C36-01 Characterizing How Surrogates Talk About End-of-life Care in the Intensive Care Unit: A Secondary Analysis of a Multicenter Observational Study

Abstract Rationale Discussions about how best to care for patients nearing the end of life are common in the intensive care unit (ICU). Prior research has focused on improving how clinicians communicate with surrogates, but less is known about how surrogates respond during these discussions. Methods This is a secondary qualitative analysis of a multicenter focused ethnography from January 2024-May 2025, which included patients admitted to the ICU with respiratory failure and receiving mechanical ventilation at 6 medical ICUs across 3 health systems in the Midwestern and Northeastern United States. In this secondary analysis, we analyzed data from observed formal ICU family meetings captured during the parent study. Data included transcribed audio recordings, ethnographer field notes, and electronic health record (EHR) documentation. We used a combined deductive and inductive coding approach to identify and characterize discussions of end-of-life care. Our focus was on articulated statements by surrogates and other family members. Results A total of 24 meetings regarding 16 unique patients were analyzed. In 19 of 24 (79%) meetings, the possibility of discontinuing life-sustaining treatment (LST) was explicitly discussed. The option of discontinuing LST was initially raised by clinicians in 8 (33%) meetings and by surrogates in 11 (46%). In 2 meetings (8%) regarding a single patient, the surrogate explicitly rejected discussions about discontinuing LST. We identified two major themes characterizing surrogate and other family member responses during these discussions: (1) putting an end to suffering that prolongs the inevitable and (2) the patient and family must say their goodbyes (Table 1). While surrogates expressed feeling burdened in their role, they also reflected acceptance and belief that “it’s gotta be done (wife).” Clinician reactions to these themes were highly variable and included directly engaging, reacting with oblique or unrelated considerations, or not addressing these comments. Clinicians’ EHR documentation varied considerably in its description of surrogate responses. Conclusions During discussions with ICU clinicians about end-of-life care, we found surrogates primarily respond with expressions that indicate acceptance of what is viewed as an inevitable dying process. Our findings suggest efforts to improve these challenging discussions should expand from focusing on deliberative “decision making” to also supporting family who are accepting and finding meaning in the dying process. This abstract is funded by: NHLBI R01 HL168474