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
Problem: futile care in the ICU
1.
2.
3.
4.
5.
6.
What is futile care?
Common
Many causes
Poor prognostication
Sensitive topic, significant effect
Multidisciplinary approach needed
Dartmouth Atlas -End of Life -2006
Jack Wennberg, PhD, Elliott Fisher, PhD
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
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)
Intervention
• Multidisciplinary family conferences within 24
hours of patient’s ICU admission
• Objectives:
1.
2.
3.
4.
Discuss clinical condition
Determine family’s perspectives, patient’s wishes
Make decisions on care
Education
Target population
MICU Mortality Histogram by LOS
Jan 07- Jan 09
70
60
50
40
Focus Area:
Length of Stay 2-14 days
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Length of MICU stay in days
Process Map
MICU Family Conference Process
•
•
•
•
•
Identify high-risk patients
Assemble team
Schedule conference
Discussion template*
Document
Introductions
Discuss patient status (Dx, Px, Tx)
Determine patient’s wishes & establish
surrogate.
Answer questions
Develop plan of care & make decisions
Plan on future meetings
Patient assessed
for high risk of
death
No
Criteria met
Yes
Family conference
scheduled by
Nurse Manager/
Charge Nurse
Family conference
held following
defined format
Additional follow
up conference
scheduled as
needed
No
Decision making
and plan of care
agreed upon
Yes
Results
documented in
chart
Plan of care implemented
Results
• Intervention vs. control (historical)
Control
Intervention
Number of patients
264
45
Age (mean)
60.7
63.7
49.4%
49.8%
Mortality risk
3.78
3.8
DRG weight
2.35
2.91
66.8%
71.1%
% male
Met Iezonni criteria*
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
Results
Challenges
•
•
•
•
No conference room!
Teamwork
Communication
Variety to clinical situations & family dynamics
What we accomplished
• Family conference = part of standard of care
LOS 2.3 days
•  futile care*
Costs: > 5 day group (~80)
Avoided 184 days
•  satisfaction with care
saved $847,504
– Improved quality of EOL care
• Improved communication
• Developed process & format for meetings
• Education for trainees
Lessons Learned
1. No silver bullet!
2. Don’t know what we don’t know
3. Communication is not easy!
4. Focus…focus…focus…
5. Structure intervention (details)
6. Successes & failures
7. Re-evaluate…feedback…revise
8. Not everyone on board
9. More ideas
10.Benefit to intervention = more than expected!
“…For the secret to the care of the
patient is in caring for the patient.”
- Dr. Francis W. Peabody