Since the advent of evidence-based medicine, where current scientific evidence is used to inform medical decision making, clinical diagnoses and treatments have improved, however clinical uncertainty will always remain. One area where such uncertainty is particularly common is that of intensive care units (ICUs) dealing with seriously ill patients whose conditions can quickly change. In these environments clear communication between healthcare professionals, patients and their families is especially important. Irene Higginson from King’s College London, UK and colleagues addressed the need for improved communication through developing a new interventional tool called PACE (psychosocial assessment and communication evaluation) and evaluating its impact in an ICU setting, as published in a recent BMC Medicine study. Higginson explains the importance of developing better aids for communication and the difference this could make in healthcare.
How did this research come about, and why is there a need for a tool to improve communication and palliative care in ICUs?
Communication and support for patients and their families are of central concern in healthcare. However, evidence shows that these are often poorly addressed, especially at times of rapid changes in health status and during clinical uncertainty. The Intensive Care Unit is a setting in which patients are profoundly ill and where their circumstances can change rapidly. Previous research has highlighted concerns in relation to support for patients and families, lack of adequate control of patient’s symptoms, inconsistent or lack of communication and attention to patients and families’ individual wishes and to dignity, respect and peace in the Intensive Care Unit. This led us to believe that there was a need to improve communication and palliative care in Intensive Care Units, and to develop a tool to try and achieve this.
What are the challenges associated with communication within an ICU setting?
The Intensive Care Unit is a highly challenging environment for patients and families. Patients are normally profoundly ill making communication very difficult. The nature of that illness and its severity means that it is often difficult or impossible to communicate with them directly – many are for example unconscious and in the process of being ventilated. Their families are entering a very unfamiliar place and are often in shock about what has happened and struggle to cope with this while supporting the patient as best they can. Although the central goal of the Intensive Care Unit is to preserve or extend life, the nature of illness or trauma means that sometimes this is not possible. Staff strive to actively treat the person’s illness, and support them, and seek to extend life. However, the severity of the illnesses that individuals face means that sometimes this is not possible. Things can change quickly, and there is a lot of information for families to take in.
What is the PACE tool and how does it work?
PACE stands for psychosocial assessment and communication evaluation. The goal of developing this tool was to improve assessment and communication for all patients in the ICU, both those who may deteriorate and equally those who may recover. PACE comprises the training programme and an assessment, which is recorded in the clinical notes. The training programme involves collaborative work between the ICU and hospital palliative care team staff to look at ways to improve communication and how the PACE questions might serve as a prompt to improve social assessment and continue communication. The record within PACE asks for assessment of five aspects of care:
1) Family Details; such as children, relationships and guardianships.
2) Social Details; such as language, culture, but also financial concerns or even the need for transport and parking for the family.
3) Patient Preferences; including any previous wishes about who they would want to inform their treatment
4) Communication and information; how much the patient and the families are aware of the situation and who is key in a family to be involved in communication. It also involves explaining what happens in the ICU and finally any other aspects which the patient, family or staff feel is important. The record then gives space for a continuing log of any communication updates. This is so when the clinical team change during the 24 hour period, everyone is kept up to date.
5) Any other issues; a list providing useful resources as a prompt for staff to receive additional support if needed. PACE is completed by the key worker for the patient, usually a nurse within 24 hours of admission.
In your study you have tested PACE in an ICU setting. How could PACE be implemented on a wider scale and in other settings?
We tested PACE in ICU because it is where there is a lot of uncertainty for patients and families. But similar needs for good communication and psychosocial care, and the presence of uncertainty, exist across the healthcare system. PACE helps the staff to get to know the patient and family better, and helps the family and patient feel that someone is interested in them and their wishes, as well as in the purely biomedical aspects of their condition. So we believe it could be helpful in other settings, especially in hospitals but this would need testing. In ICU there are higher levels of staffing than the rest of the hospital, so it may be more difficult to train staff to ask the questions correctly, and to listen well to families and patients’ answers and wishes. There may be a need to modify the training component of PACE or the questions it asks for it to best work in other settings.
How easy will it be to implement PACE into clinical practice and what will this involve?
The implementation of any tool is important as a tool is only as good as the implementation that supports it. We deliberately kept PACE short, so it couldn’t be a tick box exercise or a check list – we wanted the staff to think about what the assessment meant and to take the time to listen to patients and families. Our research in the implementation found that in general PACE was completed within 24 to 48 hours of admission (only about half of PACEs were completed within 24 hours and the rest within 48 hours). Most people found it easy to record the family history, the family condition and the social circumstances but more difficult to ask about prior preferences that the patient might have. This is where the training and support, which needs to be ongoing, is important.
What’s next for your research? Are their plans for a Phase III study of PACE?
We want to test PACE more widely and a Phase III study is exactly the right next step. We would like to try this in several centres – at the moment PACE has been tested in one hospital. We are about to plan an expansion of the work and seek potential partners. We want to see if there are benefits of PACE but also if there are any downsides to using it. So far, we are encouraged because it appears that PACE is not only feasible but it seems to improve communication, information, the families perception of the honesty of staff, and symptom control. The next test is to evaluate this further with comparative trials. Our development and preliminary evaluation was supported by the UK National Institutes of Health Research (NIHR), and we will need to approach them or a charity to support the next phase in the work.
Questions from Joanna Denyer, Senior Assistant Editor for BMC Medicine and Stephanie Harriman, Deputy Medical Editor for BioMed Central.
Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty
BMC Medicine 2013, 11:213
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