Can We Talk? Life-Support Decisions Take Longer When Patients, Family Don’t Discuss Treatment Wishes, Pitt Study Finds

Family caregivers who had not discussed life-support measures with critically ill patients took nearly two weeks longer to decide to forgo further medical intervention than did those who had prior conversations about the issues, according to researchers in the University of Pittsburgh’s School of Medicine and Graduate School of Public Health.

Also, a patient’s loved ones were more confident about acting as surrogate decision makers when they perceived their communication with intensive care physicians to be of high quality, said senior investigator Douglas B. White, a professor and director of the Program on Ethics and Decision Making in Critical Illness in the School of Medicine’s Department of Critical Care Medicine.

“This is the first evidence to suggest that how a doctor guides family members through the foreign territory of critical illness may influence their ability to act as a surrogate,” White said. “Teaching doctors to be better communicators may be an important step in improving end-of-life decisions for patients. The study also reinforces the value of patients, families, and friends having prior conversations about the end of life so that they can feel comfortable with their decisions about medical care.”

For the study, conducted at four intensive care units at the University of California San Francisco Medical Center between 2005 and 2008, the researchers surveyed 230 caregivers who were making decisions on behalf of incapacitated patients on ventilators with greater than a 50 percent chance of dying from their illnesses. They found that caregivers who hadn’t had a prior conversation with patients about treatment preferences were less confident about making decisions, and it took them 40 percent longer—33 days versus 21 days—to decide to discontinue life support.

“This prolongation of the dying process may not be in the best interest of patients, and it places an enormous burden on the health care system,” White said. “Health care reform will provide incentives for formal advance-care planning between physicians and patients, such as the completion of advance directives and living wills. Our findings indicate that informal conversations between patients and their families may be very important for both patient-centered decisions and the family’s comfort with the huge responsibility of being a surrogate.”

The research team shared its findings in a poster presentation at the Society of Critical Care Medicine Congress earlier this month in San Diego. The project was funded by the National Institutes of Health.