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CHAPTER 17: Caring for the Family 119

huddle and “time-out” by clinicians and others just before the meeting
TABLE 17-2 Principles of Proactive Communication During a Family
Conference: The VALUE Checklist begins, in order to ensure consistent information and messages. There
are a series of procedural best practices and techniques (eg, the VALUE
VALUE family members approach and others) that are associated with higher-quality outcomes
V: Value family statements from the conference itself. Family conferences should often be attend-
A: Acknowledge and address family emotions ing supervised, rather than conducted by unsupervised novice trainees
with little experience. The procedure itself can be taught and assessed
L: Listen and respond to family members
using high-fidelity human simulation. 38-40 Finally, when the conference
U: Understand the patient as a person is complete, a note about the conference should be written in the medi-
- Explore and focus on patient values and treatment preferences cal record. 41
E: Elicit family questions
CONCLUSIONS
Patient- and family-centered care is an integral part of providing
high-quality care in the ICU. Family members of ICU patients are
TABLE 17-3 Commonly Recommended Approaches to Supporting the Families at high risk for developing long-term, significant morbidity from the
of Critically Ill Patients ICU experience, with astonishingly high rates of depression, anxiety,
Provide support—and supportive environments—for families. and posttraumatic stress disorder. ICU providers and directors should
• Be attentive to providing a comfortable ICU environment and waiting room. 42 be particularly attentive to creating supportive environments for the
• Offer social work and clergy/chaplaincy support. 37,43,44 families of ICU patients and creating policies and routines that support
• Strongly consider open visiting hours for families. 37,45 the family. Besides improving the physical environment (waiting rooms
• Strongly consider encouraging families to participate in ICU rounds when desired. 37,45 and ICU rooms), ICUs can create policies that provide families access to
Communicate routinely and consistently with ICU patients and families. consistent information about their loved ones’ care: experts commonly
recommend open visiting hours and family presence in ICU rounds.
• Begin family conferences within 48-72 hours of ICU admission. 37,45 Stronger levels of evidence support focusing on routine, early family
• Conduct multidisciplinary family conferences using the VALUE approach (Table 17-2) conferences and on conducting family meetings using a structured
34
in a private room. 24 approach summarized in the VALUE mnemonic: Value and appreciate
• Provide culturally competent care, taking into account communication preferences of what the family members said, Acknowledge family members’ emotions,
patients and families. 37 Listen to what family members say, ask questions that allow providers to
• Ensure that the entire multidisciplinary team provides consistent information to patients Understand who the patient is as a person, and to Elicit questions from
and families about diagnosis, prognosis, and the plan of treatment. 37,45 the family members.
Care for patients during the dying process, and for families after the death of a loved one.
• Palliative care should be a formal part of critical care education, and palliative care con-
sultation sought routinely and when needed. 37
• Provide bereavement services and follow-up care for family members whose loved ones die. 37 KEY REFERENCES
• A controlled trial to improve care for seriously ill hospitalized
patients. The study to understand prognoses and preferences for
stress symptoms, less depression, and less anxiety. The proactive com- outcomes and risks of treatments (SUPPORT). The SUPPORT
34
munication strategy used included an end-of life family conference Principal Investigators. JAMA. 1995;274(20):1591-1598.
according to specific guidelines 25,29,35,36 and concluded with the provision • Azoulay E, Pochard F, Chevret S, et al. Half the family members of
of a brochure on bereavement. What is particularly useful for practi- intensive care unit patients do not want to share in the decision-
tioners is that the authors integrated the key communication elements making process: a study in 78 French intensive care units. Crit
into a mnemonic and checklist—the VALUE checklist 24,34 (summarized Care Med. 2004;32(9):1832-1838.
in Table 17-2). This checklist specifies the following five objectives: to • Curtis JR, Nielsen EL, Treece PD, et al. Effect of a quality-
Value and appreciate what the family members said, to Acknowledge improvement intervention on end-of-life care in the intensive
the family members’ emotions, to Listen, to ask questions that would care unit: a randomized trial. Am J Respir Crit Care Med.
allow the caregiver to Understand who the patient was as a person, 2011;183(3):348-355.
and to Elicit questions from the family members. In this randomized,
controlled trial, use of this instrument significantly reduced family • Curtis JR, Sprung CL, Azoulay E. The importance of word choice
members’ subsequent anxiety, depression, and PTSD. in the care of critically ill patients and their families. Intensive Care
Several other items are commonly recommended for support of Med. 2014; 40:606-608.
the family of ICU patients. Although generally based on lower qual- • Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the
ity of evidence than randomized controlled trials, many of these make intensive care unit. Lancet. 2010;376(9749):1347-1353.
intuitive sense, are associated with little risk, and require few additional • Curtis JR, White DB. Practical guidance for evidence-based ICU
resources. These items were the subject of a 2004-2005 American family conferences. Chest. 2008;134(4):835-843.
College of Critical Care Medicine Task Force and are published as a for-
37
mal clinical practice guideline. A number of these recommendations • Hunziker S, McHugh W, Sarnoff-Lee B, et al. Predictors and
are summarized in Table 17-3. correlates of dissatisfaction with intensive care. Crit Care Med.
2012;40(5):1554-1561.
TREATING FAMILY CONFERENCES LIKE PROCEDURES • Kentish-Barnes N, Lemiale V, Chaize M, Pochard F, Azoulay E.
Assessing burden in families of critical care patients. Crit Care
From an operational standpoint in our own practice—particularly when Med. 2009;37(10 suppl):S448-S456.
teaching trainees—we have found it helpful to conceptualize family • Lautrette A, Darmon M, Megarbane B, et al. A communication
conferences like invasive procedures. Why? They have many things strategy and brochure for relatives of patients dying in the ICU.
in common. Like invasive procedures, family conferences have high N Engl J Med. 2007;356(5):469-478.
risks of causing significant harm if done incorrectly. There should be a

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