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

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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.