Monday, July 11, 2016

JAMA Got It Wrong: Giving Prognostic Information to Families of Critically Ill Patients Is Not the Same as Palliative Care

by Elizabeth Lindenberger

I know I am not alone in my disappointment this week with the authors’ conclusions in “Effect of Palliative Care-Led Meetings for Families of Patients with Critical Illness: A Randomized Clinical Trial.” The study intervention involved the provision of an informational brochure and two focused meetings specifically designed to provide families with information about prognosis. The study found no difference in most outcomes between usual care and the intervention, and PTSD symptoms were in fact increased in the intervention group. The authors concluded that "these findings do not support routine or mandatory palliative care–led discussion of goals of care for all families of patients with chronic critical illness.” What? How does this very specific, targeted intervention that deviates dramatically from usual palliative care practice become equated with palliative care?

As a palliative care physician at Mount Sinai, I participated in this study. I am not surprised by the negative results. These family meetings were highly scripted, designed to provide information about prognosis, and rarely involved the primary team. The study had great potential to make a contribution to the practice of critical care medicine, specifically to answer the question of whether offering prognostic information earlier in the critical illness trajectory could benefit patients and families. However, the study was designed such that the informers were not the patients' treating physicians. In fact, ICU team physicians participated in only 3-8% of meetings. Palliative care providers were chosen to given the information because of their expertise in communication. And yet nothing about the intervention resembled a standard palliative care intervention, which would have involved the entire IDT, multiple meetings for relationship building, information provided only when welcomed by the family, and the 100% presence of the ICU treating team at the meetings.

I remember back to one particularly distressing family meeting spent managing a family member’s anger at what to them was shocking, new information about prognosis provided in the study brochure. This family was not ready to receive information about prognosis, especially without their primary team present. This is not standard palliative care. Again, I believe this study was bold and important in testing a specific information-giving intervention for a vulnerable patient population at high risk for unwanted overtreatment and suffering.  It is the study’s conclusions that are flawed, and I worry about their potential for depriving critically ill patients and their families from the benefits of true gold standard palliative care.

Elizabeth Lindenberger, MD, is a palliative care physician and program director for the Hospice and Palliative Medicine Fellowship at the Icahn School of Medicine at Mount Sinai in New York. This is her first Pallimed post.

(For more opinion on this JAMA article please see Alex Smith's post at Geripal - Ed.)

Photo Credit: @ismaelnieto

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