Association between communication quality during ICU Family Meetings and Patient Health Outcomes

摘要 重症监护室（ICU）患者的家属面临着生死抉择，这种经历是 压力很大，可能导致不良的心理健康结果。临床医生沟通不良 加重代理人的压力，阻碍决策，损害对临床医生的信任，并对医院征税 资源多项大型、严格的随机对照试验未能成功降低 代理人的社会心理困扰虽然心理测量学上健全的问卷测量沟通 质量，他们可能无法捕捉动态的细微差别，在那一刻的通信质量和依赖 自我报告。因此，需要有理论基础的，严谨的，客观的沟通 评估，以更好地评估传播干预措施，并阐明未来有希望的方向 干预措施。本项目的目标是应用一种创新的、理论驱动的方法来评估 通信质量分析（CQA），以最大的已知数据集的音频记录 ICU家庭会议（R 01 HL 094553）。CQA是由联合PI货车Scoy和Scott开发的一种新方法 这是基于多重目标理论的。该方法假设临床沟通涉及三个 目标类型：任务（例如，制定以患者为中心的护理决策目标），关系（例如，申明 临床医生-家庭关系），和身份（例如，尊重他人）。高质量的沟通发生在 注意力集中在所有目标上;当任何一个目标被忽视时，沟通质量就会降低。不像许多 沟通措施，无论是自评问卷或检查表，评估如果沟通 行为发生时，CQA使用客观评级来评估目标实现的程度和程度。 我们之前的工作（R21 NR 017259）确定了在以下情况下使用CQA的有效性、可行性和可靠性： 评估模拟的临床医生-患者接触。下一步是将分析应用于大型数据集 它包括来自美国13个ICU的244个录音家庭会议， 注意并检查CQA评分是否与关键健康结果相关。具体而言，我们的目标是： 1：描述ICU家庭会议期间如何实现多个沟通目标， 将沟通质量分析应用于护理讨论的目标。当这一目标实现时， ICU期间任务、关系和身份目标实现程度的第一个表征 家庭会议。目的2：评估CQA评分是否通过直接效应或 介导的间接作用：治疗联合（即，代理人对医生的信任），决策 结果（即，决策冲突），和ICU利用（即，住院时间、插管持续时间）。如果成功， 这项研究将建立关于临床医生如何在家庭治疗期间关注理论衍生目标的基本知识， 会议，以及这一目标的关注是否与关键的健康结果有关，这一点特别重要 在一个被负面试验困扰的领域促进有效的干预发展。

ABSTRACT Family members of patients in the intensive care unit (ICU) face life and death decisions, an experience that is highly stressful and may lead to poor psychosocial health outcomes. Poor clinician communication exacerbates surrogates’ stress, impedes decision-making, damages trust in clinicians, and taxes hospital resources. Multiple large, rigorous, randomized controlled trials have been unsuccessful in reducing psychosocial distress of surrogates. While psychometrically sound questionnaires measure communication quality, they may fail to capture the nuance of dynamic, in-the-moment communication quality and are reliant on self-report. Thus, there is a need for a theoretically-grounded, rigorous, and objective communication assessment to better evaluate communication interventions and to shed light on promising directions for future interventions. The goal of this project is to apply an innovative, theory-driven method for assessing communication called Communication Quality Analysis (CQA), to the largest known dataset of audio-recorded ICU family meetings (R01HL094553). CQA is a novel methodology developed by co-PIs Van Scoy and Scott that is grounded in Multiple Goals Theory. The method assumes that clinical communication involves three types of goals: task (e.g., making patient-centered goals of care decisions), relational (e.g., affirming the clinician-family relationship), and identity (e.g., respecting others). High quality communication occurs when attention is given to all goals; low quality communication occurs when any goal is ignored. Unlike many communication measures that are either self-rated questionnaires or checklists that assess if a communication behavior occurs, CQA uses objective ratings to assess how well and the extent to which goals are achieved. Our previous work (R21NR017259) established the validity, feasibility, and reliability of using CQA in evaluating simulated clinician-patient encounters. The next step is to apply the analysis to a large dataset which consists of 244 audio-recorded family conferences from 13 ICUs across the US to characterize goal attention and examine if CQA scores are associated with key health outcomes. Specifically, our aims are: Aim 1: To characterize how multiple goals of communication are attended to during ICU family conferences by applying Communication Quality Analysis to goals of care discussions. When this aim is achieved, it will yield the first characterization of the extent to which task, relational, and identity goals are achieved during ICU family meetings. Aim 2: To assess if CQA scores are associated with outcomes through direct effects or mediated indirect effects on: therapeutic alliance (i.e., surrogate’s trust of physicians), decision-making outcomes (i.e., decisional conflict), and ICU utilization (i.e., length of stay, duration of intubation). If successful, this study will build essential knowledge about how clinicians attend to theory-derived goals during family meetings and whether this goal attention is associated with key health outcomes, which is especially important for facilitating effective intervention development in a field plagued by negative trials.