INTRODUCTION

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Meeting the needs of their patients' family members is an essential part of the responsibilities of intensive care unit (ICU) physicians and nurses, who are committed to easing the pain and suffering of those who have a critically ill relative or close friend. A major task of ICU physicians is to provide family members with the appropriate, clear, and compassionate information they need to participate in making decisions about patients who are unable to speak for themselves. Evaluations of family needs supply valuable information for improving the comprehension, satisfaction, and decision-making capacity of families (1). Moreover, satisfaction of proxies is considered a major criterion in the assessment of quality of care and of compliance with accreditation requirements (2, 3).

Since the descriptive study by Molter reported in 1979 (1), family needs in ICU patients have been the focus of several publications (1) reporting small, single-center studies that used univariate analysis to identify determinants of satisfaction, usually in one individual per family. The results of these studies suggest that family members want honest, intelligible, and timely information; liberal visiting policies; and the assurance that their loved one is being cared for by competent and compassionate people. Providing better information was associated with better results in terms of meeting the needs (1, 2) and increasing the level of satisfaction (14) of family members.

A modified version of Molter's Critical Care Family Needs Inventory (CCFNI) has been validated recently by Johnson and coworkers as a reliable instrument for evaluating the needs of next-of-kin and secondary respondents in the same family (2). Johnson and coworkers found that family members were more likely to be dissatisfied when more than two ICU physicians cared for the patient, different nurses were assigned to the patient on two consecutive days, the family members were male, the APACHE II score was lower, and the most significant family member was not a sibling of the patient.

We undertook a prospective multicenter study with the dual goal of measuring the ability of ICU staff to meet family needs and of identifying parameters that could be worked on to improve family satisfaction.

	METHODS

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An invitation to participate in this study was sent to the heads of 72 French ICUs, all of whom were members of the French Society of Critical Care Medicine. The study ICUs were selected from a total of 120 ICUs using a randomization procedure. A physician in each center collected ICU and patient characteristics on a standardized form. The following ICU characteristics were recorded: university or community hospital; structure of the unit (number of beds, number of senior physicians, number of junior physicians [fellows], patient-to-nurse ratio, existence of a waiting room, existence of a room used only for meeting with families); and habits regarding interactions with families (regular meetings of physicians and nurses to discuss family needs at least once a week, family information booklet, total visiting hours allowed per day, whether a given family always received information from the same physician, whether the ICU had a written protocol for interacting with families). Each participating ICU included 15 consecutive patients admitted for longer than 2 d, starting on 7 December 1998. For each patient, the following information was recorded: age, sex, geographic origin, marital status, occupation, reasons for ICU admission, and clinical status at admission including the Simplified Acute Physiology Score II (SAPSII) score (15). Length of ICU stay and vital status at ICU discharge were also recorded. Family members were defined as all individuals who visited the patient in the ICU, regardless of their relationship to the patient. All family members who entered the patient's room were informed that a study focusing on their needs was ongoing and that they could participate in the study by completing a questionnaire. Those who accepted were offered a seat in a quiet place and were asked to complete a questionnaire and the CCFNI, anonymously. A caregiver was available to answer any questions.

Each family member entered the following data on a standardized questionnaire: age, sex, relationship to the patient, occupation, chronic illness (defined as regular need for any medication or medical attention), and commuting time to the hospital. The questionnaire included items on the time family members would have wanted to spend receiving information from the ICU physician and the time actually allowed; how satisfied they were with the information provided by junior physicians; whether they received contradictory information; whether they were told of the specific role of each ICU caregiver; whether they were receiving support from their usual doctor (the family general practitioner or the physician who cared for the patient before ICU admission); whether they needed more information on the diagnosis, prognosis, or treatment in the patient; and whether they wanted help from a psychologist. The instrument used to measure family needs and satisfaction was a modified version of the CCFNI (3) recently validated by Johnson and colleagues (2) (Appendix ). All questionnaires were given to family members between the third and fifth days following admission and were recovered immediately after completion; no questionnaires were taken home by family members. The study was approved by the ethics committee of the Société de Réanimation de Langue Française.

Statistical Analysis

Results are expressed as medians and quartiles. With the exception of items 11 and 14, each CCFNI item received a score of one if the answer was 1 or 2 (indicating satisfaction, see Appendix ) or zero if the answer was 3 or 4 (indicating dissatisfaction). The scoring pattern was inversed for items 11 and 14, as these are formulated in such a way that replies 1 and 2 indicate dissatisfaction (score = 0), whereas replies 3 and 4 indicate satisfaction (score = 1). The satisfaction score was calculated as the sum of the scores on all items; the smallest possible score was 0 (extreme dissatisfaction) and the highest possible score was 14 (extreme satisfaction). The effect of potential predictors on the satisfaction score was analyzed using a Poisson regression model: the logarithm of the satisfaction score was modeled as a linear function of the parameter representing each variable, in both univariate and multivariate analyses. Standard errors and chi-squares were corrected to take into account potential overdispersion (i.e., when the variances of the dependent variable exceed the mean). Results of the Poisson regression model were used to compute the expected percentage change in the satisfaction score with each one-unit decrease in the dependent variable. All statistical tests were done using the SAS 6.12 (SAS Inc., Cary, NC) package.

	RESULTS

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Forty-three ICUs (661 beds) participated in the study and included a total of 645 patients; eight patients died before their family members could be invited to complete the questionnaire. This left 637 patients for the study. The ICU physicians and/or nurses who collected the study data constitute the French FAMIREA group. Of the 931 people who visited study patients, 920 accepted and 11 declined to complete the questionnaire; 895 (97.3%) family members actually completed the 14-item CCFNI. These 895 questionnaires form the basis for this study.

Characteristics of the 43 ICUs

As shown in Table 1, 21 (49%) ICUs were both medical and surgical, 20 (46.5%) were medical, and two (4.5%) were surgical. Six (14%) were pediatric ICUs. In 29 (69.7%) ICUs, physicians and nurses met regularly to discuss family needs. Only in 11 (25.5%) ICUs was information about a given patient provided by the same physician throughout the patient's ICU stay.

Characteristics of the 637 Patients

Median age was 57 yr (34-72) (Table 2). Fifty-six (8.8%) patients received no visits from family members within the first 5 d after admission.

Characteristics of Family Members Who Completed the Questionnaire

Although 120 (13%) family members were not of French descent, only 28 (3%) did not speak French (Table 3). Some family members were unable to complete the questionnaire; however, all the study patients who received visits had at least one family member who spoke enough French to complete it. Of the family members, 217 (23.5%) were spouses. One hundred thirty-five respondents (14.7%) were family members of pediatric ICU patients.

The ratio of the time family members would have liked to spend receiving information over the time actually allowed them was 1.5 (1). The difference between the desired and actual allowed times was 5 min (0-10). One hundred five (11.7%) family members reported receiving contradictory information, 492 (55%) did not know the specific role of each caregiver, and 439 (47.7%) were not receiving help from their usual doctor. Eight hundred thirty-seven family members (91%) were satisfied with the information provided by junior physicians.

Predictors of Family Satisfaction

Table 4 displays the results of the univariate Poisson regression models. Variables with p values of 0.10 or lower were introduced jointly in a multivariate Poisson regression model. The final model was derived from the set of explanatory variables that jointly predicted the satisfaction score in the full model. Seven predictors were identified (Table 5), namely, family members of French descent, knowledge by family members of the specific role of each caregiver in the ICU, patient to nurse ratio  3, information provided by a junior physician, no perceived contradictions in information given by caregivers, adequate time spent by caregivers providing information, and help from the usual doctor. For instance, the expected satisfaction score for family members in ICUs where junior physicians provided information was 30.4% higher than in ICUs where there are no junior physicians or where junior physicians do not provide information (after adjustment for confounding variables). On the other hand, families that felt they received contradictory information had satisfaction scores 21.1% lower than those that felt they did not.

None of the other study data was significantly correlated with family satisfaction. No differences in family satisfaction were found between pediatric and adult ICUs (median score was 2 [2-3] in both adult and pediatric ICUs; p = 0.67). Other factors such as whether a family information booklet was available also failed to correlate with family member satisfaction (median score was 2 [2-3] in both ICUs where an information booklet was available, p = 0.43). Moreover, satisfaction was not correlated with the SAPSII score, length of stay, or mortality.

	DISCUSSION

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We report the results of the first prospective multicenter study of the needs of ICU patient families. These results were obtained using a recently validated variant of Molter's CCFNI (1) in 920 family members. Of the seven parameters associated with satisfaction, one was related to family member characteristics and six to caregiver and ICU practices.

The level of satisfaction in our study cannot be compared with that in other studies because no score cut-offs for the CCFNI or other scales evaluating ICU family satisfaction have been validated. Moreover, this study was conducted in France, and important differences in family needs may exist between North American and French ICUs. However, the characteristics of our patients and ICUs were similar to these reported in other countries (2, 7, 15), and our predictors of satisfaction seem objective and generalizable to the ICUs of many other countries.

We pooled results from pediatric and adult ICUs because we found no significant differences in family needs between these two groups. Price and coworkers reported that the CCFNI was reliable not only in adult but also in pediatric ICUs (10).

We chose to include all visitors independently from their relationship to the patient. Better comprehension has been reported in spouses of ICU patients (16), and previous studies have found that spouses were more likely to be satisfied than visitors with other relationships to the patient (17). A striking finding from our study is that all family members had their needs equally met. Doctors may view spouses as more directly involved in the outcome of a patient than other relatives, but the satisfaction of all family members should receive attention (20). The relationship between families and ICU caregivers evolves from trust and the mutual goal of wanting what is best for the patient. It involves, on the one hand, healthcare professionals committed to shouldering full responsibility for their patients' safety and, on the other hand, relatives who are suddenly called on to make decisions for a person they know intimately. ICU physicians who may decide to primarily inform spouses should check that the information is passed on to other family members (21).

Most of the family members who were not of French descent were able to participate in the study. Their needs were significantly less well met than those of French family members. Cross-cultural interactions in ICUs have been reported (24, 25). The inadequacy of merely offering information to family members is particularly obvious in cross-cultural situations: physicians should seek to determine how well the information is understood despite cultural differences in values, perceptions, expectations regarding healthcare, and style of expression and behavior. Even when the relatives speak the same language as the physician, there may be gaps in the comprehension of shades of meaning, etiquette, and styles of expression that, combined with unfamiliar medical and technical terms, may lessen satisfaction.

Six predictors of satisfaction in this study were caregiver-related. This lends optimism to the feasibility of improving family satisfaction, as caregiver-related factors can be modified. Family members expressed preference for a structured caregiver team in which the specific role of each caregiver was known to them. They also expressed a wish that all information be supplied to them in a personalized manner by a single physician, aware of the need to avoid contradictions. Obviously, for family members, quality of care encompasses more than merely treating the patient for an acute illness, a component of care that was rated as very satisfactory in this study. Families also want to receive effective and intelligible information devoid of inconsistencies. In our multicenter study, the number of physicians per ICU did nor correlate with satisfaction, but family members indicated a preference for receiving information from a single junior or senior physician whom they could get to know, rather than from several caregivers who might contradict each other. Consistent with this finding, satisfaction was better when the family's own doctor, that is, a person well aware of the structure and balance of relationships within the family, was involved in providing information. These data suggest that caregivers should develop structured communication programs (24, 25).

Another caregiver-related predictor of satisfaction was a lower ratio of the time family members would have liked to spend receiving information over the time actually allowed them. Earlier studies also found that spending "sufficient" time with the family was important to allow families to adjust to the emotional distress produced by a critical illness in a relative (16, 24, 26). Ours is the first study in which the importance of "sufficient" time was emphasized by the family members themselves.

Physicians' obligations include providing care, teaching, and carrying out clinical or fundamental research. A fourth and no less important duty is to meet the informational needs of patients and their families by disclosing all available information in a frank, direct, and empathetic way. The extent to which relatives of ICU patients are satisfied with efforts to meet their needs is dependent mainly on caregiver-related factors, which are amenable to modification.