The healing power of listening in the ICU

How to communicate with families living in complete isolation

IMPORTANCE

During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.

OBJECTIVE

This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation.

EVIDENCE REVIEW

PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.

FINDINGS

Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.

CONCLUSIONS AND RELEVANCE

The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Meaningful shared decision-making: complex process demanding cognitive and emotional skills

BACKGROUND

Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences.

METHODS

The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM.

RESULTS

We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills.

CONCLUSIONS

We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

What can we learn from simulation-based training to improve skills for end-of-life care? Insights from a national project in Israel

BACKGROUND

Simulation-based training improves residents' skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families.

METHODS

Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection - including a description of our own responses and evolution of thought as well as system effects.

RESULTS

The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas.

CONCLUSIONS

Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care.

Involvement of ICU families in decisions: fine-tuning the partnership

Families of patients are not simple visitors to the ICU. They have just been separated from a loved one, often someone they live with, either abruptly or, in nearly half the cases, because a chronic condition has suddenly worsened. They must cope with a serious illness of a loved one, while having to adapt to the unfamiliar and intimidating ICU environment. In many cases, the outcome of the critical illness is uncertain, a situation that causes considerable distress to the relatives. As shown by our research group and others, families exhibit symptoms of anxiety (70%) and depression (35%) in the first few days after admission, as well as symptoms of stress (33%) and difficulty understanding the information delivered by the healthcare staff (50%). Furthermore, relatives of patients who die in the ICU are at risk for psychiatric syndromes such as generalized anxiety, panic attacks, depression, and posttraumatic stress syndrome. In this setting of psychological distress, families are asked to consider sharing in healthcare decisions about their loved one in the ICU. This article aims to foster the debate about the shared decision-making process. We have three objectives: to transcend the overly simplistic position that opposes paternalism and autonomy, to build a view founded only on an evaluation of actual practice and experience in the field, and to keep the focus squarely on the patient. Families want information and communication time from the staff. Nurses and physicians need to understand that families can share in decisions only if the entire ICU staff actively promotes family involvement and, of course, if the family wants to participate in all or part of the decision-making process.

Discharge practices for the intensive care patient: a qualitative exploration in the general ward setting

OBJECTIVE

To explore how registered nurses (RNs) in the general ward perceive discharge processes and practices for patients recently discharged from the intensive care unit (ICU).

BACKGROUND

Patients discharged from the ICU environment often require complicated and multifaceted care. The ward-based RN is at the forefront of the care of this fragile patient population, yet their views and perceptions have seldom been explored.

DESIGN

A qualitative grounded theory design was used to guide focus group interviews with the RN participants.

METHODS

Five semi-structured focus group interviews, including 27 RN participants, were conducted in an Australian metropolitan tertiary referral hospital in 2011. Data analyses of transcripts, field notes and memos used concurrent data generation, constant comparative analysis and theoretical sampling.

RESULTS

Results yielded a core category of 'two worlds' stressing the disconnectedness between ICU and the ward setting. This category was divided into sub categories of 'communication disconnect' and 'remember the family'. Properties of 'what we say', 'what we write', 'transfer' and 'information needs' respectively were developed within those sub-categories.

CONCLUSION

The discharge process for patients within the ICU setting is complicated and largely underappreciated. There are fundamental, misunderstood differences in prioritisation and care of patients between the areas, with a deep understanding of practice requirements of ward based RNs not being understood. The findings of this research may be used to facilitate inter departmental communications and progress practice development.

Important questions asked by family members of intensive care unit patients

OBJECTIVES

Relatives often lack important information about intensive care unit patients. High-quality information is crucial to help relatives overcome the often considerable situational stress and to acquire the ability to participate in the decision-making process, most notably regarding the appropriate level of care. We aimed to develop a list of questions important for relatives of patients in the intensive care unit.

DESIGN, SETTING, AND PARTICIPANTS

This was a multicenter study. Questions asked by relatives of intensive care unit patients were collected from five different sources (literature, panel of 28 intensive care unit nurses and physicians, 1-wk survey of nurses and 1-wk survey of physicians in 14 intensive care units, and in-depth interviews with 14 families). After a qualitative analysis (framework approach and thematic analysis), questions were rated by 22 relatives and 14 intensive care unit physicians, and the ratings were analyzed using principal component analysis and hierarchical clustering.

RESULTS

The five sources produced 2,135 questions. Removal of duplicates and redundancies left 443 questions, which were distributed among nine predefined domains using a framework approach ("diagnosis," "treatment," "prognosis," "comfort," "interaction," "communication," "family," "end of life," and "postintensive care unit management"). Thematic analysis in each domain led to the identification of 46 themes, which were reworded as 46 different questions. Ratings by relatives and physicians showed that 21 of these questions were particularly important for relatives of intensive care unit patients.

CONCLUSION

This study increases knowledge about the informational needs of relatives of intensive care unit patients. This list of questions may prove valuable for both relatives and intensive care unit physicians as a tool for improving communication in the intensive care unit.

Wooden's pyramid: building a hierarchy of skills for successful communication

BACKGROUND

John Wooden, the legendary college basketball coach, created the "Pyramid of Success", which he constructed from 14 timeless character traits and interpersonal skills that are critical to competitive greatness. Wooden's pyramid is a powerful symbol that he and others have used for several decades as an educational tool to promote leadership and teamwork.

AIM

This article proposes the "Pyramid of Relational Excellence (PRE)", patterned after Wooden's pyramid, as a mnemonic-based educational symbol for communication skills training.

METHOD

Literature review, personal reflection.

RESULTS

The PRE is constructed of four tiers with a total of 12 building blocks, with each successive tier built upon the one beneath it. The building blocks represent fundamental elements that are known to be critical to successful communication.

CONCLUSIONS

The PRE is process oriented rather than task oriented and focuses exclusively on the face-to-face encounter. It therefore complements established communications curricula, such as the UK communication wheel and others, which are more comprehensive and task oriented. The PRE is constructed of timeless, fundamental principles. It is therefore particularly well suited for training medical students and residents.

Informational coping style and depressive symptoms in family decision makers

BACKGROUND

Overwhelmed family decision makers of chronically critically ill patients must comprehend vital information to make complex treatment decisions that are consistent with patients' preferences. Exploration of informational coping styles of family decision makers may yield evidence for tailored communication practices supporting the psychological and informational needs of family decision makers.

OBJECTIVES

To describe patterns in the demographic characteristics and informational coping styles of family decision makers; to assess differences in informational satisfaction, role stress, and depressive symptoms between family decision makers classified as monitors and as blunters; and to describe the predictive associations between informational coping styles, informational satisfaction, and role stress on depressive symptoms in family decision makers.

METHODS

A secondary data analysis of 210 family decision makers of cognitively impaired patients who required 3 days or more of mechanical ventilation. On enrollment, decision makers completed the abbreviated Miller Behavioral Style Scale to assess informational coping styles, the Critical Care Family Satisfaction Survey's informational subscale to assess informational satisfaction, a single-item measure of role stress, and the Center for Epidemiological Studies Depression scale to assess depressive symptoms.

RESULTS

No associations emerged between demographic characteristics and informational coping styles of family decision makers. Monitors had higher depression scores than did blunters. Both information coping style and informational satisfaction influenced depressive symptoms; however, role stress was the most significant predictor.

CONCLUSIONS

Family decision makers classified as monitors were at higher risk for depression than were those who seem to avoid information. Targeting monitors with additional psychological and informational support may mitigate their psychological impairment.

End-of-life communication in the intensive care unit

OBJECTIVE

Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life (EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current research and recommendations for ICU EOL communication.

DESIGN

For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent bibliographies and cross-referenced known EOL ICU communication researchers.

RESULTS

Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency.

CONCLUSIONS

Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality of ICU palliative care and EOL communication.

Does palliative care improve quality? A survey of bereaved family members

Palliative care is the interdisciplinary specialty that aims to relieve suffering and improve the quality of care for patients with serious illness and their families. Although palliative care programs are becoming increasingly prevalent in U.S. hospitals, the impact of hospital palliative care consultation programs on the quality of care received by family members is not well understood. We conducted prospective quantitative telephonic interviews of family members of patients who died at Mount Sinai Medical Center between April and December 2005 using the validated "After-Death Bereaved Family Member Interview," to assess quality of medical care at the end of life. Multivariable techniques were used to compare family satisfaction of palliative care patients vs. usual care patients controlling for age, race (white vs. nonwhite), diagnosis (cancer vs. noncancer), socioeconomic status (Medicaid vs. non-Medicaid), and functional status (number of dependent activities of daily living). One hundred ninety eligible subjects were contacted and successful interviews were completed with 149 (78.4%) family members (54 palliative care and 95 usual care patients). Palliative care showed benefit, with 65% of palliative care patients' family members reporting that their emotional or spiritual needs were met, as compared to 35% of usual care patients' family members (P=0.004). Sixty-seven percent of palliative care patients' family members reported confidence in one or more self-efficacy domains, as compared to 44% of usual care patients' family members (P=0.03). Our study shows that palliative care consultation is associated with improved satisfaction, with attention to family and enhanced self-efficacy. Palliative care offers a unique approach by integrating the needs of the family into the care of the patient.

A Clinical Communication Strategy to Enhance Effectiveness and CAHPS Scores: The ALERT Model

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a national annual report that surveys patients and rates health plans on a variety of metrics, including claims processing, customer service, office staff helpfulness, and ability to get needed care. Although physicians may feel they have no immediate control over many aspects of this questionnaire, there is an important area of the survey where they do have direct control: "how well the doctor communicates."It is well established that effective physician-patient communication has beneficial effects not only on physician and patient satisfaction but also on adherence to medical advice, diagnostic accuracy, and malpractice risk. The creators of the CAHPS survey developed and incorporated four questions seeking to ascertain the patient's impression of the physician's communication skills. These questions assess how well the physician listened carefully to the patient, how often the physician explained things understandably, how often the physician showed respect for what the patient said, and how often the physician spent enough time with the patient.Many excellent clinical communication models exist that touch on aspects of the CAHPS topics, but it behooves physicians to be mindful of the exact survey questions. The ALERT model of communication was developed to facilitate physicians' recall of these measures. By incorporating key verbal and nonverbal communication skills, clinicians can address and improve their scores on this important area of the CAHPS survey.