Background Although communication problems between family surrogates and intensive care unit (ICU) clinicians have been documented, there are few effective interventions. Nurses have the potential to play an expanded role in ICU communication and decision making. Objectives To conduct a pilot randomized controlled trial of the Family Navigator (FN), a distinct nursing role to address family members’ unmet communication needs early in an ICU stay. Methods An inter-disciplinary team developed the FN protocol. A randomized controlled pilot intervention trial of the FN was performed in a tertiary referral hospital ICU to test the feasibility and acceptability of the intervention. The intervention addressed informational and emotional communication needs through daily contact using structured clinical updates, emotional and informational support modules, family meeting support and follow-up phone calls. Results Twenty-six surrogate/patient pairs (13 per study arm) were enrolled. Surrogates randomized to the intervention had contact with the FN 90% or more of eligible patient days. All surrogates agreed or strongly agreed that they would recommend the FN to other families. Open-ended comments from both surrogates and clinicians were uniformly positive. For both groups, 100% of baseline data collection interviews and 81% of 6–8 week follow-up interviews were completed. Conclusions A fully integrated nurse empowered to facilitate decision making is a feasible intervention in the ICU setting. It is well-received by ICU families and staff. A larger randomized controlled trial is needed to demonstrate an impact on important outcomes, such as surrogate well-being and decision quality.

While surrogates considered many factors, they focused more often on patient well-being than on patient preferences, in contravention of our current ethical framework. Surrogates more commonly prioritized patient preferences if they had advance directives available to them.

Context Although many family members who make surrogate decisions report problems with communication, there is no validated instrument to accurately measure surrogate/clinician communication for older adults in the acute hospital setting. Objectives To validate a survey of surrogate-rated communication quality in the hospital that would be useful to clinicians, researchers and health systems. Methods After expert review and cognitive interviewing (n=10 surrogates), we enrolled 350 surrogates (250 development sample and 100 validation sample) of hospitalized adults aged 65 and older from three hospitals in one metropolitan area. The communication survey and a measure of decision quality were administered within hospital days 3 and 10. Mental health and satisfaction measures were administered 6–8 weeks later. Results Factor analysis showed support for both one-factor (Total Communication) and two-factor models (Information and Emotional Support.) Item reduction led to a final 30 item scale. For the validation sample, internal reliability (Cronbach’s alpha) was 0.96 (total), 0.94 (Information) and 0.90 (Emotional Support). Confirmatory Factor Analysis fit statistics were adequate (one factor model, CFI=0.981, RMSEA=0.62, WRMR=1.011; two factor model CFI=0.984, RMSEA=0.055, WRMR=0.930) Total score and subscales showed significant associations with the Decision Conflict Scale (Pearson correlation −0.43, p<.001 for total score). Emotional support was associated with improved mental health outcomes at 6–8 weeks such as anxiety (−0.19 p<0.001) and Information was associated with satisfaction with the hospital stay (0.49, p<0.001). Conclusion The survey show high reliability and validity in measuring communication experiences for hospital surrogates. The scale has promise for measurement of communication quality and is predictive of important outcomes such as surrogate satisfaction and well-being.

IMPORTANCE An important aspect of high-quality care is ensuring that treatments are in alignment with patient or surrogate decision-maker goals. Treatment discordant with patient goals has been shown to increase medical costs and prolong end-of-life difficulties. OBJECTIVES To evaluate discordance between surrogate decision-maker goals of care and medical orders and treatments provided to hospitalized, incapacitated older patients. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included 363 patientsurrogate dyads. Patients were 65 years or older and faced at least 1 major medical decision in the medical and medical intensive care unit services in 3 tertiary care hospitals in an urban Midwestern

Emotional support of hospital surrogates is consistently associated with better psychological outcomes and decision quality, suggesting an opportunity to improve decision making and well-being.

Context: Although religion and spirituality are important to surrogate decision makers, little is known about the role of religion in decision making regarding life sustaining treatments.Objectives: To determine the relationships between dimensions of religion and spirituality and medical treatment decisions made by surrogates. Methods:This prospective, observational study enrolled patient/surrogate dyads from three hospitals in one metropolitan area. Eligible patients were 65 years or older and admitted to the medicine or medical intensive care services. Baseline surveys between hospital days 2-10 assessed seven dimensions of religion and spirituality. Chart reviews of the electronic medical record and regional health information exchange 6 months after enrollment identified the use of life sustaining treatments and hospice for patients who died.Results: There were 291 patient/surrogate dyads. When adjusting for other religious dimensions, demographic, and illness factors, only surrogates' belief in miracles was significantly associated with a lower surrogate preference for DNR status (Adjusted odds Ratio (aOR) 0.39, 95%

Author Contributions Dr. Torke had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Torke,

No abstract