Communication with Family Members: Still Struggling? · 2019. 9. 27. · Communication for all...

Communication with Family

Members: Still Struggling?

Assistant Professor - University of Toronto

Clinician Scientist – Sunnybrook Research Institute

Critical Care and Respirology

Sunnybrook Health Sciences Center

Tasnim Sinuff, MD, PhD, FRCPC

Conflicts of Interest - None

Points For Discussion

• Why communication with families of all

critically ill patients?

• Family members’ expectations

• Language differences, prognosis, empathy

• Is there a path forward?

Communication for all Families

• Patient’s survival uncertain when communication

should occur (early in admission)1

• Families of survivors less satisfied with

communication1,2,3

• Anxiety, depression, PTSD in families of ICU

survivors3,4,5

1. Wall RJ, et al. Chest 2007;132:1425–33. 2. Azoulay E, et al. Crit Care Med. 2000;28(8):3044-3049.

3. Prochard, et al. Crit Care Med. 2001;29:1893-1897. 4. Azoulay, et al. AJRCCM 2005;171:987-994.

5. Cameron JI, et al. AJRCCM 2012:A1090.

• Predictors of lower surrogate role confidence

• Poor quality of communication with MD

• Decreasing trust with MD

• Lack of trust about prognosis

Majesko, A, et al. Crit Care Med. 2012;40:2281-2286.

Decision Making

Poor Comprehension

• Family Members

• Language differences

• Cultural differences

• No personal

experience of ICU

• No healthcare

professionals in family

• Not the spouse

Azoulay E, et al. Crit Care Med. 2000;28(8):3044-3049.

• Clinicians

• First meeting <10

minutes

• Discussing

• Diagnosis

• Prognosis

• Coma

• Respiratory failure

• Lack of consideration of language and cultural

differences

• Lack of discussion about prognosis

• Lack of empathy and support

Curtis JR, et al. Crit Care Med. 2001;29(2 Suppl):N26-N33.

Dissatisfaction

• Emotional and spiritual

support

• Compassion

• Daily updates

• Talk to RN daily

• Direct and open

communication

• Given the prognosis

Maxwell KE, et al. Heat Lung 2007;36:367-376. Siddiqui et al. International Arch Med. 2011,4:21.

• Emotional support

• Twice daily updates

• Daily updates OK

• Strong, decisive MD

• Soft, sympathetic MD

• MD delivers bad news

Technical

Jargon

Inadequate

Feedback

Language and

Cultural

Differences

Poor

Listening

Content and

Quality of

Information

Lack of

Understanding

Of Wants or

Needs

Degree of

Knowledge of

Receiver

Religious

Differences

Interpersonal

Differences

Emotional

Interference

Lack of

Empathy

Thorton DJ, et al. Crit Care Med. 2009;37:89-95.

Time Spent Interpreted

(n=10)

English

(n=51) p value

Conference duration (min) 26(13) 32(15) 0.25

Clinician Speech

Duration (min)

Proportion

11(6)

43%

20(10)

61%

0.001

0.004

Family Speech

Duration (min)

Proportion

7(7)

25%

8(6)

24%

0.66

0.75

Interpreter Speech

Duration (min)

Proportion

8(4)

32% -

Thorton DJ, et al. Crit Care Med. 2009;37:89-95.

Support During Interpreted Conferences

• Active listening

• Allowing pauses

• Easing emotional burden

• Valuing family statements

• Asking about patient as a person

31% of ‘support’ codes expressed less frequently

Pham K, et al. CHEST 2008;134:109-116

Alterations During Interpreted Conferences

• 55% chance of alteration for each interpreted exchange

• More than ¾ of alterations – potential consequences

• 93% likely to have negative effect on communication

• Omissions

• Editorializations

• Interference with transfer of information

• Reduced emotional support

• Reduced rapport

Family: What we want to know is that after

his lungs get better and when he wakes up will

his brain suffer and affect his ability to recognize

people?

Interpreter (translating): Okay, she wants to

know about the lungs, when he wakes up, so

about his lungs, …what about after, so it will

not affect him?

Pham K, et al. CHEST 2008;134:109-116

Pham K, et al. CHEST 2008;134:109-116

Doctor: The problem with this option is that he

may have to stay on this machine for the rest of

his life.

Interpreter (translating): But the problem with

this option is that he will have to stay on this

machine for the rest of his life.

Conversations about Prognosis

Azoulay E, et al. Crit Care Med. 2000;28(8):3044-3049.

• Prospective study

• 102 MICU patients and

families

• MD & family interviewed

after family conference

43%

20%

LeClaire MM, et al. CHEST 2005;128:1728-35.

Trend towards association between shorter prognostic

interval and greater satisfaction (p=0.06)

• 81% received

prognostic

information at

least once

• Prognostic

interval of

1.7+/- 2.8 days

(median, 1

day)

1. Hickey M. Heart Lung. 1990;19:401-15.

2. Christakis NA and Iwashyna TJ. Arch Intern Med 1998;158:2389-95.

• Prognostic information most important to families1

• Difficult for physicians2

• Prognostication is stressful

• Believe families expect too much certainty

• Fear of being wrong

Prognostication

Sinuff, et al. Crit Care Med 2006;34:878-85.

• Moderate ability to discriminate between

survivors and non-survivors

• Limited usefulness of outcome prediction

within first 24 hours for clinical decision

making

Prognostication

Empathy

Empathy

”The act of correctly acknowledging

the emotional state of another

without experiencing that state

oneself.”

Markakis K, et al. Meeting of the Society of General Internal Medicine,

San Francisco, California, April 29-May 1, 1999.

Empathy

”Imagining what it is like to be that

person, experience the situation as

she or he does.”

Burnard, P. Prof Nurse 1988;3:388-91

The Defining Attributes of Empathy

1. Perspective Taking – recognize another

person’s perspective as their truth

2. Non-judgment

3. Understanding another’s feelings

4. Communicating your understanding

Wiseman, T. Journal of Advanced Nursing1996;23:1162-67.

Empathy

Selph RB, et al. J Gen Intern Med 2008;23:1311–7.

Empathic statements per conference: 1.6(1.6)

1/3 of conferences - no empathic statements

Selph RB, et al. J Gen Intern Med 2008;23:1311–7.

Proportion of conferences

containing empathic statements

# (%)

(N=51)

Empathy about surrogate

decision-making 22 (43)

Empathy about critical illness

in loved one 16 (31)

Empathy about anticipating

death of family member 14 (27)

Empathic statement in response

to explicit family emotions 13 (25)

Empathy

• More empathic statements, higher satisfaction

with communication (p=0.04)

• Increase by 1 empathic statement, increased

satisfaction score (p<0.05)

Selph RB, et al. J Gen Intern Med 2008;23:1311–7.

A Path Forward?

Listening and Responding

• Focus on potential missed opportunities (i.e., listen,

ask, respond)1,2

• Acknowledge/address family emotions (empathy)1,2

• Explore patients' preferences, principles of

surrogate decision-making, and assure non-

abandonment3

1Curtis JR, et al. J Crit Care 2002;17:147–60. 2Curtis JR, et al. Contemp Clin Trials 33 (2012) 1245–1254 3Curtis JR, et al. Am J Respir Crit Care Med; 2005;171:844–9.

Proportion of Family Speech

McDonagh, et al. Crit Care Med 2004;32:1484-88.

Family Conference Mean (SD)

(Range)

Duration of Conference 32 (15) min

(7-74)

Proportion of Family Speech 29%

(14-44)

Proportion Family Speech

McDonagh, et al. Crit Care Med 2004;32:1484

• Listen more talk less

• Increased proportion of speech associated with

• Increased satisfaction with communication

• Decreased conflict

• Increased ratings of needs met

Empathy

• Include empathic statements about

• The difficulty of having a critically ill loved one

• The difficulty of surrogate decision making

• The impending loss of a loved one

Selph RB, et al. J Gen Intern Med 2008;23:1311–7.

Recommendation Example

Take a moment at beginning of family

conference to inquire about families’

emotional state.

“Before we talk about how our

father is doing, tell me how

you are are. How are you

holding up?”

Acknowledge both verbal and non-verbal

expressions of emotion. Use the

expressions of emotion as opportunities

to support family members.

“I agree…it is really sad. It is one

of the toughest things….”

Create empathic opportunities by

acknowledging that most families face

significant emotional burden when a

loved one is critically ill.

“Many families find this to be one

of the hardest things they have

ever been through. How are you

doing?”

Valuing what family members communicate

Acknowledging emotions

Listening

Understanding the patient as a person

Eliciting questions

• Higher proportion of families able to express their

emotions

• Decreased symptoms of depression (p=0.003), anxiety

(p=0.02), and PTSD (p=0.01) 90 days after patient’s

death

Curtis JR, et al. Crit Care Med 2001;2001:29:Suppl 2:N26-33.

Lautrette A, et al. NEJM 2007; 356:469-478.

Communication Bundles

• Design – cohort study (pre-post), 2/3 teaching hospitals

• Intervention – local champion tailored intervention, PDSA

cycles, Day 1 and 3 bundles, educational materials,

educational outreach, monthly conference calls, 2 “Learning

Sessions (2010, 2011)”

• ‘Key providers’ – at least 1 RN and 1 MD

• Study duration – 21 months

• Primary Outcome – compliance with communication-

specific process measures

Black MD, et al. Crit Care Med 2013; 41:2275–2283

16 ICUs – Rhode Island ICU Collaborative

Communication Bundles

Black MD, et al. Crit Care Med 2013; 41:2275–2283

Day 1 Bundle

Identify surrogate decision-maker, code status, presence or

absence of advance directives, patient’s pain assessment,

patient’s dyspnea assessment, ICU brochure for family

Day 3 Bundle

Multidisciplinary meeting (at least 1 RN and 1 MD) with SDM,

discuss prognosis, assess patient-specific goals, assess need

for spiritual care (i.e., offer social work or pastoral care)

Black MD, et al. Crit Care Med 2013; 41:2275–2283

Day 1 Bundle 10% to 84% OR (95% CI) 1.15 (1.14, 1.16)

Day 3 Bundle 2% to 29% OR (95% CI) 1.12 (1.11, 1.14)

<0.001

A Communication Facilitator?

• Design - cRCT

• Intervention – multifaceted, interprofessional, involing a

‘communication facilitator’ (nurse or social worker)

• Theory – self-efficacy

• Role of facilitator – facilitate communication among the

interprofessional ICU team and critically ill patient's family

• Outcomes – anxiety, depression, PTSD at 3 and 6 months

post ICU stay

Curtis JR, et al. Contemp Clin Trials 2012;33:1245–1254.

A Communication Facilitator?

Curtis JR, et al. Contemp Clin Trials 2012;33:1245–1254.

Questions?

Empathy

Wiseman, T. Advances in Nursing Science 2007;30:E61-E72.

Communication

Intervention (#RCTs)

Outcomes Improved

Outcomes Not

Improved

Printed Information Only

(1 multi-centre)

(Azoulay et al., 2002)

Comprehension Satisfaction,

Depression, Anxiety

Printed Information Plus

Standardized (VALUE)

Family Meetings

(1 multi-centre)

(Lautrette et al., 2007)

PTSD, Depression,

Anxiety, Non-beneficial

Treatment

Satisfaction,

ICU LOS

Ethics Consultations for

Treatment Conflicts

(1 single centre, 1 multi-

centre)

(Schneiderman et al., 2000

and 2003)

Non-beneficial

Treatment,

Days of Nutrition and

Hydration, Duration MV,

ICU LOS, Hospital LOS

Mortality

Recommendations to Improve

Communication: White Paper

Curtis, JR and White, D. CHEST 2008;134:835-843.

• Discussing prognosis effectively

• Address barriers raised by cross-cultural

communication

• Involve integrated interdisciplinary team

• Assessing spiritual needs