Practical Guidance for Evidence-Based ICU Family Conferences

Abstract

Because most critically ill patients lack decision-making capacity, physicians often ask family members to act as surrogates for the patient in discussions about the goals of care. Therefore, clinician-family communication is a central component of medical decision making in the ICU, and the quality of this communication has direct bearing on decisions made regarding care for critically ill patients. In addition, studies suggest that clinician-family communication can also have profound effects on the experiences and long-term mental health of family members. The purpose of this narrative review is to provide a context and rationale for improving the quality of communication with family members and to provide practical, evidence-based guidance on how to conduct this communication in the ICU setting. We emphasize the importance of discussing prognosis effectively, the key role of the integrated interdisciplinary team in this communication, and the importance of assessing spiritual needs and addressing barriers that can be raised by cross-cultural communication.We also discuss the potential value of protocols to encourage communication and the potential role of quality improvement for enhancing communication with family members. Last, we review issues regarding physician reimbursement for communication with family members within the context of the US health-care system. Communication with family members in the ICU setting is complex, and high-quality communication requires training and collaboration of a well-functioning interdisciplinary team. This communication also requires a balance between adhering to processes of care that are associated with improved outcomes and individualizing communication to the unique needs of the family. Keywords communication; critical care; end-of-life care; family; medical decision making; palliative careBecause most critically ill patients do not have decision-making capacity, family members frequently become involved with clinicians in discussions about the goals of care and often must represent patients' values and treatment preferences in these discussions. 1 Therefore, clinician-family communication is a central component of good medical decision making in the ICU. Prior studies 2 suggest that family members view clinicians' communication skills as more important than our clinical skills. However, clinician-family communication in the ICU is often inadequate. One study 3 found that only half of families of ICU patients sufficiently understand basic information about patients' diagnoses, prognoses, or treatments after a In the ICU setting, there is an additional reason to focus on the needs of the family. Since family members are often serving as surrogate decision makers, decisions about the care of the patient depend in part on the family. To the extent that family members' distress affects their ability to provide substituted judgment, these burdens of family members can interfere with patient care. Therefore, effective communication with family members that minimiz...

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

“…Efforts to resolve disagreements should therefore include exploration of differences in perception. Only a tiny minority of patients would request resuscitation if they understood their prognosis to be very poor 16 , and others have suggested effective ways to discuss prognosis 19 . Table 3.…”

“…Advance Care Planning may help reduce this negative response; by normalizing the subject and raising it before an acute illness, physicians may help reduce anxiety and shock when it is raised during a deterioration 18,23 .Both FC and DNR patients emphasized the importance of honesty, clarity, and sensitivity when discussing this issue. Previous studies have highlighted the deficiencies of resuscitation conversations 7,[24][25][26] , and others have proposed techniques to improve them 11,19,25,[27][28][29] .…”

Analysis of enacted difficult conversations in neonatal intensive care

“…Interdisciplinary communication is a key component of good endof-life care for patients and families. 31 Including nurses, social workers and chaplains in family meetings may enhance the quality of communication exchanges and meet the different family needs.…”

The Use of Informed Assent in Withholding Cardiopulmonary Resuscitation in the ICU

“…High-quality communication about withholding and withdrawing life support in the ICU does not assume that one size fits all; an important aspect of this communication is to determine the role individual family members want to play in such decisions [20]. Some want to be centrally involved in all decisions and others want to defer such decisions to the clinicians [19,21].…”