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116 PART 1: An Overview of the Approach to and Organization of Critical Care

The narrative as a means to better understand any experience— • Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in
particularly a difficult one—has long been used by medical anthropolo- critical care nursing staff. Am J Respir Crit Care Med. April 1,
gists. Nursing literature has incorporated the narrative as a reflexive 2007;175(7):698-704.
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learning tool. The narrative is also helpful in healing following difficult
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experiences, for example, in survivors of critical illness. In traumatic • Pronovost P, Berenholtz S, Dorman T, et al. Improving commu-
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events such as in those exposed to conflict or war, narrative is considered nication in the ICU using daily goals. J Crit Care. 2003;18:71-75.
a treatment that involves emotional exposure to the memories of trau- • Quenot JP, Rigaud JP, Prin S, et al. Suffering among carers work-
matic events and the reorganization of these memories into a coherent ing in critical care can be reduced by an intensive communication
chronological story. Narratives are based on the teller’s personal values, strategy on end-of-life practices. Intensive Care Med. January
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cultural beliefs, and emotions, and legitimize the narrator’s reasoning. 2012;38(1):55-61. Epub 2011 Nov 30.
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Medicine, after all, combines rational and irrational elements, joining • Teixera C, Tibiero O, Fonseca AM, Carvalho AS. Ethical decision
attention to the body with concern for the moral dimensions of sickness making in intensive care units: a burnout risk factor? Results from
and suffering. The tales physicians tell are always those of their patient’s a multicenter study conducted with physicians and nurses. J Med
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illness or disease, and not their own. Narratives by trainees and caregiv- Ethics. 2014;40:97-103.
ers in meaningful or difficult end-of-life decision-making situations may
be helpful in fostering introspection, learning, and resolution of difficult
experiences. Alleviation of stress may lie in the simple telling of the tale.
The American Association of Critical Care Nurses considers commu-
nication, consisting of exchange of information or respectful dialogue, REFERENCES
as the most important element in establishing and sustaining a healthy Complete references available online at www.mhprofessional.com/hall
work environment. Teamwork, however, means different things to
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physicians and nurses. Creating a culture that encourages communica-
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tion, and incorporates the discussion of patient safety issues during ICU
rounds, has been touted as a potential aid in ICU adverse event reduc-
tion, and certainly effective communication between physicians and
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nurses is linked to fewer errors. Since ICU conflicts appear to be inde- CHAPTER Caring for the Family
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pendent predictors of severe burnout in both physicians and nurses,
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communication strategies are useful during end-of-life care and in 17 Sabina Hunziker
the prevention and management of ICU conflicts. Most publications Michael D. Howell
addressing communication in the ICU, and aimed at physicians, particu-
larly around end of life, focus on the physician’s ability to communicate
with the family or decision makers. In contrast, the nursing literature
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implicates poor communication as one of the most important causes of KEY POINTS
moral distress among the staff. Nursing assessments of quality of care
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are strongly related to their perception of collaboration. Physicians may • Family members of ICU patients often serve as surrogate decision
not be natural leaders in establishing interprofessional intensive care makers and are at high risk to develop long-term psychological prob-
communication strategies. An initiative that considers communication lems, such as depression, anxiety, and posttraumatic stress disorder.
as a safety feature on par with infection control would require orga- • Proactive communication has been shown to be an important
nization and buy-in from all stakeholders. If such an initiative were factor improving satisfaction and lower psychological burden in
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mandated, a prospective evaluation on the well-being of caregivers in families of patients dying in the ICU (end-of-life situation).
the ICU could determine whether improved communication strategies • It can be assumed that around 50% of family members do not
could alleviate the stressors associated with burnout. understand the diagnosis, prognosis, and treatment of their loved
ones. Better information and higher completeness of information
have been shown to result in increased family satisfaction.
KEY REFERENCES • Relatives’ preference for involvement in the decision-making pro-
cess varies. Physicians should respect their preference and adapt
• AACN Standards for Establishing and Sustaining Healthy Work the family conference accordingly.
Environments: A Journey to Excellence—Executive Summary
AACN website http://www.aacn.org/wd/hwe/docs/execsum.pdf. • Family conferences can be improved if (a) they occur promptly
• Embriaco N, Azoulay E, Barrau K, et al. High level of burnout in after ICU admission of the patient, (b) information is consistent
across treating teams, (c) there is an adequate room for the confer-
intensivists: prevalence and associated factors. Am J Respir Crit ence with privacy and good atmosphere, and (d) health care work-
Care Med. April 1, 2007;175(7):686-692. ers ensure that in an end-of-life situation the patient will not suffer
• Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. and provide explicit support for decisions made by the family.
Burnout syndrome among critical care healthcare workers. Curr • Empathic statements and more time listening to family members
Opin Crit Care. 2007;13:482-488. (and less time talking by health care workers) improve families’
• Fraser K, Huffman J, Ma I, et al. The emotional and cognitive experiences in the ICU.
impact of unexpected simulated patient death: a randomized con-
trolled trial. Chest. 2014;145:958-973.
• Halpern NA, Pastores SM, Oropello JM, Kvetan V. Critical care
medicine in the United States: addressing the intensivist shortage
and image of the specialty. Crit Care Med. 2013;41(12):2754-2761. INTRODUCTION
• Kim MM, Barnato AE, Angus DC, Fleisher LA, Kahn JM. The In recent years, the focus of health care workers in the critical care
effect of multidisciplinary care teams on intensive care unit mor- settings has broadened from looking at disease only to patient- and
tality. Arch Intern Med. February 22, 2010;170(4):369-376. family-centered care. In line with this, the Institute of Medicine defines
high-quality care as safe, timely, efficient, effective, equitable, and

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