***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Although experts advocate that physicians should express empathy to support family members faced with difficult end-of-life decisions for incapacitated patients , it is unknown whether and how this occurs in practice . Objectives To determine whether clinicians express empathy during deliberations with families about limiting life support , to develop a framework to underst and these expressions of empathy , and to determine whether there is an association between more empathic statements by clinicians and family satisfaction with communication . Design Multi-center , prospect i ve study of  audiotaped physician-family conferences in intensive care units of four hospitals in 2000–2002 . Measurements We  audiotaped 51 clinician-family conferences that addressed end-of-life decisions . We coded the transcripts to identify empathic statements and used constant comparative methods to categorize the types of empathic statements . We used generalized estimating equations to determine the association between empathic statements and family satisfaction with communication . Main Results There was at least one empathic statement in 66 % ( 34/51 ) of conferences with a mean of 1.6 ± 1.6 empathic statements per conference ( range 0–8 ) . We identified three main types of empathic statements : statements about the difficulty of having a critically ill loved one ( 31 % of conferences ) , statements about the difficulty of surrogate decision-making ( 43 % of conferences ) , and statements about the difficulty of confronting death ( 27 % of conferences ) . Only 30 % of empathic statements were in response to an explicit expression of emotion by family members . There was a significant association between more empathic statements and higher family satisfaction with communication ( p = 0.04 ) . Conclusions Physicians vary considerably in the extent to which they express empathy to surrogates during deliberations about life support , with no empathic statements in one-third of conferences . There is an association between more empathic statements and higher family satisfaction with communication Abstract Objective . To describe the substitute decision-makers ' perspectives related to decision-making in the intensive care unit ( ICU ) and to determine those variables associated with their overall satisfaction with decision-making . Design . Prospect i ve , multicenter , cohort study . Setting . Six Canadian university-affiliated ICUs . Patients and participants . We distributed a vali date d , self-administered question naire assessing 21 key aspects of communication and decision-making to substitute decision-makers of ICU patients who were mechanically ventilated for more than 48 h. Intervention . None . Measurements and results . A group consisting of 1,123 substitute decision-makers received question naires ; 789 were returned ( 70.3 % response rate ) . Respondents were most satisfied with the frequency of communication with nurses and least satisfied with the frequency of communication with physicians . In terms of overall satisfaction with decision-making , 560 ( 70.9 % ) of the respondents were either completely or very satisfied . The majority ( 81.2 % ) of respondents preferred some form of shared decision-making process . Factors contributing the most to satisfaction with decision-making included : complete satisfaction with level of health care the patient received , completeness of information received , and feeling supported through the decision-making process . Satisfaction with decision-making varied significantly across sites . Conclusions . In this multicenter observational study , we found that most substitute decision-makers for ICU patients wanted to share decision-making responsibility with physicians and that , overall , they were satisfied with their decision-making experience . Adequate communication , feeling supported , and achieving the appropriate level of care for their family member were key determinants of satisfaction with decision-making in the ICU BACKGROUND Most deaths in intensive care occur after withdrawal of life support . Although preparation of patients ' families is recommended , the specific information required has not been theoretically developed or tested . OBJECTIVE To assess the feasibility of testing 4 tailored messages to prepare families of patients having a planned withdrawal of life support , to assess barriers to conducting such a study , and to obtain preliminary data on measurable effects that could be used to compare such preparation with usual care . Self-regulation theory was used to structure the messages . METHODS Families were r and omly assigned to usual care ( n=10 ) or to an intervention group ( n=10 ) that received 1 of 4 tailored messages to prepare them for withdrawal of life support . They were contacted 2 to 4 weeks later to complete the Profile of Mood States and to give their evaluation of the experience , inclusive of the information received . RESULTS Compared with the usual-care group , the intervention group was significantly more satisfied with the information they received and understood better what was to happen . The intervention group had lower negative mood scores and higher positive mood scores than did the usual-care group , although the difference was not significant . Unsolicited comments by the usual-care participants were requests for the specific information that had been received by the intervention group . CONCLUSIONS The information provided was considered helpful . A larger sample might yield more significant differences . Further work is needed on other aspects of preparation such as healthcare support , spiritual issues , and preparation for funeral arrangements Objective To determine the level of satisfaction of family members with the care that they and their critically ill relative received . Design Prospect i ve cohort study . Setting Six university-affiliated intensive care units across Canada . Methods We administered a vali date d question naire to family members who made at least one visit to intensive care unit patients who received mechanical ventilation for > 48 hrs . We obtained self-rated levels of satisfaction with 25 key aspects of care related to the overall intensive care unit experience , communication , and decision making . For family members of survivors , the question naire was administered while the patient was still in the hospital . For family members of nonsurvivors , the question naire was mailed out to the family member 3–4 wks after the patient ’s death . Main Results A total of 891 family members received question naires ; 624 were returned ( 70 % response rate ) . The majority of respondents were satisfied with overall care and with overall decision making ( mean ± sd item score , 84.3 ± 15.7 and 75.9 ± 26.4 , respectively ) . Families reported the greatest satisfaction with nursing skill and competence ( 92.4 ± 14.0 ) , the compassion and respect given to the patient ( 91.8 ± 15.4 ) , and pain management ( 89.1 ± 16.7 ) . They were least satisfied with the waiting room atmosphere ( 65.0 ± 30.6 ) and frequency of physician communication ( 70.7 ± 29.0 ) . The variables significantly associated with overall satisfaction in a regression analysis were completeness of information received , respect and compassion shown to the patient and family member , and the amount of health care received . Satisfaction varied significantly across sites . Conclusions Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit . Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction Background Symptoms of anxiety and depression are common among family members of ICU patients and are culturally dependent . The aim of the study was to assess the prevalence of symptoms of anxiety and depression and associated factors in family members of ICU patients in two Central European countries . Methods We conducted a prospect i ve multicenter study involving 22 ICUs ( 250 beds ) in the Czech and Slovak Republics . The  Hospital Anxiety and Depression Scale ( HADS ) was used to assess symptoms of anxiety and depression in family members of ICU patients . Family member underst and ing of the patient ’s condition was assessed using a structured interview and a question naire was used to assess satisfaction with family member/ICU staff communication . Results Twenty two intensive care units ( both adult and pediatric ) in academic medical centers and community hospitals participated in the study . During a 6 month period , 405 family members of 293 patients were enrolled . We found a high prevalence of anxiety and depression symptoms – 78 % and 54 % , respectively . Information leaflets distributed to family members did not lower incidences of anxiety/depression . Family members with symptoms of depression reported higher levels of satisfaction according to the modified Critical Care Family Needs Inventory . Extended contact between staff and family members was the only related factor associated with anxiety reduction ( p = 0.001 ) . Conclusion Family members of ICU patients in East European countries suffer from symptoms of anxiety and depression . We identified limited family member/ICU staff communication as an important health care professional-related factor associated with a higher incidence of symptoms of anxiety . This factor is potentially amenable to improvement and may serve as a target for proactive intervention proactive intervention Objectives : There is growing recognition of the importance of spiritual care as a quality domain for critically ill patients and their families , but there is a paucity of research to guide quality improvement in this area . Our goals were to : 1 ) determine whether intensive care unit ( ICU ) family members who rate an item about their spiritual care are different from family members who skip the item or rate the item as “ not applicable ” and 2 ) identify potential determinants of higher family satisfaction with spiritual care in the ICU . Design : Cross-sectional study , using data from a cluster r and omized trial aim ed at improving end-of-life care in the ICU . Setting : ICUs in ten Seattle-area hospitals . Subjects : A total of 356 family members of patients dying during an ICU stay or within 24 hrs of ICU discharge . Intervention : None . Measurements and Main Results : Family members were surveyed about spiritual care in the ICU . Chart abstract ors obtained clinical variables including end-of-life care processes and family conference data . The 259 of 356 family members ( 73 % ) who rated their spiritual care were slightly younger than family members who did not rate this aspect of care ( p = .001 ) . Multiple regression revealed family members were more satisfied with spiritual care if a pastor or spiritual advisor was involved in the last 24 hrs of the patient 's life ( p = .007 ) . In addition , there was a strong association between satisfaction with spiritual care and satisfaction with the total ICU experience ( p < .001 ) . Ratings of spiritual care were not associated with any other demographic or clinical variables . Conclusions : These findings suggest that for patients dying in the ICU , clinicians should assess each family 's spiritual needs and consult a spiritual advisor if desired by the family . Further research is needed to develop a comprehensive approach to ICU care that meets not only physical and psychosocial but also spiritual needs of patients and their families Objectives : Spiritual distress is common in the ICU , and spiritual care providers are often called upon to provide care for patients and their families . Our goal was to evaluate the activities spiritual care providers ’ conduct to support patients and families and whether those activities are associated with family satisfaction with ICU care . Design : Prospect i ve cohort study . Setting : Three hundred fifty-bed tertiary care teaching hospital with 65 ICU beds . Subjects : Spiritual care providers and family members of patients who died in the ICU or within 30 hours of transfer from the ICU . Interventions None . Measurements and Main Results : Spiritual care providers completed surveys reporting their activities . Family members completed vali date d measures of satisfaction with care and satisfaction with spiritual care . Clustered regression was used to assess the association between activities completed by spiritual care providers and family ratings of care . Of 494 eligible patients , 275 family members completed surveys ( response rate , 56 % ) . Fifty-seven spiritual care providers received surveys relating to 268 patients , completing 285 surveys for 244 patients ( response rate , 91 % ) . Spiritual care providers commonly reported activities related to supporting religious and spiritual needs ( ≥ 90 % ) and providing support for family feelings ( 90 % ) . Discussion s about the patient ’s wishes for end-of-life care and a greater number of spiritual care activities performed were both associated with increased overall family satisfaction with ICU care ( p < 0.05 ) . Discussion s about a patient ’s end-of-life wishes , preparation for a family conference , and total number of activities performed were associated with improved family satisfaction with decision-making in the ICU ( p < 0.05 ) . Conclusions : Spiritual care providers engage in a variety of activities with families of ICU patients ; several are associated with increased family satisfaction with ICU care in general and decision-making in the ICU specifically . These findings provide insight into spiritual care provider activities and provide guidance for interventions to improve spiritual care delivered to families of critically ill patients OBJECTIVE Admission to the ICU is a major event in a patient ’s life and also for family members . We tried to eluci date how family members and ICU caregivers experience the dying process of their patients . METHODS The prospect i ve study took place in three Dutch ICUs . Patients who had stayed . 48 h and died in the ICU were eligible . The  Quality of Dying and Death ( QODD ) question naire was used , with addition of items pertaining to the patient ’s autonomy . Values indicate median and interquartile range . RESULTS We included 100 consecutive patients .  ICU stay before death was 8 ( 3 - 16 ) days . APACHE ( Acute Physiology and Chronic Health Evaluation ) II score at admission was 24 ( 19 - 31 ) . Family response rate was 89 % . Families were satisfied with overall QODD ( score , 8 [ 7 - 9 ] ) and felt supported by the ICU caregivers ( 8 [ 7 - 9 ] ) . Pain control was scored lower by family members ( 8 [ 5.75- 8.25 ] ) than by nurses and physicians ( 9 [ 8 - 10 ] , P 5 .024 ) Almost always , physicians discussed the patient ’s end-of-life wishes with family members , although families rated the quality of the discussion lower ( 7 [ 5.5 - 8.5 ] ) than physicians ( 9 [ 6.5 - 10 ] ) ( P 5 .045 ) . The majority of the families ( 89 % ) felt included in the decision-making process . More than one-half of the family members ( 57 % ) believed that the physician made the fi nal decision alone after giving information , whereas 36.8 % believed they had participated in making the decision . Family members rated the QODD question naire as difficult ( 6 [ 5 - 8 
    Output:
    
Conclusions : Families can provide valuable insight and information on the quality of care provided in the ICU at end of life .
Their perceptions of communication , decision making , nursing care , the ICU environment , and spiritual support strongly influence their satisfaction or dissatisfaction with end-of-life care in the ICU .
Personalized and frequent communication ; assistance in the decision-making process ; compassionate nursing care ; a warm , family-friendly environment ; and spiritual support can help alleviate the sequelae and enhance family satisfaction with end-of-life care in the ICU