Medical Manuscript

Palliative Care in Critical Care Settings:

A Systematic Review of CommunicationBased Competencies Essential for Patient
and Family Satisfaction

American Journal of Hospice

& Palliative Medicine
1-9
The Author(s) 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1049909116667071
ajhpm.sagepub.com

Andrew W. Schram, MD, MBA1, Gavin W. Hougham, PhD2,

David O. Meltzer, MD, PhD3,4, and Gregory W. Ruhnke, MD, MS, MPH3

Abstract
Background: There is an emerging literature on the physician competencies most meaningful to patients and their families.
However, there has been no systematic review on physician competency domains outside direct clinical care most important for
patient- and family-centered outcomes in critical care settings at the end of life (EOL). Physician competencies are an essential
component of palliative care (PC) provided at the EOL, but the literature on those competencies relevant for patient and family
satisfaction is limited. A systematic review of this important topic can inform future research and assist in curricular development.
Methods: Review of qualitative and quantitative empirical studies of the impact of physician competencies on patient- and
family-reported outcomes conducted in accordance with the Preferred Reporting Items for Systematic reviews and MetaAnalyses guidelines for systematic reviews. The data sources used were PubMed, MEDLINE, Web of Science, and Google
Scholar. Results: Fifteen studies (5 qualitative and 10 quantitative) meeting inclusion and exclusion criteria were identified.
The competencies identified as critical for the delivery of high-quality PC in critical care settings are prognostication, conflict
mediation, empathic communication, and family-centered aspects of care, the latter being the competency most frequently
acknowledged in the literature identified. Conclusion: Prognostication, conflict mediation, empathic communication, and
family-centered aspects of care are the most important identified competencies for patient- and family-centered PC in critical
care settings. Incorporation of education on these competencies is likely to improve patient and family satisfaction with EOL care.
Keywords
palliative care, critical care, prognostication, conflict mediation, empathic communication, family-centered aspects of care, patient
satisfaction

Introduction
Much has been written about interventions that impact the
quality of palliative care (PC) in the intensive care unit (ICU).1
Most studies of these interventions focus on how they affect
resource utilization, mortality, and quality metrics defined by
the Robert Wood Johnson Foundation (RWJF) Critical Care
Workgroup that focuses on processes of care. These quality
metrics are dimensions of patient- and family-centered
decision-making, communication within the team and with
patients and family, continuity of care, emotional and practical
support for patients and family, symptom management and
comfort care, spiritual support for patients and family, and
emotional and organizational support for clinicians.2
Systematic reviews have evaluated PC interventions in the
ICU and postgraduate PC curricula as well as competency in
clinical care important for the delivery of high-quality PC.1,3-5
Quality of care related to technical aspects of clinical care, such

as effective treatment and symptom control, is clearly important for high-quality PC. However, there has been no review of
studies evaluating the physician competency domains outside
these technical aspects of clinical care most important for

Department of Internal Medicine, Rush University Medical Center, Chicago,

IL, USA
2
Battelle Memorial Institute, Seattle, WA, USA
3
Section of Hospital Medicine, Department of Medicine, University of Chicago,
Chicago, IL, USA
4
Center for Health and the Social Sciences, University of Chicago, Chicago, IL,
USA
Corresponding Author:
Gregory W. Ruhnke, MD, MS, MPH, Section of Hospital Medicine, Department
of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 5000,
Chicago, IL 60637, USA.
Email: gruhnke@medicine.bsd.uchicago.edu

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

American Journal of Hospice & Palliative Medicine

2
patient- and family-centered outcomes in the ICU at the end of
life (EOL). A review of knowledge regarding the competencies
necessary for high-quality patient- and family-centered care
specifically focusing on communication skills at the EOL may
provide a stronger framework for care delivery and the training
of physicians and other clinicians.
The aforementioned quality metrics are process measures
that are likely to be associated with improved patient and family experience at the EOL. However, these measures have significant limitations. 2 Recent research also suggests that
adherence to these technical aspects of care does not always
correlate with patient satisfaction.6 In particular, the simple
occurrence of communication with patients and their families,
such as that would typically occur in the content of a family
conference, does not measure the quality of the communication. The competencies targeted by this review may be critical
complements to the process measures identified by the European Association for Palliative Care7,8 (EAPC) and the RWJF
Critical Care Workgroup2 and may provide direction for future
iterations of these measures.

a language other than English. Given that the literature in this

area is relatively sparse, we chose to exclude study quality (eg, a
specific sample size, only randomized controlled trials) as a
component of our study identification strategy.

Inclusion Procedure
We selected articles for inclusion using a 2-step procedure.
First, we screened all abstracts retrieved through the specified
search for eligibility based on the inclusion and exclusion criteria stated above. Second, we evaluated in their entirety all
articles that were deemed relevant through the initial screen
and articles whose abstracts did not contain sufficient information to make a determination. Articles that met the inclusion
criteria resulting from this second full-text screen were
included in this review. Two investigators (A.W.S. and
G.W.H.) independently performed the reviews, with the 4 disagreements independently adjudicated by a third investigator
(G.W.R.).

Results
Methods
We conducted this systematic review of qualitative and quantitative studies in accordance with the Preferred Reporting
Items in Systemic Reviews and Meta-Analyses guidelines, an
evidence-based method of ensuring that a minimum set of
studies with a given set of characteristics are evaluated and
reported in systematic reviews.9

Search Strategy
We performed a structured search of PubMed and the Web of
Science using the following key search terms: palliative care,
medical futility, intensive care, critical care, critical illness,
communication, empathy, decision making, shared decisionmaking, prognosis, conflict, support, prognostication, patient
satisfaction, family satisfaction, and satisfaction (see Appendix
A for full search syntax).
We identified additional relevant publications by formally
reviewing the bibliographies of articles identified in the aforementioned search as well as by performing a forward-looking
citation search in Google Scholar through which we reviewed
all articles cited by the most recent (2009) narrative review
article covering a similar literature.10

Inclusion and Exclusion Criteria

The inclusion criteria were deliberately broad to capture the
emerging topic of physician competencies necessary for PC in
the ICU outside clinical decisions themselves. Articles selected
for inclusion were original research (not reviews or commentaries) that identified such physician competencies thought to
impact patient and/or family satisfaction. Studies of the identified competencies that did not include measures of satisfaction
were excluded. We excluded case reports and all publications in

Our structured database search, depicted in Figure 1, yielded

142 articles, including 123 unique references. Twenty-seven
additional articles were also selected for first-stage review
based on the bibliographic and forward-looking search strategies described above, yielding a total of 150 unique articles. Of
these, we selectively conducted second-stage, full-text reviews
of 36 articles identified as potentially relevant based on the
abstract. Through this process, we selected 15 articles for inclusion in this systematic review, which are shown in Table 1.
We identified 4 competency domains necessary for clinicians to provide high-quality PC in the ICU: prognostication,
conflict mediation, empathic communication, and familycentered aspects of care.
PrognosticationThe ability to effectively communicate
prognostic information to patients and family
members.
Four studies explicitly concluded that prognostication was
an essential competency for physicians managing EOL decisions in the ICU. Families understand that prognostic information is imperfect but expect and desire that the best available
information be shared by the patients physicians. Effective
communication of prognostic information is important to
patients and designated surrogates11 and is the foundation of
many important clinical decisions in the ICU.13 Even with all
that is known about prognostic uncertainty and the variable
desire across families to discuss prognosis in detail, patient and
families still expect conversations regarding prognosis.23
Although patients and families expect conversations about
prognosis to occur, physicians often do not discuss it with
clarity. One study of 3124 patients showed that the prognosis
was only discussed in 37.8% of cases, despite family conferences having occurred in 73.0% of cases.24

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

Included

Eligibility

Screening

Identification

Schram et al

Records identified through

database searching
(n = 142)

Additional records identified

through other sources
(n = 27)

Unique records after

duplicates removed
(n = 150)

Records screened
(n = 150)

Records excluded
(n = 114)

Full text articles assessed for

eligibility
(n = 36)

Full text articles excluded

(n = 22)
Review or commentary
(n = 7)
Did not measure patient or
family satisfaction (n = 11)
Provider competency not
identified (n = 4)

Studies included in
qualitative synthesis
(n = 14)

Figure 1. Preferred Reporting Items in Systemic Reviews and Meta-Analyses (PRISMA) flowchart of included and excluded studies.

Families desire for conversations about prognosis, however, does not imply that they expect physicians to make
choices for them. There is no consensus among surrogates
about whether physicians should routinely provide a specific
recommendation regarding life-support decisions for incapacitated patients.12 Furthermore, families do not necessarily make
choices consistent with physician prognoses when making
medical decisions. One study found that 18% and 32% of surrogate decision makers chose continuation of aggressive treatment despite physicians estimating 0% and <1% chances of
survival, respectively.15 In this study, surrogates significant
doubt about physicians ability to prognosticate accurately was

the most important factor driving their requests to continue

aggressive treatments inconsistent with estimated prognosis.
Conflict mediationThe ability to detect and mediate
disagreement between family members and clinicians.
Two studies explicitly concluded that conflict mediation
was an essential competency. The most common sources of
conflict in the ICU are EOL decisions, communication perceived as poor by surrogates, and changes in treatment plans.16
Specifically, conflict often arises from disagreement between
physicians and family members regarding assessment of

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

Methods/Measures

Patients

Results

Prognosticationthe ability to effectively communicate prognostic information to patients and family members
Prospective cohort study, audio- Surrogates for incapacitated patients 93% of surrogates believed that avoiding discussions about prognosis
Apatira et al
not acceptable
at high risk for death in medical
recorded semistructured
(2008)13
3% of surrogates felt that physicians should withhold prognostic
ICU, surgical ICU, neurologic
interviews with surrogates
information
ICU, and cardiac ICU (n 142)
Preparation for the future major reason for surrogates desiring
prognostic information
Evans et al
Prospective cohort study,
Surrogates for incapacitated patients 87% of surrogates wanted physicians to discuss an uncertain prognosis
(2009)23
Belief that prognostic uncertainty unavoidable and acceptable
semistructured interviews
at high risk for death in medical
12% thought that discussions about uncertain prognosis should be
ICU, surgical ICU, neurologic
avoided
ICU, and cardiac ICU (n 142)
Family satisfaction did not vary by physician specialty
Kross et al
Cluster randomized trial, family Family members of patients who
(2014)24
died in the ICU or within 30 hours Patients with neurology or neurosurgery attending physician had
surveys addressing
higher quality of dying than those with medicine attending physician
after transfer (n 3124 patients)
satisfaction, nurse surveys, and
Patients with surgery attending had lower quality of dying than those
chart abstraction
with medicine attending physician
Family conference occurred in 73% of cases
Prognosis discussed in 38% of cases
White et al
Surrogate decision makers for
56% of surrogates preferred to receive recommendation on whether
Prospective cohort study, in(2009)12
critically ill patients (n 169)
to limit life support (nonsignificant)
depth interview and survey
42% preferred not to have a recommendation (nonsignificant)
after viewing video
2% felt that both approaches were equally acceptable (nonsignificant)
Conflict mediationthe ability to detect and mediate disagreement between family members and clinicians
Schuster et al
Surrogate decision makers (n 230) Conflict identified by physician or surrogate in 63% of cases
Prospective cohort study,
Physicians less likely to perceive conflict than surrogates (27.8% vs
(2014)25
and physicians (n 100) of 175
questionnaires addressing
42.3%)
critically ill patients
perception of physician
Surrogate satisfaction with physician bedside manner resulted in lower
surrogate conflict as well as
odds of conflict
preferences about clinician
Surrogate feeling of discrimination associated with higher odds of
surrogate communication
conflict
Zier et al
Semistructured interviews
Surrogate decision makers for
64% of surrogates expressed doubt about accuracy of physicians
(2009)15
critically ill patients (n 50)
futility predictions
32% of surrogates elected to continue life support with <1% survival
estimate
18% of surrogates elected to continue life support when physician
believed patient had no chance of survival
Empathic communicationthe ability to provide support to patients and family members during conversation
70% of family members still had lingering questions or issues about
Radwany et al
Prospective cohort study,
Family members of ICU patients
treatment or medical conditions
(2009)17
semistructured interview
who later died in the hospital
70% of family members still harbored feelings of resentment about
(n 93)
care received or toward providers

Authors

Table 1. Publications Selected for Review.

N/A

N/A

(continued)

Significance
defined as .05

Significance
defined as .05

Significance
defined as .05

N/A

N/A

P Value

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

Methods/Measures

Patients

Results

P Value

Prospective cohort study, family

satisfaction in the ICU (FSICU) survey, chart review

Gries et al
(2008)19

Abbreviations: EOL, end of life; ICU, intensive care unit; N/A, not available; SICU, surgical intensive care unit.

Wall et al
(2007)27

Osborn et al
(2012)28

Nelson et al
(2010)18

Significance
Family members of patients in ICUs Increased family satisfaction associated with withdrawal of life
defined as .05
(n 356)
support, chart documentation of physician recommendations to
withdraw life-support discussions of patients wishes, and
discussions of families spiritual needs
Family members of patients in SICUs Communication intervention including clinical event-triggered family Significance
defined as .05
(n 89)
meeting increased perception of health-care team functionality and
ability to share in decisions regarding family member care

Family members of patients in ICU

addressing end-of-life decisions
(n 51 conferences)

Significance
Family members of patients in ICUs Increased proportion of family speech during family meeting
defined as .05
associated with increased family satisfaction with physician
having conversations about EOL
communication and decreased family ratings of conflict with
care (n 51 conferences
physicians
involving 214 family members)
Focus groups with patients and
Patients and family members of
Patient- and family-defined characteristics of high-quality ICU palliative N/A
family members
patients in ICUs (n 48)
care include timely, clear, and compassionate communication,
clinical decision-making focused on patient preferences,
maintenance of comfort, dignity, and personhood, open access and
proximity to patients for family, interdisciplinary support, and
bereavement care when necessary
Higher QOD-1 scores associated with support for family as decision Significance
Family satisfaction in the ICU (FS- Family members of patients who
died in the ICU (n 1290)
makers, family control over patient care, and ICU atmosphere
defined as .05
ICU) and Single-Item Quality
of Dying (QOD-1)
questionnaires
Significance
Family members of patients in the
Families of patients dying in the ICU more satisfied with their ICU
Medical record review, family
defined as .01
ICU (n 539)
experience than those who survived
satisfaction in the ICU (FSDifferences attributed to inclusion in decision-making,
ICU)
communication, emotional support, respect, and compassion
shown to family, and consideration of family needs

Prepost trial of intervention to

improve ICU communication,
family member satisfaction
surveys
McDonagh et al Cross-sectional study,
(2004)30
audiotaped physicianfamily
conferences

Huffines et al
(2013)29

Prospective cohort study,

audiotaped physicianfamily
conferences

Selph et al
(2008)26

Significance
66% of conferences contained at least 1 empathic statement
defined as .05
Mean of 1.6 (+1.6) empathic statements
Association between more empathic statements and higher family
satisfaction with communication
Significance
Stapleton et al Prospective cohort study,
Association between more empathic statements during family
Family members of critically ill
defined as .05
(2006)20
conferences and higher family satisfaction
patients addressing end-of-life
audiotaped physicianfamily
Statements included assurances that the patient would not be
decisions (n 51 conferences),
conferences
abandoned before death, assurances that the patient would be
questionnaires addressing
comfortable and would not suffer, and support for familys decisions
satisfaction with communication
about end-of-life care, including support for decision to withdraw
(n 159)
or not to withdraw life support
Family-centered aspects of carethe ability to respect families and respond to their needs and wishes to facilitate shared decision-making, particularly when the patient cannot
communicate.

Authors

Table 1. (continued)

American Journal of Hospice & Palliative Medicine

6
medical futility. In 1 study, 64% of surrogates expressed doubt
about the accuracy of physicians futility predictions.15
Severe conflict, such as that leading to litigation, is rare in
the ICU.14 However, moderate conflict is common, identified
by physicians or surrogates in 63% of 175 cases.25 Physicians
are less likely to perceive conflict than surrogates (27.8% vs
42.3%), with little overlap in the cases where conflict was
perceived. Surrogate satisfaction with physician bedside manner is an important predictor of reduced conflict.25 Early studies suggest that communication interventions can be effective
in preventing physicianpatient conflict.14 When conflict does
occur, early and intensive communication and principled negotiation are important in attempts to resolve disagreement.16
Empathic communicationThe ability to provide support
to patients and family members during conversation
using both specific statements and nonverbal cues.
Three studies explicitly concluded that empathic communication was an essential competency. One study identified
empathic communication present in 66% of ICU family conferences.26 Increased numbers of empathic statements were
associated with greater family satisfaction with communication. Examples include assurances that the patient would not
be abandoned before death or suffer, as well as support for
family decisions about EOL care.20 In a sample of 93 family
members of decedents, 70% still had lingering questions or
issues about treatment or medical conditions that caused feelings of resentment about care received or toward physicians.17
Although appropriate language is an important part of
empathic expression, psychological insight, self-awareness,
and their expression are perhaps even more essential than felicitous words alone.22 Specifically, the ability of a physician to
appropriately recognize a patient or family members emotional state is critical to delivering effective and appropriate
empathic care.21
Family-centered aspects of careThe ability to respect
families and respond to their needs and wishes to facilitate shared decision-making, particularly when the
patient cannot communicate.
Six studies explicitly concluded that family-centered care
was an essential competency. In qualitative studies, family
members of critically ill patients have a clear view on what
defines high-quality ICU PC: timely, clear, and compassionate
communication; clinical decision-making respectful of patient
preferences; maintenance of comfort, dignity, and personhood;
open access and proximity to patients for family members;
interdisciplinary support; and bereavement care.18 A related
set of competencies was validated in a quantitative analysis
of 895 families across 2 studies.19,27 Inclusion in decisionmaking, communication, discussion of patient wishes, and
discussion of spiritual needs consistently improved family
member satisfaction with care.19,27,28 Families of patients who
have experienced critical events and/or resent certain aspects of

treatment are at risk of significant dissatisfaction, such as feelings of resentment and lingering concerns.17
At least 1 study showed that satisfaction was greater among
families of patients dying in the ICU, compared to the families
of ICU survivors.27 Differences were attributed to inclusion in
decision-making, communication, emotional support, respect
and compassion shown to the family, and consideration
of family needs. 27 Family meetings are an ideal way to
strengthen family-centered care. An intervention including
triggers for family meetings increased family member perception of health-care team functionality and the ability of family
members to participate in decisions.29
A related family-centered aspect of care is that of active
listening. One study involving 214 family members suggested
that an increased proportion of family speech during family
meetings was significantly associated with improved family
satisfaction regarding physician communication. Increased
family speech was also associated with decreases in family
physician conflict ratings.30 Bereaved family members commonly identified unmet needs for emotional support and
empathically conveyed information about the process of
death.31 Despite this evidence that carefully conducted family
meetings can improve satisfaction with care, there is much
stronger evidence regarding their potential to reduce resource
utilization, largely by facilitating the withdrawal of care likely
to be futile.1,32

Discussion
High-quality clinical care is essential for patients receiving PC
in critical care settings, particularly for patients at the EOL.
The EAPC and RWJF Critical Care Workgroup provide excellent frameworks for developing interventions targeted at ICU
process measures important for delivering high-quality clinical
care, particularly at the EOL.2,7,8 However, there are several
understudied complementary physician competency domains
outside direct clinical care also essential for the provision of
PC. These competencies focus primarily on communication
skills. This review evaluates the literature on such competencies and identifies the following, about which there are qualitative and quantitative studies to suggest a critical role:
prognostication, conflict mediation, empathic communication,
and family-centered aspects of care. These competencies have
also been identified by studies evaluating the components of
communication at the EOL valued by families of decedents10
and are considered critical components of PC that is respectful
of families cognitive and emotional needs. We conclude that
these competencies are essential for the delivery of highquality patient- and family-centered PC in the ICU. A deeper
understanding of these competencies should direct future education efforts for PC physicians caring for patients in critical
care settings at the EOL, thereby complementing the RWJF
Critical Care Workgroup guidelines and the EAPC framework.
Although most of the literature identified in this review focused
primarily on aspects of care by physicians, the competencies
identified are likely to apply broadly to training and care

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

Schram et al

provided by other members of the health-care team. The competencies identified are also likely to be important in clinical
settings other than those involving EOL care.
Despite a deliberately broad search, we found only a sparse
literature addressing physician competencies outside direct
clinical care most important for PC in critical care settings
that maximizes the satisfaction of patients and their families.
Given the importance of physician communication and
prognostication at the EOL, future research might focus on
rigorous evaluation of how to best teach physicians and nurses
these critical skills. Future research might also focus on linking the broader literature on physician competencies in EOL
care more directly to patient and family satisfaction rather
than technical quality alone.
The core competency domains identified in this review may
be targeted during the training of medical students, house staff,
and in continuing medical education programs for physicians,
as well as the education of allied health professionals. Historically, education of medical students regarding PC has focused
primarily on medical management of issues important to the
geriatric population, such as delirium, pain, and polypharmacy.33 Communication skills, including the ability to discuss
and document advance directives, are gradually becoming
recognized as important skills for US medical students entering
residency.30 However, recognition of the importance of developing conflict mediation skills and communication of prognosis is still relatively undeveloped in undergraduate medical
education, at least in the United States.34 On the other hand, US
PC fellowships do recognize the importance of all the competencies we have identified, which are defined as core competencies by the Hospice and Palliative Medicine Competencies
Project Work Group of the American Academy of Hospice and
Palliative Medicine.35 The EAPC has published a White Paper
highlighting core competencies essential for development
through PC education.7,8 The data summarized by our review
provide further support for the broad set of competencies
defined in this EAPC White Paper. The EAPC emphasizes the
importance of physicians developing PC competencies at all
levels of training and specialization, a recommendation consistent with the peer-reviewed literature we have cited. We are
unable to make specific evidence-based recommendations
regarding the stages of training where the 4 competencies
should be developed and mastered. However, it is likely that
early introduction of these concepts and practical education
will produce mastery among a higher proportion of physicians.
Research suggests that communication skills akin to the
ones identified in this systematic review can be effectively
taught to clinicians. 36 Current studies on PC educational
initiatives, however, rely heavily on a pre/postintervention
evaluation based on either learner surveys or simulation, such
as role-playing and standardized patients.5 For example, in
1 study, self-assessed comfort level discussing EOL issues
increased after an educational intervention among a sample
of residents.37 Our findings suggest the importance of incorporating patient and family perspectives into investigations of
PC educational interventions. The significant opportunities for

research funding focused on PC indicate interest in these topics

and recognition of their importance. For example, the National
Institute of Health offers an opportunity with a particular
interest in developing prognosis calculators and improving the
communication of prognosis, entitled the Advancing the
Science of Geriatric Palliative Care.38 Private foundations
including the Y.C. Ho/Helen and Michael Chiang Foundation,
the Fan Fox & Leslie R. Samuels Foundation, and the Hearst
Foundations have also supported PC education initiatives.39
Our findings regarding both the competencies of prognostication and conflict mediation imply that physicians efforts to
discuss prognosis with families are often insufficient. The literature indicates that physicians are not able to accurately predict prognosis at the EOL.40 For example, physician prediction
of survival in terminally ill patients with cancer overestimated
survival by at least 4 weeks in 27% of cases.40 The challenge of
this uncertainty, coupled with the emotional difficulty of discussing prognosis, has historically led many physicians to
avoid such crucial conversations.41 Our review suggests that
this avoidance jeopardizes patient- and family-centered outcomes and must be overcome.

Team Communication
In addition to the competency domains for which we identified
empirical data, the dearth of rigorous studies regarding the
impact of team communication on patient and family satisfaction is notable. We would expect that the ability of health-care
physicians to effectively communicate among themselves
would also be an important determinant of patient satisfaction
and the delivery of high-quality care. Good teamwork would
improve satisfaction by enhancing patient perception of team
function and quality of care. In addition, the literature speculates that better team communication would improve shared
decision-making processes between clinicians and family
members by ensuring common understandings of the goals of
care.42,43 The active use of a communication facilitator may
reduce the distress of patients family members in the ICU.42
Despite this, the literature provides almost no guidance regarding the actual impact of team dynamics and communication on
patient and family satisfaction with PC provided. We also
noted limited data on spiritual support as a physician competency. Both the EAPC framework7,8 and the RWJF Critical
Care Workgroup2 concluded that addressing patient and family
spiritual needs is extremely important, but they have not been
specified as a clinician competency important to patients.26,31
Since religion is generally at the center of spirituality, clinicians generally defer this important task to chaplains. Future
research might address how various members of the health-care
team can best assist in meeting patients spiritual needs and the
specific role of the clinician.
Future research in this area should focus on how the identified competencies impact patient and family perception
regarding the quality of clinical care as well as the impact these
skills have on more objective metrics (eg, the impact of skilled
conflict mediation on patient safety measures). Medical

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

American Journal of Hospice & Palliative Medicine

8
education research in this area might focus on innovative initiatives to train physicians at all stages of their careers in the key
competencies we have identified. Additionally, research could
focus on developing standardized patient- and family-centered
quality metrics to durably track physician and hospital performance. In the end, high-quality PC in critical care settings is
more than simply the best clinical care as defined by World
Health Organization measures but also requires complementary physician competencies that enhance communication as
well as patient and family satisfaction.

Appendix A
Search Terms Used
PubMed: (palliative care OR medical futility) AND
(intensive care OR critical care OR critical illness)
AND (communication OR empathy OR decision making OR prognosis OR conflict OR support OR
shared decision-making OR prognostication) AND
(patient satisfaction OR satisfaction OR family
satisfaction)
Web of Science: TS (palliative care OR medical futility) AND TS (intensive care OR critical care OR
critical illness) AND TS (communication OR empathy OR decision making OR prognosis OR conflict
OR support OR shared decision-making OR prognostication) AND TS (patient satisfaction OR satisfaction
OR family satisfaction)
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

References
1. Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ,
Pronovost PJ. Evidence-based palliative care in the intensive care
unit: a systematic review of interventions. J Palliat Med. 2014;
17(2):219-235.
2. Mularski RA, Curtis JR, Billings JA, et al. Proposed quality measures for palliative care in the critically ill: a consensus from the
Robert Wood Johnson Foundation Critical Care Workgroup. Crit
Care Med. 2006;34(11):S404-S411.
3. Fawole OA, Dy SM, Wilson RF, et al. A systematic review of
communication quality improvement interventions for patients
with advanced and serious illness. J Gen Intern Med. 2013;
28(4):570-577.
4. Mularski RA, Puntillo K, Varkey B, et al. Pain management
within the palliative and end-of-life care experience in the ICU.
Chest. 2009;135(5):1360-1369.
5. Shaw EA, Marshall D, Howard M, Taniguchi A, Winemaker S,
Burns S. A systematic review of postgraduate palliative care curricula. J Palliat Med. 2010;13(9):1091-1108.

6. Mularski RA, Hansen L, Rosenkranz SJ, Leo MC, Nagy P, Asch

SM. Medical record quality assessments of palliative care for
intensive care unit patients. Do they match the perspectives of
nurses and families? Ann Am Thorac Soc. 2016;13(5):690-698.
7. Gamondi C, Larkin P, Payne S. Core competencies in palliative
care: an EAPC White Paper on palliative care educationpart 1.
Eur J Palliat Care. 2013;20(2):2013.
8. Gamondi C, Larkin P, Payne S. Core competencies in palliative
care: an EAPC White Paper on palliative care educationpart 2.
Eur J Palliat Care. 2013;20(3):2013.
9. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting
items for systematic reviews and meta-analyses: the PRISMA
statement. Ann Intern Med. 2009;151(4):264-269.
10. Schaefer KG, Block SD. Physician communication with families
in the ICU: evidence-based strategies for improvement. Curr
Opin Crit Care. 2009;15(6):569-577.
11. Eves MM, Esplin BS. She just doesnt know him like we do:
illuminating complexities in surrogate decision making. J Clin
Ethics. 2015;26(4):350-354.
12. White DB, Evans LR, Bautista CA, Luce JM, Lo B. Are physicians recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit
Care Med. 2009;180(4):320-325.
13. Apatira L, Boyd EA, Malvar G, et al. Hope, truth, and preparing
for death: perspectives of surrogate decision makers. Ann Intern
Med. 2008;149(12):861-868.
14. Fassier T, Azoulay E. Conflicts and communication gaps in the
intensive care unit. Curr Opin Crit Care. 2010;16(6):654-665.
15. Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, White DB.
Surrogate decision makers responses to physicians predictions
of medical futility. Chest. 2009;136(1):110-117.
16. Luce JM. End-of-life decision making in the intensive care unit.
Am J Respir Crit Care Med. 2010;182(1):6-11.
17. Radwany S, Albanese T, Clough L, Sims L, Mason H, Jahangiri S.
End-of-life decision making and emotional burden: placing family
meetings in context. Am J Hosp Palliat Med. 2009;26(5):376-383.
18. Nelson JE, Puntillo KA, Pronovost PJ, et al. In their own words:
patients and families define high-quality palliative care in the
intensive care unit. Crit Care Med. 2010;38(3):808-818.
19. Gries CJ, Curtis JR, Wall RJ, Engelberg RA. Family member
satisfaction with end-of-life decision making in the ICU. Chest.
2008;133(3):704-712.
20. Stapleton RD, Engelberg RA, Wenrich MD, Goss CH, Curtis JR.
Clinician statements and family satisfaction with family conferences in the intensive care unit. Crit Care Med. 2006;34(6):
1679-1685.
21. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee
M. Physician empathy: definition, components, measurement,
and relationship to gender and specialty. Am J Psychiatry.
2002;159(9):1563-1569.
22. Fins JJ, Solomon MZ. Communication in intensive care settings:
the challenge of futility disputes. Crit Care Med. 2001;29(2
suppl):N10-N15.
23. Evans LR, Boyd EA, Malvar G, et al. Surrogate decision-makers
perspectives on discussing prognosis in the face of uncertainty.
Am J Respir Crit Care Med. 2009;179(1):48-53.

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016

Schram et al

24. Kross EK, Engelberg RA, Downey L, et al. Differences in end-oflife care in the ICU across patients cared for by medicine, surgery,
neurology, and neurosurgery physicians. Chest. 2014;145(2):
313-321.
25. Schuster RA, Hong SY, Arnold RM, White DB. Investigating
conflict in ICUs-is the clinicians perspective enough? Crit Care
Med. 2014;42(2):328-335.
26. Selph RB, Shiang J, Engelberg R, Curtis JR, White DB. Empathy
and life support decisions in intensive care units. J Gen Intern
Med. 2008;23(9):1311-1317.
27. Wall RJ, Curtis JR, Cooke CR, Engelberg RA. Family satisfaction
in the ICU: differences between families of survivors and nonsurvivors. Chest. 2007;132(5):1425-1433.
28. Osborn TR, Curtis JR, Nielsen EL, Back AL, Shannon SE, Engelberg RA. Identifying elements of ICU care that families report as
important but unsatisfactory decision-making, control, and ICU
atmosphere. Chest. 2012;142(5):1185-1192.
29. Huffines M, Johnson KL, Naranjo LLS, et al. Improving family
satisfaction and participation in decision making in an intensive
care unit. Crit Care Nurse. 2013;33(5):56-68.
30. McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated
with increased satisfaction. Crit Care Med. 2004;32(7):
1484-1488.
31. Gallagher R, Krawczyk M. Family members perceptions of endof-life care across diverse locations of care. BMC Palliat Care.
2013;12(1):25.
32. Billings JA. The end-of-life family meeting in intensive care part
I: indications, outcomes, and family needs. J Palliat Med. 2011;
14(9):1042-1050.
33. Leipzig RM, Granville L, Simpson D, Anderson MB, Sauvigne K,
Soriano RP. Keeping granny safe on July 1: a consensus on

34.

35.

36.
37.

38.

39.
40.

41.

42.

43.

minimum geriatrics competencies for graduating medical students. Acad Med. 2009;84(5):604-610.
Angus S, Vu TR, Halvorsen AJ, et al. What skills should new
internal medicine interns have in July? A national survey of internal medicine residency program directors. Acad Med. 2014;89(3):
432-435.
Arnold R, Billings JA, Block SD, et al. Hospice and Palliative
Medicine Core Competencies Version 2.3. Chicago, IL: American
Academy of Hospice and Palliative Medicine; 2009.
Maguire P, Pitceathly C. Key communication skills and how to
acquire them. BMJ. 2002;325(7366):697-700.
Bagatell R, Meyer R, Herron S, Berger A, Villar R. When children die: a seminar series for pediatric residents. Pediatrics. 2002;
110(2 pt 1):348-353.
National Institute on Aging. Apply for palliative care research funding. 2014. Web site http://www.nia.nih.gov/research/blog/2013/12/
apply-palliative-care-research-funding. Accessed May 16, 2014.
Funding | Aahpm.org. 2014. Web site http://www.aahpm.org/fel
lowship/default/funding.html. Accessed May 16, 2014.
Glare P, Virik K, Jones M, et al. A systematic review of physicians survival predictions in terminally ill cancer patients. BMJ.
2003;327(7408):195-198.
Christakis NA, Iwashyna TJ. Attitude and self-reported practice
regarding prognostication in a national sample of internists. Arch
Intern Med. 1998;158(21):2389-2395.
Curtis JR, Ciechanowski PS, Downey L, et al. Development and
evaluation of an interprofessional communication intervention to
improve family outcomes in the ICU. Contemp Clin Trials. 2012;
33(6):1245-1254.
Puntillo KA, McAdam JL. Communication between physicians
and nurses as a target for improving end-of-life care in the intensive care unit: challenges and opportunities for moving forward.
Crit Care Med. 2006;34(11):S332-S340.

Downloaded from ajh.sagepub.com at UNIV FED DO RIO GRANDE DO NOR on September 12, 2016