Clinical Communication

A Talking Map for Family Meetings in the Intensive Care Unit

Journal of Clinical Outcomes Management. 2017 January;24(1)

References

1. Hickey M. What are the needs of families of critically ill patients? A review of the literature since 1976. Heart Lung 1990;19:401–15.

2. Mosenthal AC, Murphy PA, Barker LK, et al. Changing culture around end-of-life care in the trauma intensive care unit. J Trauma 2008;64:1587–93.

3. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469–78.

4. Selecky PA, Eliasson AH, Hall RI, et al. Palliative and end-of-life care for patients with cardiopulmonary diseases. Chest 2005;128:3599–610.

5. Henrich NJ, Dodek P, Heyland D, et al. Qualitative analysis of an intensive care unit family satisfaction survey. Crit Care Med 2011;39:1000–5.

6. Azoulet E, Chevret S, Leleu G, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000;28:3044–9.

7. Curtis JR. Communicating about end-of-life care with patients and families in the intensive care unit. Crit Care Clin 2004;20:363–80.

8. Hope AA, Hsieh SJ, Howes JM, et al. Let’s talk critical. Development and evaluation of a communication skills training program for critical care fellows. Ann Am Thorac Soc 2015;12:505–11.

9. Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med 2007;167:453–60.

10. Vital Talk. Conduct a family conference. Accessed 27 June 2016 at www.vitaltalk.org/clinicians/family.

11. Kramer M, Schmalenberg C. Securing “good” nurse/physician relationships. Nurs Manage 2003;34:34–8.

12. Johnson D, Wilson M, Cavanaugh B, et al. Measuring the ability to meet family needs in an intensive care unit. Crit Care Med 1998;26:266–71.

13. Back AL, Arnold RM. “Isn’t there anything more you can do?’’: when empathic statements work, and when they don’t. J Palliat Med 2013;16:1429–32.

14. Curtis JR, Engelberg RA, Wenrich MD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med 2005;171:844–9.

15. Pollak KI, Arnold RM, Jeffreys AS, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol 2007;36:5748–52.

16. Back AL, Arnold RM, Tulsky JA. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. Cambridge: Cambridge University Press; 2009.

17. Back AL, Arnold RM, Baile WF, et al. Approaching difficult communication tasks in oncology. CA Cancer J Clin 2005;55:164–77.

18. Schenker Y, White D, Crowley-Matoka M, et al. “It hurts to know…and it helps”: exploring how surrogates in the ICU cope with prognostic information. J Palliat Med 2013;16:243–9.

19. Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness. Am J Respir Crit Care Med 2012;186:480–6.

20. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 2005;171:987–94.

21. White DB, Braddock CH, Bereknyei et al. Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med 2007;167:461–7.

Each member of the treating team should also introduce themselves. Even if the clinician has been working with the family, it is polite to be formal and give your name and role. Given the number of people the family sees every day, one should not assume that the family remembers all of the clinicians.

In teaching hospitals, providers should also help the family understand their level of training. Surrogates do not always understand the different roles or level of training between students, residents and fellows, advanced practice providers, consultants and their attending physicians. Uncertainty about the roles can lead to family members feeling as though they are receiving contradictory information. Family satisfaction decreases when multiple attending physicians are involved in a patient’s care [12]. When possible, a consistent presence among providers at family meetings is always best.

3. Ask the Family's Understanding of the Situation (Ask-Tell-Ask)

Most family meetings in the ICU will require the transmission of a large amount of medical information. Using a specific communication strategy, Ask-Tell-Ask ( Table 2 ), allows for the information to be calibrated based on what the family knows and wants to know.

Asking the family to explain the situation in their own language reveals how well they understand the medical facts and helps the medical team determine what information will be most helpful to the family. An opening statement might be “We have all seen your dad and talked to many of his providers. It would help us all be on the same page if you can you tell me what the doctors are telling you?” Starting with the family’s understanding builds trust with the medical team as it creates an opportunity for the family to lead the meeting and indicates that the team is available to listen to their concerns. Asking surrogates for their understanding allows them to tell their story and not hear a reiteration of things they already know. Providing time for the family to share their perspective of the care elicits family’s concerns.

In a large meeting, ensure that all members of the family have an opportunity to communicate their concerns. Does a particular person do all of the talking? Are there individuals that do not speak at all? One way to further understand unspoken concerns during the meeting is to ask “I notice you have been quiet, what questions do you have that I can answer?” There may be several rounds of “asking” in order to ensure all the family members’ concerns are heard. Letting the family tell what they have heard helps the clinicians get a better idea of their health literacy. Do they explain information using technical data or jargon? Finally, as the family talks the clinicians can determine how surprising the “serious news” will be to them. For example, if the family says they know their dad is doing much worse and may die, the information to be delivered can be truncated. However if family incorrectly thinks their dad is doing better or is uncertain they will be much more surprised by the serious news.