How to talk with families of intensive care unit patients

When a patient in an intensive care unit is too sick to communicate, it is often the family that must make critical decisions about the patient’s care.

This may mean deciding with the medical team whether to proceed with a difficult operation, for example, or to withdraw life support.

This a situation that many of us are likely to confront: today, approximately one in five American’s dies in an intensive care unit, often with members of their families acting as surrogate decision makers because the patient cannot communicate his or her wishes.

These are difficult decisions, and often the family members themselves may be elderly or ill. It is not uncommon for surrogate decision makers develop anxiety, depression and post-traumatic stress disorder from the ordeal.

In a paper appearing in the journal Chest, Dr. J Randall Curtis and Dr. Douglas White, describe strategies hospital intensive care teams can take to improve communication between the teams and family members grappling with these difficult decisions.

“Doctors often give great overall care,” says Curtis, “and yet communication with families is the often component that is the least successful.”

Curtis, a professor of Medicine at the University of Washington, is director of the UW’s End of Life Research Program at Harborview Medical Center. 

White is an assistant professor in the Pulmonary and Critical Care Division of the University of California, San Francisco.

Sometimes, families hear different messages from different members of the intensive care team, one message from the nurses, for example, and another message from the doctors. “Families say getting these mixed messages is one of the most distressing things about the experience,” Dr. Curtis says.

In the journal article, Curtis and White describe a systematic approach to improve communication between the health-care team and families of these patients.

They propose that such an approach should be used whenever major decisions that depend on the patient’s values and preferences need to be made, such as decisions to limit life-sustaining care when the chances of survival are poor or it is likely that even if the patient were to survive, his or her quality of life would be poor.

In these situations, Curtis and White argue, the best source of information about the patient’s values and prefereces is likely to be the family, and that information is crucial if the health-care team and the family are to make an informed decision about the patient’s care.

To improve communication between the health-care team and the family, Curtis and White recommend that formal family conferences be held. Before these conferences, the health-care team should hold a pre-conference so that the team can reach a consensus on the patients prognosis and treatment options. 

“Often families will hear one thing from the nurses and another thing from the doctors,” says Curtis. “Families say getting these ‘mixed messages’ is one of the most distressing things” about their experience in intensive care units.

During the conference the health-care providers should spend more time listening and less time talking and to empathetically acknowledge “the difficulty of having a critically ill loved one, the difficulty of surrogate decision making, and the sadness of having a loved one die,” Curtis and White write.

Curtis and White encourage the use of a mnemonic to guide clinicians when they are speaking with families, called V.A.L.U.E—

V.A.L.U.E.

A 5-step mnemonic to improve ICU
clinician communication with families

V = Value comments made by the family

A = Acknowledge family emotions

L = Listen

U = Understand the patient as a person

E = Elicit family questions

The team also needs to communicate to the family that whatever happens the team will not abandon patient or allow them to suffer at the end-of-life.

Although communication needs will vary from family to family and situation to situation, the researchers write, it is important that the intensive care unit team adopt a standardized, systematic approach to ensure that communication between the team and families is successful.

Reference: Chest. 2008;134:835-843

To learn more:

• Visit UW’s End of Life Care Research Program, which includes information about clinical trials underway to study ways to improve ICU communications and links to other palliative care and end-of-life care resources.
• The paper by Curtis and White is in the October issue of Chest (subscription or fee required).
• Visit the National Library of Medicine’s webpage on End of Life Care for information and links to additional resources.

Tags: ICUs, Intensive Care Units, Palliative Care

Category: End-of-Life Care, Palliative Care, Social & Family Issues, Uncategorized