Challenge of assessing symptoms in seriously ill intensive care unit patients

Abstract

Objectives Determine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients’ symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters. Design Prospective study of proxy reporters of symptoms in seriously ill patients. Settings Two intensive care units in a tertiary medical center in the Western United States. Patients Two hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians. Interventions None. Measurements and Main Results On the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients’ and family members’ ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients’ and physicians’ ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients’ and nurses’ ratings. Two symptoms had symptom-distress correlation coefficients between patients’ and physicians’ ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively. Conclusions Patient–family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients’ symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians’ and patients’ symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients’ symptoms. Proxy overestimation of patients’ symptom scores warrants further study because this may influence decisions about treating patients’ symptoms.

Underestimation of Patient Breathlessness by Nurses and Physicians during a Spontaneous Breathing Trial

“…Our results are in contrast to the findings in Puntillo et.al (32) who suggests that more experienced physicians reported symptom assessment closer to patient self-reports. This difference may be caused by that in the study by Puntillo et al most of the physicians were trainees, while in our study even the most naïve physician were residents with some years of ICU experience.…”

“…The discrepancies between clinicians and patients appear to be even more apparent when symptoms are severe (30,31). Although Puntillo et al (32) found the average values of clinician ratings and patient ratings were nearly equal (in contrast to our present data), their ICC values show that clinicians did poorly at estimating an individual patient's shortness of breath (in agreement with our present data). In this study the assessments were completed within a range of 2-8 hours, while in our study the symptom ratings were done at the same time.…”

Palliative care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board

“…In some studies, patients rank their symptoms higher than proxy reporters [33, 34], while in other reports the opposite is true [35, 36]. Recently, the agreement between ICU patients and their family members on the distress of patient pain, dyspnea, restlessness, fear, and thirst was demonstrated to be moderately strong [37]. Overall, data suggest that proxy reporters can help identify symptoms that might be distressing for the patient.…”

Comparison of the symptoms reported by post-operative patients with cancer and nurses’ perception of patient symptoms

“…Another study found that ICU nurses tended to overestimate symptom intensity and distress (Puntillo et al . ).…”