ARTICLE: Looking Beyond the Tip of a Tusk: Balancing the Evidence in Prognosis-related Communication.

AUTHORS: Rebecca A Aslakson and Mary Catherine Beach

JOURNAL: Am J Respir Crit Care Med. 2017 May 16. doi: 10.1164/rccm.201704-0851ED. [Epub ahead of print]

Evidence supports a poor prognosis for patients with chronic critical illness; 30- 40% die prior to hospital discharge, and another 40% die within one year of hospital discharge [1,2]. Among one-year survivors of chronic critical illness, 90% report being dependent on others for Activities of Daily Livings and instrumental Activities of Daily Living [3]. Caregivers therefore also suffer a high prevalence of detrimental mood symptoms [4] and more than three-quarters either cut back or stop work altogether due to the demands of caregiving [3]. In summer of 2016, Carsons et al reported the outcomes of their clusterrandomized controlled trial where palliative care-trained physician or nurse communicators were tasked with communicating prognosis to surrogates of patients with chronic critical illness [5]. The group hypothesized that skilled proactive communication would decrease mood symptoms among surrogates. Although no differences were found in the primary outcome of mood symptoms, the study found an increase in a secondary outcome of surrogate post-traumatic stress disorder associated with the intervention. While discussed in a detailed commentary [6], study findings remain debated and controversial [7]. In this issue of AJRCCM, the study authors present the concurrently completed qualitative work. [8] In this current study, 66 prognosis-related conversations between 51 surrogates and 33 palliative care clinicians (23 physicians and 10 nurse practitioners) concerning 43 chronically critically ill patients were audiorecorded and analyzed Page 2 of 8 AJRCCM Articles in Press. Published on 16-May-2017 as 10.1164/rccm.201704-0851ED Copyright © 2017 by the American Thoracic Society using grounded theory. Study authors found 6 domains of surrogate reactions to prognosis-related communication. Two domains were practical – “mobilization of support” and “consideration of surrogate role”. Two domains involved surrogate processing of information – “emotion” and “characterization of patient”. The final two domains described specific surrogate reactions and were innately contradictory – “receptivity” to, and “deflection/rejection” of, prognosis-related information.

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