A multicenter, ethnographic study of interprofessional support for families facing goals of care decisions in intensive care units.

RATIONALE: Professional society guidelines recommend interprofessional support for families facing goals-of-care decisions in intensive care units (ICU). However, there is limited knowledge about whether this occurs and how best to achieve it. OBJECTIVES: We sought to characterize the current nature of, barriers to, and suggestions for interprofessional support for surrogates in ICUs. METHODS: We conducted a multi-method ethnographic study, including direct observation and semi-structured interviews with interprofessional ICU team members in four hospitals. Our conceptual approach combined elements of the Implementation Outcomes Framework and the COM-B model. We used an inductive thematic analysis approach with findings organized into previously identified, theory-derived domains of teamwork. RESULTS: Between March 2021 and December 2023, we conducted 133 hours of observations and 53 interviews with ICU team members such as physicians, nurses, and social workers. Although participants endorsed the value of interprofessional support during interviews, ethnographic observation revealed numerous shortcomings in actual practice. Nurses, social workers, and chaplains were not frequently invited to family meetings, and there was low involvement of social workers and chaplaincy in longitudinal family support. Barriers to interprofessional support included insufficient role clarity, physician-leader inclusiveness, valuing of psychosocial support of families in addition to informational support, psychological safety, training among non-physicians, team member availability, and standardized care processes. Participants made suggestions for improvement, including establishing organizational expectations for the structure and content of interprofessional support, increasing psychological safety and role clarity, training in serious illness communication, and promoting leader inclusiveness. CONCLUSIONS: We identified numerous shortcomings in interprofessional support for surrogate decision-makers in the ICUs across multiple domains of effective teams. Organizations can improve interprofessional support by clarifying roles and increasing visibility of non-physician team members, providing opportunities for communication and coordination of support through enhanced routines such as pre-rounds huddles or pre-family meeting huddles as well as improved documentation of support, providing specialty communication training, improving psychological safety, developing family support protocols, and altered staffing models. This would involve targeting multiple levels for behavior change-individual, team, and organizational.