Communication of Prognostic Information for Critically III Patients: Results

Communication FrequencyBaseline descriptive statistics of the patients and subjects are in Table 1. The majority of the subjects were white and well educated, and we were able to recruit subjects from both Methodist Hospital (a community hospital) and FUMC (an academic hospital). Patients were severely ill with a mean APACHE II score of 25, and nearly 40% died while in the ICU. Nearly 60% of the patients had been in an ICU at least once before.

Seventy subjects completed baseline surveys on enrollment. Forty-three subjects completed a second survey, 25 completed a third survey, 12 completed a fourth survey, and 2 completed a fifth survey. Sixty-four subjects (91%) completed follow-up mailed surveys after hospital discharge. This provided 216 surveys for analysis.

Prognostic Interval

Eighty-one percent of the subjects reported receiving prognostic information from a physician at least once. The mean (± SD) prognostic interval was 1.7 ± 2.8 days (median, 1 day). The distribution of prognostic interval (Fig 1) shows the most frequent intervals were 0 or 1 days; that is, most subjects received some type of prognostic information on the day of ICU admission or the following day. A multivariate Cox model showed that none of the hypothesized baseline characteristics were associated with time to delivery of prognosis (Table 2).

Communication Frequency

The reported rate of communication between subject and physician per day (defined as any type of communication not just prognosis) varied considerably: mean, 1.4 ± 1.7 times per day (median, 1). The rate was not associated with hospital, patient age, APACHE II score, subject education, or whether the subject had knowledge of health care, but there was a significantly lower communication rate for patients receiving surgical services (Table 3). Figure 2 shows the median and interquartile range of the communication rate during the interval prior to each follow-up survey and shows that the surrogate-reported communication rate decreases as the ICU length of stay increases. For instance, on the second and third surveys, the mean reported communication rate had decreased to 1 ± 1.5 times per day and 0.8 ± 0.7 times per day, respectively. The graphic trend in post-ICU satisfactionFigure 2 was confirmed statistically by regressing ICU days on frequency of communication: there was a statistically significant inverse relationship (p = — 0.06, p < 0.001; 146 observations, 70 subjects).

When asked about the desired frequency of communication in the baseline survey, more than half of subjects wished to communicate with physicians two or more times a day, whereas 40% reported once a day was adequate. Surrogates’ desired frequency of communication decreased over the ICU stay (P = — 0.042, p < 0.001; 146 observations, 70 subjects). Although both the reported and desired rate of communication declined with time in the ICU, the reported rate of communication had a steeper slope indicating a higher rate of decline.

Satisfaction

Subjects rating of satisfaction with communication was generally high, as shown in Table 4. The mean global (summated five subscales) satisfaction was 18 ± 5 (median, 18; minimum, 5; maximum, 25). There was a strong positive association between higher global satisfaction and male gender, but not with age, education, or hospital (p = — 0.44, p < 0.001). Global satisfaction had a declining trend as the ICU stay progressed (p = — 0.079, p = 0.07; 149 observations, 70 subjects). Additionally, satisfaction with communication frequency decreased significantly over the ICU stay (p = — 0.34, p = 0.006; 147 observations, 70 subjects). Likewise, increased communication frequency was strongly positively associated with increased satisfaction with communication overall (p = 0.73, p < 0.001; 149 observations, 70 subjects). Regressing the prognostic interval on post-ICU satisfaction showed a trend toward an association between shorter prognostic interval and greater post-ICU satisfaction (p = — 0.52, p = 0.06, n = 51).

Decision Making

Seventy-eight percent of the subjects recalled discussing major medical decisions with the physician. Fifty-three percent correctly identified our definition of surrogate decision making. Four subjects checked the correct answer in addition to one other, suggesting 60% had a partial understanding of the substituted judgment concept. Others made decisions based on what the whole family wanted (28%), what the subject wanted for the patient (6%), or what the subject wanted for him/herself (2%). We found no association between the presence of a living will (odds ratio, 1.3; 95% confidence interval [CI], 0.4 to 4.0) or whether a physician had explained the role in the decision-making process (odds ratio, 0.4; 95% CI, 0.1 to 2.4) and the surrogates’ correct identification of the substituted judgment concept.

Subjects who were asked by their physicians to make medical decisions were surveyed after the ICU stay about satisfaction with decision making. Table 5 shows that the majority of subjects were mostly to very satisfied with important aspects of decision making. Higher satisfaction with decision making was not associated with either prognostic interval (P = 0.61, p = 0.73, n = 50) or average rate of communication (P = 0.07, p = 0.55, n = 53). In addition, correctly identifying the substituted judgment concept was not associated with post-ICU satisfaction with decision making (P = — 0.37, p = 0.17, n = 50).

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Fig1

Figure 1. Bar chart of prognostic interval in days.

Fig2

Figure 2. Box plot of communication rate over follow-up interview number. The 0 category represents the communication rate from ICU admission to the day of completing the baseline survey.

Table 1—Baseline Characteristics of Surrogates and Patients

Variables Surrogates (n = 70) Patients (n = 70)
Age, yr 50 (13) 60 (16)
Female gender 64.0 46.0
Education
<High school 27.5 46.1
Some college/trade 34.8 33.3
College graduate 21.7 8.7
Postgraduate 15.9 11.6
Relation to patient
Spouse 45.7
Son/daughter 34.3
Parent 4.3
Brother/sister 10.0
Other 5.7
Race
White 91.3
American Indian 2.9
Black 5.8
Ethnicity
Hispanic 0.0
Knowledge of health care 70.0
Hospital
Methodist Hospital 39.0
FUMC 61.0
Clinical service
Pulmonary and or medical critical care 58.6
Surgery 5.7
Surgery consultant 5.7
Family practice/internal medicine 20.0
Other 10.0
APACHE II score 25 (5)
Living will 33
Prior ICU care 58
Organ transplant! 19

Table 2—Multivariate Cox Regression of Baseline Characteristics and Prognostic Interval

Independent Variables Hazard
Ratio
Lower 95% CI Upper
95% CI
p Value
Patient age 1.00 0.98 1.03 0.88
Clinical service* 0.91 0.39 2.15 0.83
Hospitalt 0.96 0.50 1.93 0.90
APACHE II 0.98 0.92 1.04 0.45
Education, college graduate^ 0.86 0.31 2.35 0.40
Education, postgraduate^ 1.43 0.56 3.66 0.76
Previous ICU care§ 1.01 0.46 2.25 0.45
Advanced directives^ 2.02 0.88 4.63 0.10
Knowledge of health care§ 1.36 0.65 2.92 0.37

Table 3—Multiple Ordinary Least Squares Regression of Communication Rate and Baseline Characteristics

Independent Variables P Lower
95% CI
Upper
95% CI
p Value
Patient age — 0.19 — 0.05 0.01 0.22
Clinical service* — 1.01 — 1.96 — 0.07 0.04
Hospitalt — 0.85 — 1.84 0.13 0.87
APACHE II 0.01 — 0.82 0.09 0.91
Subject education — 0.10 — 0.71 0.51 0.75
Previous ICUj 0.03 — 0.98 1.04 0.96
Knowledge of health 0.28 — 0.74 1.31 0.58
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r
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Table 4—Surrogates’ Satisfaction With Physician Communication in the ICU

Variables Poor Fair Good Very Good Excellent
Frequency of communication 7.9 14 25.7 36.4 15.9
Honesty of
communication
3.3 6.1 23 31.5 36.2
Completeness of information 3.7 12.6 26.6 33.6 23.4
Subject
understanding
2.8 8 23 39.9 26.3
Consistency of information! 6.0 18 21 32 19

Table 5—Surrogates’’ Attitudes About Decision Making in the ICU

Variables %
Included in decision making?
Very excluded 6
Somewhat excluded 4
Neither 2
Somewhat included 28
Very included 60
Involved at right time?
Far too late 4
Little too late 8
Just right 82
Little too early 6
Far too early 0
Enough information?
Too little 16
Just right 81
Too much 2
Agreement in family?
Severe conflict 2
Minimal conflict 6
Neither 2
Agreement 28
Strong agreement 63
Satisfied with decision making?
Very dissatisfied 2
Somewhat dissatisfied 8
Neither 4
Mostly satisfied 51
Very satisfied 35