A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay

Objective: To assess the effect of proactive ethics consultation on documented patient care communications and on declsions regarding high-risk intensive care unit (ICU) patients. Design: Prospective, controlled study. Patients: Ninety-nine ICU patients treated with >96 hrs of continuous mechanical ventilation. Interventions: Three groups were compared: a) a baseline group enrolled in the study prior to the establishment of the hospital's ethics consultation service; b) a control group where ethics consultation was at the option of the care team; and c) a treatment group where the ethics service intervened proactively after patients received >96 hrs of continuous mechanical ventilation. Patient care planning, for subjects in the proactive group, was reviewed with physicians and with the care team using a standardized set of prompting questions designed to focus discussion of key decision-making and communication issues for critically and terminally ill patients. Issues and concerns were identified and action strategies were suggested to those in charge of the patient's care. Formal ethics consultation, using a patient care conference model, was made available upon request. Measurements and Main Results: Post discharge chart reviews of the three groups indicated no statistically significant differences on important demographic variables including age, gender, and acuity. Comparisons of survivors and nonsurvivors for the three groups indicated, at statistically significant levels, more frequent and documented communications, more frequent decisions to forgo life-sustaining treatment, and reduced length of stay in the ICU for the proactive consultation group. Conclusion: Proactive ethics consultation for high-risk patient populations offers a promising approach to improving decision-making and communication and reducing length of ICU stay for dying patients. (Crit Care Med 1998; 26:252-259) Among the most challenging situations for which ethics is the difficult decision to forgo life-sustaining treatment for the critically and terminally ill. These end-of-life decisions have been complicated by a technological imperative which often drives decisions to continue treatment, despite the considerable burdens of prolonging suffering and death, of emotional and family debilitation, and of financial expense 1. When the prognosis is considered dismal, some physicians may avoid talking with patients or families about forgoing life-sustaining treatments; others may inhibit dialogue by cloaking recommendations in objective sounding medical jargon; and a few may circumvent dialogue by asserting their authority to unilaterally withhold or withdraw treatment, justifying their decision by appeals to medical futility 2. The largest study 3 examining the efforts to improve physician-patient communication and advance planning for critically ill patients reported discouraging results. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) 3 provided corroborative evidence of what many fear is typical of the treatment of hospitalized critically and terminally ill patients, namely, poor communication between physician and patient, poor pain management, avoidance of discussions about prognosis or about cardiopulmonary resuscitation, and failure to understand patient preferences. However, the intervention designed by SUPPORT 3 investigators to alter physician behaviors, through improved communication and understanding of prognoses and patient preferences, had no impact on important dimensions of care for critically and terminally ill patients. In particular, it failed to reduce the period of time that dying patients spent in the intensive care unit (ICU), in coma, or on mechanical ventilation. Criticism of the study's intervention pointed to the physician's reliance on nurses and computer-generated information as methods for improving physician communication and understanding 4. A more intimate, dynamic communication between patient and physician was not prompted by the provision of more data, which many of the physicians failed to read. In the present study, we focused on the use of proactive ethics consultation as a process-oriented intervention for improving communication and decision-making between physicians, patients, and the full care team. Zawacki and others 5-7 have argued that difficult decisions to forgo life-sustaining treatment require close attention to the processes of communication surrounding a particular patient's plan of care. These authors 5-7 proposed using a “counseling” or “educational” model of ethics consultation provided proactively in anticipation of difficult choices. The focus of consultation is on increasing dialogue between physicians and patients, heightening attention to whatever is perceived as problematic, encouraging questions, helping persons to challenge one another, removing obstacles to communication, and seeking the cooperation necessary to reach “a mutually beneficial outcome from informed consensus or compromise” 3. We selected this strategy during our hospital's participation in the Decisions-Near-the-End-of-Life (DNEL) program which had provided a subset of our staff with ethics education and then challenged us to develop concrete action steps to improve terminal care. The DNEL model 8 encourages multidisciplinary communication among all members of the healthcare team, planning in advance for crises, and a process-oriented approach to change which calls for active participation of inhouse leadership teams. Our medical staff strongly urged us to design a prospective study aimed at changing patterns of communication and decision-making among physicians and all involved in the patient's care. We assumed that clinical situations at risk of becoming ethically problematic could be identified in advance and that interventions could be made before indecision and frustrations have had time to ferment. Early intervention in high-risk cases may help develop psychologically and ethically functional discussions of what constitutes the limits of care for a particular patient when that patient's treatment response raises issues about what is an appropriate level of care. In particular, we hypothesized that ethics consultation provided proactively to high-risk mechanical ventilation patients would increase documented communication between physicians, patients, and the clinical team regarding important features of end-of-life decisions. Taking the perspective that communication is a critical process variable affecting the timeliness of decision-making, we also hypothesized that increased communication would promote decisions to forgo life-sustaining treatment for dying patients, for those without hope of recovery, and for those patients whose preferences directed a lower level of care. If these end-of-life decisions increased in frequency and timeliness, we expected to observe a reduction in average length of stay in the ICU.