Clinical Communication

A Talking Map for Family Meetings in the Intensive Care Unit

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

References

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Physicians can develop the capacity to recognize and respond to the emotional cues family members are delivering. Intensivists should actively look for the emotions, the empathic opportunity, that are displayed by the family. This emotion is the “data” that will help lead to an empathic response. A family that just received bad news typically responds by showing emotion. Clues that emotions are present include: the family asking the same questions multiple times; using emotional words such as “sad” or “frustrated;” existential questions that do not have a cognitive answer such as “Why did God let this happen?;” or non-verbal cues like tears and hand wringing.

Sometimes the emotional responses are more difficult to recognize. Families may continue to ask for more cognitive information after hearing bad news. Someone keeps asking “Why did his kidney function worsen?” or “I thought the team said the chest x-ray looked better.” It is tempting to start answering these questions with more medical facts. However, if the question comes after bad news, it is usually an expression of frustration or sadness rather than a request for more information. Rather than giving information, it might help to acknowledge this by saying “I imagine this new is overwhelming.”

NURSE is a helpful mnemonic for different ways to respond to emotion [16]. NURSE stands for 5 separate skills that can be used in these situations: name, understand, respect, support, and explore. Table 3 provides guidance on using NURSE and offers examples of NURSE statements.

5. Highlight the Patient’s Voice

Family meetings are often used to develop new treatment plans (given that the old plans are not working). In these situations, it is essential to understand what the incapacitated patient would say if they were part of the family meeting. The surrogate’s primary role is to represent the patient’s voice. To do this, surrogates need assistance in applying their critically ill loved one’s thoughts and values to complex, possibly life limiting, situations. Surrogate decision makers struggle with the decisions’ emotional impact, as well as how to reconcile their desires with their loved one’s wishes [18]. This can lead them to make decisions that conflict with the loved one’s values [19] as well as emotional sequelae such as PTSD and depression [20].

Clinicians have a responsibility to attend to surrogates’ emotions, to help educate surrogates regarding their role, and to explore the patient’s values. One way to focus on the values of the patient is “highlighting the patient’s voice.” This requires asking questions that help the surrogate focus on the patient, her values and her attitude toward serious illness. There are many questions a provider can use to elicit a critically ill patient’s values ( Table 4 ). You may have to use a variety of different questions to understand what is most important to the patient.

As families reflect on their loved one’s values, conflicting desires will arise. For example, someone may have wanted to live as long as possible and also values independence. Or someone may value their ability to think clearly more than being physically well but would not want to be physically dependent on artificial life support. Exploring which values would be more important can help resolve these conflicts.