Improving Patient and Family Centered Care in Advanced Critical Illness

One in five deaths in the U.S. occurs in or shortly after discharge from an intensive care
unit (ICU), typically following decisions made by surrogate decision makers to forego life
prolonging treatment. A large body of empirical research has identified deficiencies in care
processes that contribute to three important problems: 1) family members often experience
poor quality communication with ICU clinicians, leading to lasting psychological distress
associated with the ICU experience; 2) patients near the end of life frequently receive
invasive, expensive treatment that is inconsistent with their values and preferences, and 3)
end-of-life care is a major contributor to health care costs.[8, 9] Although advance care
planning can prevent some unwanted treatment, many patients wish for a trial of intensive
treatment when the prognosis is uncertain, and therefore it seems likely that the need for
interventions to improve "in-the-moment" decisions by surrogates will persist.[10, 11]

In a pilot project, the investigators developed the PARTNER intervention (PAiring
Re-engineered ICU Teams with Nurse-driven Emotional Support and Relationship-building), an
interdisciplinary intervention that 1) gives new responsibilities and advanced communication
skills training to existing ICU staff (local nurse leaders and social work members of the ICU
team); 2) changes care "defaults" to ensure frequent clinician-family meetings; and 3) adds
protocolized, nurse-administered coaching and emotional support of surrogates before and
during clinician-family meetings. The objective of this proposal is to conduct a stepped
wedge randomized controlled trial testing the PARTNER intervention in 5 ICUs among 1000
patients with advanced critical illness and their surrogates.