Alexandre Laurette, M.D., of Saint-Louis Hospital here and colleagues, who conducted a randomized study comparing a formalized family intervention with conventional ICU family conferences.
Dr. Laurette and colleagues found that three months after the death of a loved one, those family members who went through the formalized process had lower levels of post-traumatic stress disorder (PTSD) symptoms, anxiety, and depression and were better able to cope with their loss.
- Explain to interested patients that this study indicates that formal end-of-life conferences with family members of dying ICU patients -- in which families' questions, patients' lives, and family members' feelings are discussed in depth -- can help significantly reduce the burden of stress that it inevitable at times of loss.
"A proactive strategy for routine end-of-life family conferences that included provision of a brochure on bereavement, as compared with customary practice, resulted in longer meetings in which families had more opportunities to speak and to express emotions, felt more supported in making difficult decisions, experienced more relief from guilt, and were more likely to accept realistic goals of care," the investigators wrote in the Feb. 1 issue of the New England Journal of Medicine.
In an accompanying editorial, Craig M. Lilly, M.D., of the University of Massachusetts Medical School in Worcester, and Barbara J. Daly, Ph.D, R.N., of Case Western University in Cleveland, applauded the authors for taking a scientific approach to a hard-to-quantify subject.
"This study is groundbreaking in its demonstration of a statistically and clinically significant improvement in symptoms of anxiety, depression, and PTSD among family members, and it shows that expanding the focus of critical care to include family-centered outcomes is appropriate and desirable," they wrote. "In reporting these advances in the peer-reviewed literature, it is often difficult for authors to fully explain the core of their interventions, in part because of the complex, diverse, and emotion-laden nature of these multidimensional conversations."
Dr. Laurette and colleagues ramdomly assigned family members of 126 patients dying in 22 ICUs in to receive either the intervention format or to the institution's customary end-of-life conference.
Families assigned to the intervention group attended the end-of-life family conference that was held in according to detailed guidelines developed by study's co-author, J. Randall Curtis, M.D., M.P.H., of the University of Washington in Seattle.
The families were given a brochure on bereavement, and the conference focused of five objectives, represented by the acronym VALUE. Caregivers were expected to:
- Value and appreciate what the family members said.
- Acknowledge the emotions of family members.
- Understand, by asking questions "who the patient was as a person."
- Elicit questions from family members.
One investigator at each ICU was responsible for the study, which included six consecutive patients and their surrogates.
Three months after the death of the patient, one member of each family -- either the patient's designated surrogate or the chief decision maker in the group -- was interviewed by telephone. Each interviewer rated how the family member was coping via the Impact of Event Scale, with scores ranging from 0, indicating no symptoms, to 75, indicating severe symptoms related to post-traumatic stress disorder, and with the Hospital Anxiety and Depression Scale with subscale scores ranging from 0, indicating no distress, to 21, indicating maximum distress.
The investigators found that those family members who took part in the formal intervention had had significantly longer end-of-life conferences than controls, at a median of 30 minutes (interquartile range, 19 to 45 minutes), compared with 20 minutes (IR, 15 to 30 minutes, P<0.001) for controls.
In addition, participants in the formal intervention spent more of the time talking, at a median of 14 minutes, IR, eight to 20 minutes) compared with just five minutes (IR, five to 10 minutes) for family members in the customary end-of-life conferences.
At three months, the 56 participants in the intervention group who responded to the telephone interview had a significantly lower median Impact of Event scale score than did the 52 responding participants in the control group. The median score for the intervention group was 27 versus 39 for controls (P=0.02).
In addition, family members who read the bereavement brochure and took part in the VALUE conference had a lower prevalence of PTSD-related symptoms than controls, at 45% compared with 69%, P=0.01). Intervention group members also had lower median Hospital Anxiety and Depression Scale scores than controls (11, versus 17, P=0.004), and less prevalent symptoms of both anxiety (45% versus 67% P=0.02) and depression (29% versus 56%, P=0.003).
Among the limitations of the study, the authors noted, were a more paternalistic physician-patient relationship that might have skewed results in favor of the intervention, limited study inclusion criteria (the only requirement was the physician's belief that the patient would die soon), inability to determine whether all family members read the brochure and fully participated in the intervention, unblinded design, and a lack of information about potential baseline differences between the intervention group and controls.
"Recommendations to improve care for patients dying in ICUs are rooted in both observational and interventional studies," Dr. Lilly and Dr. Daly wrote in their editorial. "Observational studies confirm our own practical experience that nearly every American family will be affected by the loss of a loved one in an ICU and that the effect of this loss can be mitigated by high-quality care."
The editorialists estimated the time required for this type of internvention. They wrote that "on the basis of our research, we propose that the time clinicians working in adult ICUs spend supporting family members in shared decision making should roughly correspond to the mortality rate of the ICU patient population. For example, a full-time clinician serving a surgical ICU with a mortality rate of 2% would spend about two hours a week supporting patients and families. The same clinician would spend about two hours per day supporting families when serving a medical ICU with a mortality rate of 20%."