Validation of the Family Meeting Behavioral Skills Checklist. An Instrument to Assess Fellows' Communication Skills

Discussing End-of-Life in the Intensive Care Unit: Education Practices in Pulmonary and Critical Care Medicine Fellowship Programs

IntroductionEnd-of-life care (EOLC) is an important aspect of patient management in the Intensive Care Unit (ICU). Poor communication during this time can lead to unnecessary suffering for patients and their families. Although palliative training is required in Pulmonary and Critical Care Medicine (PCCM) fellowship programs, there is significant variability in its delivery, and data on its effectiveness are limited. This study evaluates the implementation and impact of EOLC communication instruction in PCCM fellowship programs.MethodsA web-based survey was administered to PCCM fellows in the United States from December 2023 to February 2024. Statistical analyses were conducted to assess factors influencing fellow confidence in leading EOLC discussions in the ICU.ResultsA total of 167 fellows completed the survey (response rate: 7.4%). Most respondents (61%) reported one or two types of EOLC training in their programs. Nearly half (53%) felt their training was adequate. Fellows who led more EOLC discussions were significantly more confident in doing so (P < 0.001). Greater confidence was also associated with smaller ICU census and stronger faculty mentorship (P < 0.05).ConclusionsPCCM fellows feel more confident in leading EOLC discussions when they have supportive faculty mentors, manageable ICU workloads, and ample experience with these conversations. As nearly half of fellows report insufficient training, integrating these strategies into fellowship curricula is essential for improving EOLC communication.

A retrospective analysis of mental well-being, nutritional status, and comorbidity burden in elderly patients with community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) significantly affects elderly patients, leading to high morbidity and mortality rates. This study investigates the interplay between mental health, nutritional status, and comorbidities in determining the prognosis of elderly patients with CAP.

METHODS

A retrospective cohort study was conducted with 455 patients aged 75 and older who were hospitalized for CAP. Clinical data, including demographic information, comorbidities, and laboratory results, were collected. The WHO-5 Well-Being Index (WHO-5), Mini Nutritional Assessment Short Form (MNA-SF), and Charlson Comorbidity Index (CCI) were utilized to assess mental health, nutritional status, and comorbidity burden. Statistical analyses included logistic regression, Kaplan-Meier survival analysis, and mediation analyses.

RESULTS

The study found that the 28-day mortality rate was 9.67%, while the 90-day mortality rate reached 12.31%. Spearman's correlation analysis revealed significant positive correlations between the WHO-5 Well-Being Index and MNA-SF scores (r = 0.560) and albumin levels (r = 0.245), while negative correlations were observed with CCI (r = -0.202) and C-reactive protein levels (r = -0.242). Logistic regression analysis indicated that comorbidity, malnutrition, lower well-being, CAP severity, and mechanical ventilation are significant predictors of 28-day and 90-day mortality. Kaplan-Meier survival analysis demonstrated statistically significant differences in cumulative survival among various well-being groups. Multiple mediation analyses showed that mental well-being and nutritional status significantly mediated the association between CCI and 28-day and 90-day mortality.

CONCLUSION

This study emphasizes the critical roles of mental health, nutritional status, and comorbidities in the prognosis of elderly patients with CAP. Integrating these factors into clinical assessments may provide insights to inform management strategies, potentially improving patient outcomes and reducing mortality rates in this vulnerable population.

Association Between Shared Decision-Making During Family Meetings and Surrogates' Trust in Their ICU Physician

BACKGROUND

Although trust is central to successful physician-family relationships in ICUs, little is known about how to promote surrogates' trust of ICU physicians in this setting.

RESEARCH QUESTION

Does the conduct of family conferences and physicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the physician?

STUDY DESIGN AND METHODS

A mixed-methods secondary analysis was done of a multicenter prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at six US medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range, 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine physicians' use of five SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by physicians during the family meeting impacted trust scores.

RESULTS

In adjusted models, conduct of a family meeting was associated with increased trust (average change, pre- to post family meeting: 0.91 point [95% CI, 0.4-1.4; P < .01]). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI, 0.08-0.67; P = .01). If all four elements were used, trust increased by 1.48 points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and was excluded from the final model.

INTERPRETATION

The conduct of family meetings and physicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating physician.

Training to Promote Empathic Communication in Graduate Medical Education: A Shared Learning Intervention in Internal Medicine and General Surgery

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Top Ten Tips Palliative Care Clinicians Should Know About Teaching Trainees How to Conduct a Family Meeting

The family meeting is an essential component of effective palliative care (PC); however, medical students and junior doctors-in-training often consider leading a family meeting to be a daunting task. The old "see one, do one, teach one" axiom should not apply in preparing trainees to conduct a family meeting. After a review of the literature on established PC curricula, trainee perceptions of their PC educational experiences, and documented educational interventions in preparing trainees to conduct a family meeting, we have compiled a list of 10 tips for clinical educators to consider in assisting their students to feel better equipped to conduct productive family meetings.

Communication Training in Adult and Pediatric Critical Care Medicine. A Systematic Review

Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention (n = 15), cross-sectional survey (n = 5), and instrument validation (n = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention.

Nurses' contribution to end-of-life family conferences in critical care: A Delphi study

BACKGROUND

Family conferences (FCs) in the intensive care unit play an important role in reducing the psychological burden of patients' families at the end of life. However, no studies have clarified the specific roles and contributions of nurses related to FCs for terminally ill patients in critical care and their families.

AIMS AND OBJECTIVES

To clarify nurses' contribution to FCs for terminally ill patients in critical care and their families and examine the priority of each item.

DESIGN

A modified Delphi method was used.

METHODS

This study consisted of two phases. In phase 1, an initial list was developed based on a literature review, individual interviews, and a focus group interview. Phase 2 involved two rounds of the Delphi survey. Practitioners (N = 55) from hospitals across Japan were recruited to the Expert Panel for phase 2. They were asked to rate each nurse's contribution in terms of its importance using a 9-point Likert scale (1 being "not important at all" to 9 being "very important"). Fifty participants responded to round 1 of the survey, and 46 participants completed round 2. If at least 80% of the panellists chose an importance level of 7 or higher, the item was considered "important".

RESULTS

The 65 items of the potential list were classified into three domains: preparation (16 items), discussion and facilitating meaning during a FC (32 items), and follow up after a FC (17 items). The expert panel determined that, of 65 items, 49 items on the proposed list of nurses' contribution were considered important.

CONCLUSIONS

This study clarified nurses' contribution to FCs, with consensus on their importance by expert nurses.

RELEVANCE TO CLINICAL PRACTICE

This study could be useful for improving and ensuring the quality of nurses' contribution to FCs and promoting collaboration between nurses and other medical professionals.

Evaluation of Communication Skills Among Physicians: A Systematic Review of Existing Assessment Tools

OBJECTIVE

The importance of physician training in communication skills for motivating patients to adopt a healthy life-style and optimize clinical outcomes is increasingly recognized. This study inventoried and systematically reviewed the psychometric properties of, and the skills assessed by, existing assessment tools used to evaluate communication skills among physicians.

METHODS

This review was conducted in accordance with the PRISMA guidelines (PROSPERO: CRD42018091932). Four databases (PUBMED, EMBASE, PsychINFO, and SCOPUS) were searched up to December 2018, generating 3902 unique articles, which were screened by two authors. A total of 57 articles met the inclusion criteria and underwent full data extraction.

RESULTS

Forty-five different assessment tools were identified. Only 47% of the studies mentioned underlying theories or models for designing the tool. Fifteen communication skills were assessed across the tools, the five most prevalent were information giving (46%) or gathering (40%), eliciting patients' perspectives (44%), planning/goal setting (37%), and closing the session (32%). Most tools (93%) assessed communication skills using in-person role play exercises with standardized (61%) or real (32%) patients, but only 54% described the expertise of the raters who performed the evaluations. Overall, reporting of the psychometric properties of the assessment tools was poor-moderate (4.5 ± 1.3 out of 9).

CONCLUSIONS

Despite identifying several existing physician communication assessment tools, a high degree of heterogeneity between these tools, in terms of skills assessed and study quality, was observed, and most have been poorly validated. Research is needed to rigorously develop and validate accessible, convenient, "user-friendly," and easy to administer and score communication assessment tools.

Family Meeting Training Curriculum: A Multimedia Approach With Real-Time Experiential Learning for Residents

INTRODUCTION

Effective communication skills are widely recognized as an important aspect of medical practice. Several tools and curricula for communications training in medicine have been proposed, with increasing attention to the need for an evidence-based curriculum for communication with families of patients in the intensive care unit (ICU).

METHODS

We developed a curriculum for internal medicine residents rotating through the medical ICU that consisted of a didactic session introducing basic and advanced communication skills, computer-based scenarios exposing participants to commonly encountered dilemmas in simulated family meetings, and experiential learning through the opportunity to identify potential communication challenges prior to facilitating actual family meetings, followed by structured peer debriefing. Seventeen residents participated in the study.

RESULTS

We administered the Communication Skills Attitude Scale to participants before and after participation in the curriculum, as well as a global self-efficacy survey, with some items based on the Common Ground rating instrument, at the end of the academic year. There were no significant changes in either positive or negative attitudes toward learning communication skills. Resident self-perceived efficacy in several content domains improved but did not reach statistical significance.

DISCUSSION

Our curriculum provided interactive preparatory training and an authentic experience for learners to develop skills in family meeting facilitation. Learners responded favorably to the curriculum. Use of the Family Meeting Behavioral Skills (FMBS) tool helped residents and educators identify and focus on specific skills related to the family meeting. Next steps include gathering and analyzing data from the FMBS tool.

Developing and testing a comprehensive tool to assess family meetings: Empirical distinctions between high- and low-quality meetings

BACKGROUND

The heterogeneity with regard to findings on family meetings (or conferences) suggests a need to better understand factors that influence family meetings. While earlier studies have explored frequency or timing of family meetings, little is known about how factors (such as what is said during meetings, how it is said, and by whom) influence family meeting quality.

OBJECTIVES

(1) To develop an evaluation tool to assess family meetings (Phase 1); (2) to identify factors that influence meeting quality by evaluating 34 family meetings (Phase 2).

MATERIALS AND METHODS

For Phase 1, methods included developing a framework, cognitive testing, and finalizing the evaluation tool. The tool consisted of Facilitator Characteristics (i.e., gender, experience, and specialty of the person leading the meeting), and 22 items across 6 Meeting Elements (i.e., Introductions, Information Exchanges, Decisions, Closings, Communication Styles, and Emotional Support) and sub-elements. For Phase 2, methods included training evaluators, assessing family meetings, and analyzing data. We used Spearman's rank-order correlations to calculate meeting quality. Qualitative techniques were used to analyze free-text.

RESULTS

No Facilitator Characteristic had a significant correlation with meeting quality. Sub-elements related to communication style and emotional support most strongly correlated with high-quality family meetings, as well as whether "next steps" were outlined (89.66%) and whether "family understanding" was elicited (86.21%). We also found a significant and strong positive association between overall proportion scores and evaluators' ratings (r_s=0.731, p<0.001).

CONCLUSIONS

We filled a gap by developing an evaluation tool to assess family meetings, and we identified how what is said during meetings impacts quality.