Date of Award

2017

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College

College of Nursing

First Advisor

Elaine J. Amella

Second Advisor

Martina Mueller

Third Advisor

Susan D. Newman

Fourth Advisor

Clareen Wieneck

Abstract

Purpose: The purpose of this dissertation was to determine the acceptability, feasibility, and potential impact of using Severity of Illness (SOI) mortality risk prediction scores for initiating end-of-life (EOL) goals-of-care communication in the adult Intensive Care Unit (ICU). First, an integrative review was conducted to evaluate the psychometric properties of existing SOI scoring systems and their ability to predict mortality in the adult ICU population as the basis for clinical care and provider-patient/family communication. Next, an integrative review of interventions that can guide researchers in reducing surrogate burden was conducted as the basis for conducting research that may impact surrogates of dying patients in the ICU. Finally, a mixed-methods study was conducted to determine the acceptability and feasibility of having providers use SOI mortality prediction scores for their patients as part of routine care and investigate providers’ intentions to change practice related to goals-of-care communication as a result of awareness of the scores. Problem: While healthcare teams recognize that profoundly ill patients in adult ICUs may die, many families are caught by surprise when their loved one dies in a setting with the most advanced technology and intense care available. ICU deaths account for about 20% of patient deaths in US hospitals and this rate is increasing due in part to deficiencies in EOL care communication that can compromise quality of EOL care and increase resource utilization. Previous studies suggest that communication about EOL goals-of-care is infrequent among healthcare providers, patients, and families; often occurs late in the course of illness; and relies on family members to act as patient surrogates in discussions. Furthermore, despite advances in healthcare quality, family members remain more dissatisfied with communication in the ICU than with other aspects of care. Mechanisms for increasing the timeliness and frequency of discussions about EOL goals-of-care are needed. Specific Aims: Aim 1. Evaluate four valid SOI instruments to determine which instrument, or combination of instruments, is the best fit for the study site, given providers’ perceived feasibility of use. Aim 2. Evaluate the acceptability and feasibility of having providers use SOI mortality prediction scores for their patients as part of routine workflow and practice. Aim 3. Evaluate providers’ intentions to change their practice related to goals-of-care communication with patients and/or their families as a result of awareness of SOI mortality prediction scores. Design: First, an integrative review was conducted to evaluate the psychometric properties of existing SOI scoring systems and their ability to predict mortality in the adult ICU. This review provided the foundational knowledge needed in the selection of SOI systems that were used in aim 1. Next, an integrative review of interventions that can guide researchers in reducing surrogate burden was conducted. This review provided foundational knowledge needed for designing a study that may impact surrogates of dying patients in the ICU. Lastly, an explanatory mixed-methods study was conducted to determine the acceptability and feasibility of having providers use SOI mortality prediction scores for their patients as part of routine care and investigate providers’ intentions to change practice related to goals-of-care communication as a result of awareness of the scores. Self-efficacy theory was used as the theoretical underpinning for the design of this study, specifically aim 3. Findings: Based on discrimination alone, the first integrative review found APACHE IV to be superior, but the VA ICU, SICULA, and SOFA Max were close with ‘very good’ discrimination. The second integrative review revealed six levels of intervention, from the personal ‘Direct Care of the Surrogate’ to the population-based ‘Legal/Regulatory’ and provided a framework to assist researchers when designing and conducting research that involves surrogates. The dissertation study found the use of mortality risk prediction scores as part of routine workflow and practice to be acceptable and feasible – providers agreed to participate, patient mortality risk were evaluated by the instrument chosen by the providers (i.e., the Sequential Organ Failure Assessment - SOFA), and overall, participants found use of daily mortality prediction scores possible in their setting. However, there was some disagreement related to the use of SOFA scores as an effective way for determining patient mortality risk. Based on themes that emerged from interviews, providers with limited ICU experience were eager and accepting of the mortality risk scores while those with vast experience found the scores to be an adjunct to their own intuition; though all acknowledged the benefit of looking at daily scores or ‘trends’. The most substantial of all themes identified was the need to consider SOFA scores in relation to patient context; a number alone should not determine mortality risk and whether a goals-of-care conversation needs to occur. Conclusion: This dissertation study found that overall, participants indicated that using mortality prediction scores as part of their daily workflow was acceptable and feasible. Use of SOFA scores for potentially increasing EOL goals-of-care conversations appears to be most beneficial for providers with limited ICU experience. Large-scale studies are needed to determine the effect of using mortality risk predictions on patient EOL outcomes.

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