Psychiatric–Medical ComorbidityEnd-of-life communication in the intensive care unit☆
Introduction
Because approximately 22% of all deaths in the United States occur during or after an intensive care unit (ICU) admission [1], the potential role for palliative care communication is considerable. For example, the need for clinician–family communication about withholding or withdrawing life-supporting therapies is the norm when a person dies in the ICU, rather than the exception [2], [3], [4], [5], [6]. Nevertheless, a palliative care philosophy towards dying is often perceived to be incongruent with the lack of hospitality shown to dying patients and their families, the impersonal technology and the action-oriented ICU ethos [7], [8], [9].
Difficulties with ICU EOL communication are well documented. Fifty-four percent of family members may have a poor understanding of the patient's diagnosis, treatment and prognosis; comprehension is particularly poor when physician–family meetings last for less than 10 min [10]. A recent study demonstrated that physicians tended to discuss EOL life-sustaining treatment in a scripted, depersonalized and procedure-focused manner, while surrogate decision makers showed a poor integration of the medical dilemma that was the goal of the decision-making discussion [11].
Another study showed that 40% of family members of ICU patients retrospectively perceived that conflict had occurred with ICU staff and 31% cited unprofessional behavior [12]. Examples included the physicians saying that another patient needed the dying patient's bed, talking to a sister-in-law who was a nurse while ignoring the primary caregiver and having a do-not-resuscitate (DNR) discussion at the bedside of a ventilated patient where the family members were uncertain whether he could hear or not. Curtis et al. [13] described frequent missed communication opportunities in EOL family meetings, such as addressing family emotions, affirming nonabandonment of the family and discussing palliative care or ethics. Even clear, signed advance directives and well-intentioned, competent physicians do not mitigate the intrinsic complexity of EOL communication [14] and the potential to cause iatrogenic emotional harm [15].
This concise review aims to consider barriers to better ICU EOL communication, approaches to counteracting these barriers and evidence that better communication and communication skills training might improve patient outcomes. This is followed by a practical overview of EOL ICU communication strategies.
The first step in implementing EOL palliative care is usually family communication-reorienting goals of care from hope of cure to palliation [16], [17]. Delirium and use of sedatives and analgesia result in the majority of critically ill patients unable to make their own treatment decisions, even after extubation [18], [19]. The family therefore links the patient to the ICU team. American College of Critical Care consensus statements support the importance of family-centered EOL communication [20], [21].
One problem in this regard is that doctor–family communication is not taught in most medical schools or critical care programs. Another problem is that there are considerable barriers to better ICU family communication, which is multifaceted rather than linear, and these are considered below.
Section snippets
Emotional barriers to EOL ICU communication
ICU physicians must be able to deal effectively with strong and chaotic emotions, as well as promote consensus among family and staff. When emotions, communication or deciding what is best for the patient cannot be managed within the ICU or the hospital (ethics committees, psychiatric consultations), external court intervention becomes necessary (e.g., Quinlan, Cruzan and Schiavo cases) with dramatic and long-lasting consequences [22], [23], [24], [25].
There are many inter-related reasons for
Conclusions
The ICU has become an increasingly frequent site for the implementation of EOL care and therefore critical care physicians need to be competent in family-centered EOL communication. They should be able to manage a family meeting so as to promote consensus and discuss the transition from curative to palliative goals of care, AND/DNR directives, withdrawal of life-extending treatment and the dying process.
The need for palliative care in the ICU setting is predictable when viewed from a macro
Acknowledgments
The authors gratefully acknowledge Drs. Malcolm Fisher, Stephen Streat, Rinaldo Belloma, Stephen Warrillow and Peter Saul for their thoughtful feedback on an earlier version of this manuscript.
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How to communicate with family members of the critically ill in the intensive care unit: A scoping review
2023, Intensive and Critical Care NursingCitation Excerpt :A total of 21 records (33 %) were included and further divided into three sub-categories: established communication strategies (n = 13), general communication conduct (n = 9), and facing specific communication challenges (n = 9). To this sub-category, we allocated thirteen records that recommended the use of established communication strategies for family-clinician conversations in the ICU (Kumpf et al., 2019; Ludmir and Netzer, 2019; Hartog et al.; 2018; Garrouste-Orgeas et al., 2016; Pagnamenta et al., 2016; Torke et al., 2016; Vanden Bergh and Wild, 2015; Shannon et al., 2011; Levin et al., 2010; Curtis and White, 2008; Lautrette et al., 2007; Treece, 2007; Back et al., 2005). Most records (Kumpf et al., 2019; Ludmir and Netzer, 2019; Hartog et al., 2018; Garrouste-Orgeas et al., 2016; Pagnamenta et al., 2016; Torke et al., 2016; Vanden Bergh and Wild, 2015; Curtis and White, 2008; Lautrette et al., 2007; Treece, 2007) encouraged the use of a proactive, empathic communication style, coined as the VALUE mnemonic (Lautrette et al., 2007).
The burden they bear: A scoping review of physician empathy in the intensive care unit
2021, Journal of Critical CareCitation Excerpt :An increased perception of safety by patients was highlighted in one manuscript when the intensivist displayed empathy. [29] Greater patient and family satisfaction was reported with increased intensivist empathy in nine papers. [24,25,27,29,32,36-39] Other patient-related benefits of intensivists' displays of empathy were reported as patients experiencing less anxiety [25] or less depression. [29,37]
Perception of the Quality of Communication With Physicians Among Relatives of Dying Residents of Long-term Care Facilities in 6 European Countries: PACE Cross-Sectional Study
2020, Journal of the American Medical Directors AssociationDo physicians discuss end-of-life decisions with family members? A mortality follow-back study
2018, Patient Education and CounselingCommunication Challenges of Oncologists and Intensivists Caring for Pediatric Oncology Patients: A Qualitative Study
2017, Journal of Pain and Symptom ManagementCitation Excerpt :Clear and effective communication between families of children with cancer and their children's providers is essential for informed decision-making, particularly when those children require intensive care.1 Families want timely, honest, and nonconflicting information about their child's condition2 and when they do not receive this, they experience increased levels of anxiety, distrust, and dissatisfaction with care.3 Without goals of care conversations where clinicians elicit patient and parental values, clinicians are at risk for recommending treatments that are not aligned with a family's goals.
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Work performed at Memorial Sloan-Kettering Cancer Center.
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Tomer Levin's research is supported by a grant from the Martell Foundation. No other financial support is disclosed.