乌鸦传媒

SAN DIEGO -- A nurse-led intervention designed to reduce anxiety and depression among the surrogates of patients in intensive care units (ICUs) failed to show an effect on these psychological conditions, but the intervention did improve other outcomes, researchers reported here.

In the PARTNER (Pairing Re-Engineered ICU Teams with Nurse-Driven Emotional Support and Relationship Building) study, the 6-month score on the Hospital Anxiety and Depression Scale was 11.7 among surrogates in the intervention group and 12.0 among patient surrogates who were given usual care (P=0.61), reported Douglas White, MD, of the University of Pittsburgh Medical Center.

However, the intervention did improve communication between the medical unit and surrogates and was associated with a shorter length of stay of patients in the ICU, he said at the American Thoracic Society annual meeting. The study was simultaneously published online in the .

"One in five Americans die in or shortly after discharge from an ICU – typically when a loved one decides to forego life-prolonging therapies. That difficult decision can be made unnecessarily stressful when there are problems with communication between a patient's family and their care team," said White. "PARTNER helps the clinical team establish relationships and provide support to the family well before decisions have to be made about goals of care."

PARTNER is delivered by the interprofessional team in the ICU, consisting of nurses, physicians, spiritual care providers, social workers, and others involved in patient care. The program is overseen by nurse leaders in each ICU, who receive 12 hours of training in advanced communication skills to support families. The nurses meet with the families daily and arrange interdisciplinary clinician-family meetings within 48 hours of a patient coming to the ICU. A quality-improvement specialist helps incorporate the family support intervention into the clinicians' workflow.

White explained that to test the effectiveness, PARTNER was rolled out at five University of Pittsburgh Medical Center ICUs with different patient populations and staffing. The program was implemented in a staggered fashion so that every participating ICU would eventually get the program. Before starting, none of the ICUs had a set approach to family communication or required family meetings at regular intervals.

The researchers enrolled 1,420 adult patients in the trial, with 1,106 family members agreeing to be a part of the study and the 6-month follow-up surveys. The patients were very sick, with about 60% dying within 6 months of hospitalization and less than 1% living independently at home at that point.

Families who participated in the intervention were more likely to report that their loved one received patient-centered care -- defined as where the patient's comfort, emotional well-being, beliefs, and cultural needs were respected and guided clinical actions. Of those receiving PARTNER, 79.2% of the family members scored their loved one's care in the highest patient-centeredness category, compared with 63.2% of those who received usual care, White reported.

"We also observed a slightly higher rate of in-hospital mortality, which came with families reporting more patient-centered care and better communication. This was likely because the intervention supported families in determining what goals of care were most respectful to the patient as a person in the setting of very advanced illness."

In an accompanying the study in the NEJM, Daniela Lamas, MD, of Brigham & Women's Hospital/Harvard Medical School in Boston, said the results reflect a "profound shift for critical care, which has historically measured its victories in terms of the number of patients who are living, regardless of what that life looks like."

The new findings "offer a harsh reality that complicates the definition of success," she continued. "It may be possible that providing better care for the most seriously ill patients means that those patients do not live as long. As we increasingly look beyond mortality as the primary outcome that matters, seeking to maximize quality of life and minimize suffering, this work represents and 'end to the beginning' by suggesting the next steps in moving closer to achieving those goals."