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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