Pasricha Venu, Gorman Diane, Laothamatas Kemarut, Bhardwaj Abhishek, Ganta Niharika, Mikkelsen Mark E
Penn Presbyterian Medical Center, Philadelphia, Pennsylvania.
Cleveland Clinic, Cleveland, Ohio; and.
ATS Sch. 2020 Mar 18;1(2):119-133. doi: 10.34197/ats-scholar.2019-0006OC.
: International family-centered critical care guidelines recommend formal, structured communication to ensure that clinical decision making is informed by a shared understanding of diagnosis and prognosis and patient goals and preferences. Tools to facilitate these recommendations are limited. : To examine the feasibility, acceptability, and utility of a standardized serious illness conversation (SIC) to guide communication between nonpalliative care trained providers and surrogates of critically ill, mechanically ventilated patients. : After providers received training, including simulation, we implemented SIC in October 2018. A total of 11 hospitalist providers were eligible to perform SICs over the study interval. Providers met in person with surrogates of adult, mechanically ventilated patients in the medical intensive care unit within 48 hours of intubation. To determine acceptability, surrogates were surveyed 2 months after SIC completion, and providers were surveyed between June and July 2018. To determine feasibility and utility, two independent investigators reviewed SIC documentation and coded responses into categories. : Of 72 eligible patients, advanced care planning documentation was completed in 50 patients, including 36 SICs, for an advance care planning completion rate of 69% and an SIC completion rate of 50%. The average SIC was completed in 30 minutes, 3 days after intubation. Of the 19 surrogates surveyed, 95% found the SIC to be mostly or extremely worthwhile. Nine of 11 hospitalist providers completed the follow-up survey. Each of the nine providers who completed the survey found the guide valuable to patient care and easy to administer. The conversation yielded valuable information in terms of goals, fears, and worries; sources of strength; abilities critical to the patient; and understanding how much the patient would be willing to go through for the possibility of gaining more time. : We found that implementation of a structured communication tool in the intensive care unit was feasible and acceptable to surrogates and providers; yet, fidelity to the timing and completion was modest. The tool appeared to yield valuable information for understanding the goals, fears, and care preferences of mechanically ventilated patients. Steps to increase fidelity, in accordance with family-centered care guidelines, are warranted.
国际以家庭为中心的重症监护指南建议进行正式、结构化的沟通，以确保临床决策基于对诊断、预后以及患者目标和偏好的共同理解。促进这些建议实施的工具有限。
为检验标准化重症疾病谈话（SIC）指导未经姑息治疗培训的医护人员与重症机械通气患者代理人之间沟通的可行性、可接受性和实用性。
在医护人员接受包括模拟培训在内的培训后，我们于2018年10月实施了SIC。在研究期间，共有11名住院医师有资格进行SIC。医护人员在插管后48小时内与医学重症监护病房中成年机械通气患者的代理人进行面对面交流。为确定可接受性，在SIC完成2个月后对代理人进行调查，并在2018年6月至7月期间对医护人员进行调查。为确定可行性和实用性，两名独立研究人员审查SIC文件并将回复分类编码。
在72名符合条件的患者中，50名患者完成了高级护理计划文件，其中包括36次SIC，高级护理计划完成率为69%，SIC完成率为50%。SIC平均在插管后3天、30分钟内完成。在接受调查的19名代理人中，95%认为SIC非常或极其有价值。11名住院医师中有9名完成了后续调查。完成调查的9名医护人员均认为该指南对患者护理有价值且易于实施。谈话在目标、恐惧和担忧；力量来源；对患者至关重要的能力；以及了解患者为获得更多时间愿意承受的程度等方面产生了有价值的信息。
我们发现，在重症监护病房实施结构化沟通工具对代理人和医护人员来说是可行且可接受的；然而，在时间安排和完成情况方面的依从性一般。该工具似乎为了解机械通气患者的目标、恐惧和护理偏好提供了有价值的信息。有必要按照以家庭为中心的护理指南采取措施提高依从性。
