***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 Formal family meetings have been recommended as a useful approach to assist in goal setting , facilitate decision making , and reduce use of ineffective re sources in the ICU . We examined patient outcomes before and after implementation of an intensive communication system ( ICS ) to test the effect of regular , structured formal family meetings on patient outcomes among long-stay ICU patients . METHODS One hundred thirty-five patients receiving usual care and communication were enrolled as the control group , followed by enrollment of intervention patients ( n = 346 ) , from five ICUs . The ICS included a family meeting within 5 days of ICU admission and weekly thereafter . Each meeting discussed medical up date , values and preferences , and goals of care ; treatment plan ; and milestones for judging effectiveness of treatment . RESULTS Using multivariate analysis , there were no significant differences between control and intervention patients in length of stay ( LOS ) , the primary end point . Similarly , there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions ( ICU mortality , LOS , duration of ventilation , treatment limitation orders , or use of tracheostomy or percutaneous gastrostomy ) . Exploratory analysis suggested that in the medical ICUs , the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place . CONCLUSIONS The negative findings of the main analysis , in combination with preliminary evidence of differences among types of unit , suggest that further examination of the influence of patient , family , and unit characteristics on the effects of a system of regular family meetings may be warranted . Despite the lack of influence on patient outcomes , structured family meetings may be an effective approach to meeting information and support needs . TRIAL REGISTRY Clinical Trials.gov ; No. : NCT01057238 ; URL : www . clinical trials.gov BACKGROUND Ten percent to 20 % of trauma patients admitted to the intensive care unit ( ICU ) will die from their injuries . Providing appropriate end-of-life care in this setting is difficult and often late in the patients ' course . Patients are young , prognosis uncertain , and conflict common around goals of care . We hypothesized that early , structured communication in the trauma ICU would improve end-of-life care practice . METHODS Prospect i ve , observational , prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into st and ard ICU care . The program included part I , early ( at admission ) family bereavement support , assessment of prognosis , and patient preferences , and part II ( within 72 hours ) interdisciplinary family meeting . Data on goals of care discussion s , do-not-resuscitate ( DNR ) orders and withdrawal of life support ( W/D ) were collected from physician rounds , family meetings , and medical records . RESULTS Eighty-three percent of patients received part I and 69 % part II intervention . Discussion of goals of care by physicians on rounds increased from 4 % to 36 % of patient-days . During intervention , rates of mortality ( 14 % ) , DNR ( 43 % ) , and W/D ( 24 % ) were unchanged , but DNR orders and W/D were instituted earlier in hospital course . ICU length of stay was decreased in patients who died . CONCLUSIONS Structured communication between physician and families result ed in earlier consensus around goals of care for dying trauma patients . Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU STUDY OBJECTIVES To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia ( GCI ) after cardiopulmonary resuscitation and multiple organ system failure ( MOSF ) in comparison to historical control subjects . DESIGN Comparative study of retrospective and prospect i ve cohorts . SETTING Medical ICU of a university hospital . INTERVENTIONS Patterns of end-of life care for patients with MOSF and GCI obtained through a retrospective chart review  were compared to proactive case finding facilitated by the inpatient palliative care service . Interventions included identification of patient 's advance directives or preferences about end-of life care , if any ; assistance with discussion of the prognosis and treatment options with patients or their surrogates ; and implementation of palliative care strategies when treatment goals changed to a focus on comfort measures . RESULTS Although our retrospective data demonstrated a high percentage of do-not-resuscitate decisions for the patients under investigation , a considerable time lag elapsed between identification of the poor prognosis and the establishment of end-of-life treatment goals ( 4.7 + /- 2.4 days and 3.5 + /- 0.5 days for patients with MOSF and GCI , respectively [ mean + /- SE ] ) . The proactive case finding approach decreased hospital length of stay ( mean , 20.6 + /- 4.1 days vs 15.1 + /- 2.5 days and 8.6 + /- 1.6 days vs 4.7 + /- 0.6 days for MOSF and GCI patients , respectively ; p = 0.063 and < 0.001 , respectively ) . More importantly , a proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals ( 7.3 + /- 2.9 days vs 2.2 + /- 0.8 days and 6.3 + /- 1.2 days vs 3.5 + /- 0.4 days for MOSF and GCI patients , respectively ; p < 0.05 for both ) , decreased the time dying patients  with MOSF remained in the ICU , and reduced the use of nonbeneficial re sources , thus reducing the cost of care . CONCLUSIONS Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial re sources and avoided protracted dying Objective : To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU . Design : R and omized , unblinded trial . Setting : Single medical ICU . Patients : Patients and surrogate decision makers in the ICU . Interventions : The usual care group received a st and ard pamphlet about cardiopulmonary resuscitation and cardiopulmonary resuscitation preference options plus routine code status discussion s with clinicians . The video group received usual care plus an 8-minute video that depicted cardiopulmonary resuscitation , showed a simulated hospital code , and explained resuscitation preference options . Measurements and Main Results : One hundred three patients and surrogates were r and omized to usual care . One hundred five patients and surrogates were r and omized to video plus usual care .  Median total knowledge scores ( 0–15 points possible for correct answers ) in the video group were 13 compared with 10 in the usual care group , p value of less than 0.0001 . Video group participants had higher rates of underst and ing the purpose of cardiopulmonary resuscitation and resuscitation options and terminology and could correctly name components of cardiopulmonary resuscitation . No statistically significant differences in documented resuscitation preferences following the interventions were found between the two groups , although the trial was underpowered to detect such differences . A majority of participants felt that the video was helpful in cardiopulmonary resuscitation decision making ( 98 % ) and would recommend the video to others ( 99 % ) . Conclusions : A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU , compared with receiving a pamphlet on cardiopulmonary resuscitation . Patients and surrogates found the video helpful in decision making and would recommend the video to others PURPOSE We sought to determine the effects of a communication process that was design ed to encourage the use of advanced supportive technology when it is of benefit , but to limit its burdens when it is ineffective . We compared usual care with a proactive , multidisciplinary method of communicating that prospect ively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient . This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death . MATERIAL S AND METHODS We performed a before- and -after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care .  Multidisciplinary meetings were held within 72 hours of critical care admission . Patients , families , and the critical care team discussed the care plan and the patients ' goals and expectations for the outcome of critical care . Clinical " milestones " indicative of recovery were identified with time frames for their occurrence . Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient 's goals . We measured length of stay , mortality , and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention . RESULTS Intensive communication significantly reduced the median length of stay from 4 days ( interquartile range , 2 to 11 days ) to 3 days ( 2 to 6 days , P = 0.01 by survival analysis ) . This reduction remained significant after adjustment for acute physiology and chronic health evaluation ( APACHE ) 3 score [ risk ratio ( RR ) = 0.81 ; 95 % confidence interval ( CI ) , 0.66 to 0.99 ; P = 0.04 ) . Subgroup analysis revealed that this reduction occurred in our target group , patients with acuity scores in the highest quartile who died ( RR = 0.60 ; 95 % CI , 0.38 to 0.92 ; P = 0.02 ) . The intervention , which allowed dying patients earlier access to palliative care , was not associated with increased mortality . CONCLUSIONS Intensive communication was associated with a reduction in critical care use by patients who died . Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective Comprehension and satisfaction are relevant criteria for evaluating the effectiveness of information provided to family members of intensive care unit ( ICU ) patients . We performed a prospect i ve r and omized trial in 34 French ICUs to compare comprehension of diagnosis , prognosis , treatment , and satisfaction with information provided by ICU caregivers , in ICU patient family representatives who did ( n = 87 ) or did not ( n = 88 ) receive a family information leaflet ( FIL ) in addition to st and ard information . An FIL design ed specifically for this study was delivered at the first visit of the family representative : it provided general information on the ICU and hospital , the name of the ICU physician caring for the patient , a diagram of a typical ICU room with the names of all the devices , and a glossary of 12 terms commonly used in ICUs . Characteristics of the ICUs , patients , and family representatives were similar in the two groups . The FIL reduced the proportion of family members with poor comprehension from 40.9 % to 11.5 % ( p < 0.0001 ) . In the representatives with good comprehension , the FIL was associated with significantly better satisfaction ( 21 [ 18 to 24 , quartiles ] versus 27 [ 24 to 29 , quartiles ] , p = 0.01 ) . These results indicate that ICU caregivers should consider using an FIL to improve the effectiveness of the information they impart to families Objective To develop , deploy , and evaluate an intervention design ed to identify and mitigate conflict in decision making in the intensive care unit . Design Nonr and omized , controlled trial . Setting Seven intensive care units at four Boston teaching hospitals . Patients A total of 1,752 critically ill patients , including 873 study cases analyzed here . InterventionS ocial workers interviewed families of patients deemed at high risk for decisional conflict and provided feedback to the clinical team , who then implemented measures to address the problems identified . Measurements and Main Results Patient or surrogate satisfaction with intensive care unit care and the probability of choosing a specific plan for treatment in the intensive care unit was studied . Inclusion criteria identified 873 patients at risk for decisional conflict . Thirty-nine percent of the patients in the intervention phase of the study ( 172 patients ) received the intervention . In multivariate analyses , receiving the intervention significantly increased the likelihood of deciding to forgo resuscitation ( odds ratio [ OR ] = 1.81 , p = .017 ) , the likelihood of choosing a treatment plan for comfort-care only ( OR = 1.94 , p = .018 ) , and the likelihood of choosing an aggressive-care treatment plan ( OR = 2.30 , p = .002 ) . Receiving the intervention did not significantly affect overall satisfaction with the care provided ( OR = 0.68 , p = .14 ) , satisfaction with the amount of information provided ( OR = 0.86 , p = .44 ) , or satisfaction with the degree of involvement in decision making ( OR = 0.84 , p = .54 ) . Conclusions Although there was no impact on patient or surrogate satisfaction with care provided in the intensive care unit , the intervention did facilitate deliberative decision making in cases deemed at high risk for conflict . The lessons learned from the experience with this intervention should be helpful in ongoing efforts to improve care and to achieve outcomes desired by critically ill patients , their families , and critical care clinicians In this article two new methods for building and evaluating eHealth interventions are described . The first is the Multiphase Optimization Strategy ( MOST ) . It consists of a screening phase , in which intervention components are efficiently identified for inclusion in an intervention or for rejection , based on their performance ; a refining phase , in which the selected components are fine tuned and issues such as optimal levels of each component are investigated ; and a confirming phase , in which the optimized intervention , consisting of the selected components delivered at optimal levels , is evaluated 
    Output:
    
Few studies demonstrated significant improvements in the primary outcomes .
In conclusion , there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers .