Page 156 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

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

The second step is to assess family preferences in decision making additional guidance for a structured and evidence-based approach to
and finally to adapt the strategy to both the clinical context and fam- communication during ICU family conferences. The three stages of
59
ily preferences. Significant communication skills are necessary to align an ICU family conference include activities prior to the conference,
clinicians and families around shared goals of care and implement this during the conference, and following the conference. Prior to the family
decision-making framework, and most physicians have not received conference, consensus should be achieved among the clinicians treat-
formal education or training in communication. 60,61 Fortunately there ing the patient to ensure consistency and avoid confusion. The setting
are descriptive reports and clinical trials that provide insights into how for the conference should include a private, quiet location free from
ICU clinicians should approach family conferences. 58,62 distractions, and each person present should introduce themselves and
64
After evaluating 21 articles representing 16 unique interventions, describe their relationship, whether clinical or personal, to the patient.
a systematic review of interventions to improve ICU communication The physician usually opens the conference and a strategy to achieve
identified two recurring themes associated with improved outcomes. family-centered communication starts by asking the family their per-
62
First, the use of a structured approach to communication with fami- ception of the patient’s status including diagnosis and prognosis. This
65
lies improves patient- and family-centered outcomes and timing of should be followed by active listening and offering families adequate
decisions about major treatments. The VALUE mnemonic detailed in time to speak. Then the physician often provides medical information;
44
Table 18-1 is a useful tool for clinicians demonstrated, in a randomized it is important to do this using language the family understands and con-
trial, to improve family-centered outcomes of emotional distress and firm their understanding. The conversation should center on what the
lessen the use of nonbeneficial ICU therapies. Table 18-2 provides patient’s values and treatment preferences would be in the current clini-
63
cal context. The use of empathetic statements and acknowledging and
66
43
43
TABLE 18-1 Useful Mnemonic for Critical Care Clinicians Leading ICU Family addressing family emotions can improve family experiences. Families
Conferences (Demonstrated to Improve Family Outcomes) 63 should be assured that the patient will not suffer or be abandoned prior
to death and receive explicit support for their decisions. The conclu-
67
66
Mnemonic Cue Explanation sion of a family conference should include summarizing the discussion
67
Value Appreciate what family members say and decisions, asking for questions, affirming family decisions, and
arranging for follow-up as necessary.
Acknowledge Explicitly recognize family emotions
After the family conference, it is important to establish that the fam-
Listen Allow families time to speak and to think about information presented ily understands the information provided and the treatment plans and
Understand Learn and understand who the patient is as a person knows how to contact the clinical team if additional questions arise. The
Elicit Solicit questions from family members role of nurses during and following ICU family conferences is important
as nurses often find themselves functioning as the front line for family
Data from Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for questions and concerns.
relatives of patients dying in the ICU. N Engl J Med. February 1, 2007;356(5):469-478.
The second theme identified in the systematic review of interventions
to improve ICU communication was the provision of printed information
TABLE 18-2 Key Steps for Improving Communication During Interdisciplinary to families. This practice increases family comprehension and reduces
ICU Family Conferences emotional distress associated with ICU hospitalizations. This is a simple
62
Stages of the ICU Family and effective mechanism to improve ICU clinician-family communica-
Conference Common Steps and Topics tion and several major professional societies including the American
College of Chest Physicians, American Thoracic Society, and the Society
Prior to a family conference in 1. Plan the specifics of location and setting: quiet, for Critical Care Medicine have appropriate materials available through
the ICU private place their respective Web sites. Another excellent source for ICU palliative
2. Conduct a “preconference” with the clinicians care resources can be found from the Center to Advance Palliative Care’s
to develop consensus and ensure consistency of IPAL-ICU Project available at http://www.capc.org/ipal-icu/. 68
information provided
3. Family and clinicians should introduce them- ■ PAIN ASSESSMENT AND MANAGEMENT
selves and describe their relationship with the
patient Pain assessment and management is a broad topic and full discussion
is beyond the scope of this chapter, yet some basic aspects to pain
Conducting a family conference 1. Elicit family perceptions on the patient’s status management are especially relevant to ICU clinicians if a transition to
in the ICU and expected outcomes end-of-life care is planned. ICU patients experience significant physical
2. Provide medical information using clear and sim- suffering with 55% to 75% of ICU patients who were able to complete
ple language and confirming family understanding assessment tools reporting pain, anxiety, sleep disturbance, hunger, or
3. Use active listening and provide family adequate thirst and rating these symptoms as moderate to severe in intensity.
69
time to speak Furthermore, among chronically critically ill patients completing symp-
4. Use empathic statements to provide support tom assessment tools, 90% are symptomatic with 54% reporting pain at
for families the highest possible level. 70
a. Difficulty of having a critically ill loved one The first step in symptom management is a symptom assessment.
b. Difficulty of surrogate decision making Pain is an important symptom to address, although there are many other
c. Impending loss of a loved one symptoms that are prevalent among critically ill patients as noted above.
5. Acknowledge and address family emotions A patient’s self-report is considered the most reliable pain assessment
6. Explore and focus on patient values and treat- and among patients who can communicate the 0-to-10 numeric rat-
ment preferences ing scale is the most commonly used assessment tool. This simple and
7. Affirm nonabandonment of the patient and family
71
reliable tool has been validated for ICU patients. However, many ICU
Finishing a family conference in 1. Summarize information and decisions patients are unable to reliably self-report pain so alternative assessment
the ICU 2. Ask for questions and allow family time to options are necessary. There are several objective pain assessment tools
72
consider questions designed for noncommunicative ICU patients which have received some
3. Reaffirm and support family around decisions made degree of validation. These tools combine behavioral assessments (eg,
73
Adapted with permission from Curtis JR, Vincent J-L. Ethics and end-of-life care for adults in the inten- facial expression) with physiologic indicators of pain (eg, heart rate).
74
sive care unit. Lancet. October 16, 2010;376(9749):1347-1353. Specifically, the behavioral pain scale (BPS) and the Critical-Care Pain

Section01.indd 122 1/22/2015 9:37:49 AM