Monday, July 10, 2006

Missed opportunities in ICU conferences

A couple from my backlog...

1) Clinical Medicine recently devoted an issue to palliative care (well, at least a CME section of an issue). It has several general review articles about pain management, nausea & vomiting, psychological issues in palliative care, and cancer cachexia and fatigue. The articles are all well written & reasonable, but quite basic, and one doesn't know whether to be happy that CM is devoting an entire issue to palliative care or depressed that this basic level of information is what the general medical reader is in need of. Could make good teaching materials for medical students, basic pall care talks, etc., though.

2) The American Journal of Respiratory and Critical Care Medicine published a piece about missed opportunities during family conferences about end of life issues in the ICU (free full-text here--it was actually published last year but only recently was indexed as a palliative care article by Medline which is why I read it only recently). It involves analyses of audiotapes of ~50 ICU family conferences involving breaking bad news or discussions about life-prolonging treatment limitations (these 50 conferences were about half of those that were screened for the study--the remainder were excluded because the family declined participation, etc.). The authors analyzed the tapes for 'missed opportunities' in the conferences. A couple things about this. One, they found that ~30% of conferences had a missed opportunity of one sort or the other ( e.g. physician not responding to family member emotion; not answering a question, etc.). This strikes me as a low number and either the ICU docs studied are very thorough or the authors are missing some, um, missed opportunities. Which bring me to point two, which is that by their methods they seemed to not have decided upon strict criteria to define a 'missed opportunity.' Instead it appears that they first flagged the missed opportunities, after deciding to look for them, and then analyzed them to determine what were their character (ie, how many involved not sharing asked for information). My point here is that this methodology is adequte for helping the authors define and characterize missed opportunities (which was their major goal), but not identify their frequency. This is all fine, and I hope they continue to develop this concept as in my experience they are exceedingly and flagrantly common in family meetings and similar communications in & out of the ICU and an interesting thing to study.

This group appears to have been developing a conceptual framework for studying ICU goal setting and breaking bad news conferences (this article describes their overall project and methods).

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