Effect of an Early Family Conference on Decreasing Futile Care in Critically Ill Patients in the ICU

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Physician Quality and Safety Academy Leading
Change to Improve Care

• Effect of an Early Family Conference on
  Decreasing Futile Care in Critically Ill Patients
  in the ICU

Khalid F. Almoosa, MD, MS Ruthie Siska, RN, MICU
Nurse Manager Bela Patel, MD, MICU
Director Katherine Luther, RN, MPM, Director,
Healthcare Improvement
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Problem futile care in the ICU

1. What is futile care?
2. Common
3. Many causes
4. Poor prognostication
5. Sensitive topic, significant effect
6. Multidisciplinary approach needed

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Dartmouth Atlas -End of Life -2006Jack Wennberg,
PhD, Elliott Fisher, PhD
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Aim

• Broad aim reduce futile care through improved
  decision-making
• Specific aim Increase family participation in
  end-of-life (decisions) via multidisciplinary
  family conferences
• Rationale better communication ? better
  decisions

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Measures of success

• of family participation in conference ( time)
• of families de-escalating care (DNR)
• ICU length-of-stay for decedents (days prior to
  death futile)

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Intervention

• Multidisciplinary family conferences within 24
  hours of patients ICU admission
• Objectives
• Discuss clinical condition
• Determine familys perspectives, patients wishes
• Make decisions on care
• Education

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Target population
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Process Map

• Identify high-risk patients
• Assemble team
• Schedule conference
• Discussion template
• Document

Introductions Discuss patient status (Dx, Px,
Tx) Determine patients wishes establish
surrogate. Answer questions Develop plan of care
make decisions Plan on future meetings
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Results

• Intervention vs. control (historical)

Control Intervention
Number of patients 264 45
Age (mean) 60.7 63.7
male 49.4 49.8
Mortality risk 3.78 3.8
DRG weight 2.35 2.91
Met Iezonni criteria 66.8 71.1
Control Intervention
family conference 27 60
Time to conference (days) 4.6 1.8
made DNR 85 98
Hospital length of stay (days) 10.6 8.3
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Results
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Challenges

• No conference room!
• Teamwork
• Communication
• Variety to clinical situations family dynamics

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What we accomplished

• Family conference part of standard of care
• ? futile care
• ? satisfaction with care
• Improved quality of EOL care
• Improved communication
• Developed process format for meetings
• Education for trainees

• LOS 2.3 days
• Costs gt 5 day group (80)
• Avoided 184 days
• saved 847,504

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Lessons Learned

1. No silver bullet!
2. Dont know what we dont know
3. Communication is not easy!
4. Focusfocusfocus
5. Structure intervention (details)
6. Successes failures
7. Re-evaluatefeedbackrevise
8. Not everyone on board
9. More ideas
10. Benefit to intervention more than expected!

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For the secret to the care of the patient is in
caring for the patient. - Dr. Francis W.
Peabody