A prospective study of primary surrogate decision makers' knowledge of intensive care

We sought to determine 1) primary surrogate decision makers' knowledge of their family members' intensive care and resuscitation status; 2) whether characteristics such as low education level and lack of English language fluency were associated with poor knowledge of intensive care; 3) surrogates' ratings of intensive care unit team communication; and 4) barriers to communication.

Prospective study.

Medical intensive care units of a county hospital located in an urban area.

Primary surrogate decision makers of all adults admitted >48 hrs from August 2005 to April 2006, enrolled sequentially.

Using a structured instrument consisting of visual analog scales, Likert-type questions, and an objective assessment of knowledge of family member's current intensive care, we interviewed primary surrogate decision makers after they had at least one bedside patient visit.

Of eligible primary surrogate decision makers, 81 were enrolled; 96% had spoken to hospital staff. On a scale in which 0 indicated the worst possible communication and 10 indicated the best possible communication, primary surrogate decision makers' mean (SD) ratings were 8.6 (2.3) for nurses and 7.8 (2.8) for doctors. Forty-seven percent of primary surrogate decision makers met the predetermined criteria for good understanding with no significant difference between college-educated (44%) and non-college-educated (50%) primary surrogate decision makers; more non-English-speaking primary surrogate decision makers (63%), however, had poor understanding than English speakers (40%) (mean difference in proportions 23%, 95% confidence interval 1% to 46%). Seventy-three percent (95% confidence interval 61-82) of primary surrogate decision makers correctly identified their family members' resuscitation orders (do-not-resuscitate, limited resuscitation, or full code). The primary reasons cited for poor communication/understanding were as follows: not given enough time (21%), explanations too complicated (16%), and too emotionally upset (5%).

Although most primary surrogate decision makers reported good understanding and excellent staff communication, almost half had poor understanding on objective testing; non-English speakers were more likely to have poor understanding.