J. Daryl Thornton

Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences.

Objective:Family communication is important for delivering high quality end-of-life care in the intensive care unit, yet little research has been conducted to describe and evaluate clinician-family communication with non-English-speaking family members. We assessed clinician-family communication during intensive care unit family conferences involving interpreters and compared it with conferences without interpreters. Design:Cross-sectional descriptive study. Setting:Family conferences in the intensive care units of four hospitals during which discussions about withdrawing life support or delivery of bad news were likely to occur. Participants:Seventy family members from ten interpreted conferences and 214 family members from 51 noninterpreted conferences. Nine different physicians led interpreted conferences and 36 different physicians led noninterpreted conferences. Measurements:All 61 conferences were audiotaped. We measured the duration of the time that families, interpreters, and clinicians spoke during the conference, and we tallied the number of supportive statements issued by clinicians in each conference. Results:The mean conference time was 26.3 ± 13 mins for interpreted and 32 ± 15 mins for noninterpreted conferences (p = 0.25). The duration of clinician speech was 10.9 ± 5.8 mins for interpreted conferences and 19.6 ± 10.2 mins for noninterpreted conferences (p = 0.001). The amount of clinician speech as a proportion of total speech time was 42.7% in interpreted conferences and 60.5% in noninterpreted conferences (p = 0.004). Interpreter speech accounted for 7.9 ± 4.4 mins and 32% of speech in interpreter conferences. Interpreted conferences contained fewer clinician statements providing support for families, including valuing families’ input (p = 0.01), easing emotional burdens (p < 0.01), and active listening (p < 0.01). Conclusions:This study suggests that families with non- English-speaking members may be at increased risk of receiving less information about their loved one’s critical illness as well as less emotional support from their clinicians. Future studies should identify ways to improve communication with, and support for, non-English-speaking families of critically ill patients.

Alterations During Medical Interpretation of ICU Family Conferences That Interfere With or Enhance Communication

RATIONALE Many conferences in the ICU occur with the families of patients with limited English proficiency, requiring a medical interpreter. Despite the importance of medical interpretation, little is known about the alterations that occur and their effect on communication. OBJECTIVES This study characterizes the types, prevalence, and potential effects of alterations in interpretation during ICU family conferences involving end-of-life discussions. METHODS We identified ICU family conferences in two hospitals in which a medical interpreter was used. Ten conferences were audiotaped; 9 physicians led these conferences, and 70 family members participated. Research interpreters different from those attending the conference translated the non-English language portions of the audiotaped conferences. We identified interpretation alterations, grouped them into four types, and categorized their potential effects on communication. RESULTS For each interpreted exchange between clinicians and family, there was a 55% chance that an alteration would occur. These alterations included additions, omissions, substitutions, and editorializations. Over three quarters of alterations were judged to have potentially clinically significant consequences on the goals of the conference. Of the potentially significant alterations, 93% were likely to have a negative effect on communication; the remainder, a positive effect. The alterations with potentially negative effects included interference with the transfer of information, reduced emotional support, and reduced rapport. Those with potential positive effects included improvements in conveying information and emotional support. CONCLUSIONS Alterations in medical interpretation seem to occur frequently and often have the potential for negative consequences on the common goals of the family conference. Further studies examining and addressing these alterations may help clinicians and interpreters to improve communication with family members during ICU family conferences.

Prevalence of copied information by attendings and residents in critical care progress notes.

Objectives:To determine the prevalence and mechanism of copying among ICU physicians using an electronic medical record. Design:Retrospective cohort study. Setting:Medical ICU of an urban, academic medical center. Patients:Two thousand sixty-eight progress notes of 135 patients generated by 62 residents and 11 attending physicians between August 1, 2009, and December 31, 2009. Interventions:None. Measurements and Main Results:EIghty-two percent of all residents and 74% of all attending notes contained greater than or equal to 20% copied information (p = 0.001). Although residents authored more copied notes than attendings, residents copied less information between notes than attendings (55% vs. 61%, p < 0.001). Following greater than or equal to 1 day off, residents copied less often from their own prior notes compared to attendings (66% vs. 94%, p < 0.001). Of the copied information following a day off, there was no difference in the amount of information copied into notes of residents (59%) or attendings (61%, p = 0.17). In a regression model of attending notes, no patient factors were associated with copying. However, the levels of copying among attendings varied from 41% to 82% (p < 0.001). Conclusions:Copying among attendings and residents was common in this ICU-based cohort, with residents copying more frequently and attendings copying more information per note. The only factor that was independently associated with attending copying was the attending. Further studies should focus on further elucidating the factors influencing copying in the ICU and the effects of copying on patient outcomes.

Effect of an iPod Video Intervention on Consent to Donate Organs: A Randomized Trial

BACKGROUND The gap between the supply of organs available for transplantation and demand is growing, especially among ethnic groups. OBJECTIVE To evaluate the effect of a video designed to address concerns of ethnic groups about organ donation. DESIGN Cluster randomized, controlled trial. Randomization was performed by using a random-number table with centralized allocation concealment. Participants and investigators assessing outcomes were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00870506) SETTING Twelve branches of the Ohio Bureau of Motor Vehicles in northeastern Ohio. PARTICIPANTS 952 participants aged 15 to 66 years. INTERVENTION Video (intervention; n = 443) or usual Bureau of Motor Vehicles license practices (control; n = 509). MEASUREMENTS The primary outcome was the proportion of participants who provided consent for organ donation on a newly acquired drivers license, learners permit, or state identification card. Secondary outcomes included willingness to make a living kidney donation to a family member in need and personal beliefs about donation. RESULTS More participants who viewed the video consented to donate organs than control participants (84% vs. 72%; difference, 12 percentage points [95% CI, 6 to 17 percentage points]). The video was effective among black participants (76% vs. 54%; difference, 22 percentage points [CI, 9 to 35 percentage points]) and white participants (88% vs. 77%; difference, 11 percentage points [CI, 5 to 15 percentage points]). At the end of the trial, fewer intervention than control participants reported having insufficient information about organ donation (34% vs. 44%; difference, -10 percentage points [CI, -16 to -4 percentage points]), wanting to be buried with all of their organs (14% vs. 25%; difference, -11 percentage points [CI, -16 to -6 percentage points]), and having conflicts with organ donation (7% vs. 11%; difference, -4 percentage points [CI, -8 to -2 percentage points]). LIMITATION How the observed increases in consent to donate organs might translate into a greater organ supply in the region is unclear. CONCLUSION Exposure to a brief video addressing concerns that ethnic groups have about organ donation just before obtaining a license, permit, or identification card increased consent to donate organs among white and black participants. PRIMARY FUNDING SOURCE National Institutes of Health and the Robert Wood Johnson Foundation.

Primary care physicians' attitudes and practices regarding discussing organ donation with their patients.

PURPOSE Among the general population, discussing organ donation with a primary care provider may be associated with increased willingness to donate. However, the frequency with which primary care providers hold these discussions with their patients has not been reported. SETTING Cross-sectional mail and an Internet survey of validated questions regarding organ donation were done. SUBJECTS A national sample of 831 primary care physicians. black, and Hispanic physicians were oversampled. RESULTS Few physicians reported receiving formal training in donation (17%). Only 5% of physicians have donor cards available in their practice, and only 11% have donation information available in their practice. While 30% of physicians reported discussing end-of-life care with their patients, fewer than 4% reported discussing donation with their patients. However, only 36% felt that discussing donation was outside of their scope of practice. In a multivariate regression model, predictors of discussing donation with patients included having received formal education about organ donation (odds ratio [OR], 2.6; p < .05) and discussing end-of-life care with patients (OR, 12.8; p < .001). CONCLUSIONS Very few primary care physicians reported discussing organ donation with their patients despite the majority agreeing that it was within their scope of practice. Primary care physicians who had received education on the subject or who regularly discuss end-of-life care with their patients were more likely to discuss donation. Efforts to improve donation in the general population should include a focus on understanding and improving communication about organ donation between providers and their patients.

Where There Is Smoke…There Is Sleep Apnea: Exploring the Relationship Between Smoking and Sleep Apnea

Smoking and OSA are widely prevalent and are associated with significant morbidity and mortality. It has been hypothesized that each of these conditions adversely affects the other, leading to increased comorbidity while altering the efficacy of existing therapies. However, while the association between smoking and OSA is plausible, the evidence is less than conclusive. Cigarette smoking may increase the severity of OSA through alterations in sleep architecture, upper airway neuromuscular function, arousal mechanisms, and upper airway inflammation. Conversely, some evidence links untreated OSA with smoking addiction. Smoking cessation should improve OSA, but the evidence to support this is also limited. This article reviews the current evidence linking both conditions and the efficacy of various treatments. Limitations of the current evidence and areas in need of future investigation are also addressed.

Effects of a Video on Organ Donation Consent Among Primary Care Patients: A Randomized Controlled Trial.

ABSTRACTBACKGROUNDLow organ donation rates remain a major barrier to organ transplantation.OBJECTIVEWe aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.DESIGNThis was a randomized controlled trial between February 2013 and May 2014.SETTINGThe waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.PATIENTSThe study included 915 patients over 15.5 years of age who had not previously consented to organ donation.INTERVENTIONSJust prior to their clinical encounter, intervention patients (n = 456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n = 459) visited their provider per usual routine.MAIN MEASURESThe primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.KEY RESULTSIntervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).LIMITATIONHow the observed increases in organ donation consent might translate into a greater organ supply is unclear.CONCLUSIONWatching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.TRIAL REGISTRATIONclinicaltrials.gov Identifier: NCT01697137