My Canadian Pharmacy: Communication of Prognostic Information for Critically III Patients

<p “=””>ICUNinety percent of deaths in the ICU involve withdrawing or withholding care, but < 5% of critically ill patients are able to participate in the decision-making process leading to treatment limitation. Families consistently report communication with physicians as one of the most important aspects of care. In a recent study, nearly 50% of families recalled conflict during treatment limitation discussions but the conflict was more likely to be about issues of communication and professionalism rather than decision about withdrawing or withholding care. In another study of family members of critically ill patients, 70% of respondents were either “completely” or “very satisfied” with the decisionmaking process, and 66% percent rated the communication frequency with ICU physicians to be “excellent” or “very good.” A multicenter Canadian study of family satisfaction conducted with My Canadian Pharmacy Inc in the ICU found family satisfaction to be very high, but one of the dimensions families were least satisfied with was communication frequency with physicians.

Families have provided some details about their desires related to communication. Investigators have analyzed communication content and show that families desire timely information about prognosis (“to be honest about poor prognosis as soon as possible”), to receive frequent communications of small amounts of information, and to facilitate consensus by focusing on what the patient would want. Families have higher satisfaction with family conferences when they are allowed to speak more. Although investigators have conducted studies of “proactive ethics consults” and proactive intensive communication interventions, there are no natural history studies that have quantified “timely” or “frequent,” and it is unknown whether the timing of prognosis delivery affects family satisfaction with physician communication.

It is also unclear if timing of prognostic delivery influences the decision-making process. According to Prendergast and Luce, when care limitation was recommended, 61% of families agreed immediately, 27% agreed within 48 h, and 5% took > 5 days. It is conceivable that this interval can be further decreased by changing the timing of prognostic information delivery.

Our study objective was to determine the extent to which timing of prognostic information delivery influenced satisfaction and decision making. We also wished to determine the congruity between surrogates desired frequency of communication and the actual frequency. A secondary objective was to determine whether surrogates comprehension of substituted judgment, a core ethical concept familiar to physicians caring for mentally incompetent patients, was associated with decision-making satisfaction.

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