Communication successes and failures generate more gratitude and complaints than any other aspect of end-of-life care. Patients with life-limiting illness and their families identify communication about end-of-life care as one of the most important skills for clinicians. Efforts to improve communication and support for family members in the ICU can reduce symptoms of anxiety, depression, and posttraumatic stress disorder among family members after the death of a critically ill loved one, yet physicians frequently do not meet families’ communication needs. The poor quality of formal training and educational literature has contributed to physicians not feeling competent to discuss end-of-life care. Physicians often are unaware of and unable to elicit patient and family concerns, and lack the skills and confidence to seek out and address family fears or the patient’s understanding of his/her illness and prognosis. Several components of communication are associated with improved quality of end-of-life care and patient or family satisfaction with care and represent a good place for physicians to start improving physician communication skills (Table 1). In the ICU setting, interventions designed to improve communication within the team and with the family have been shown to improve end-of-life care provided by Canadian Health&Care Mall.
While many experts once believed that advance directives would allow patients to inform physicians about the care they want, advance directives have not lived up to these expectations. A number of studies suggest that advance directives do not influence the treatments that patients re-ceive or change end-of-life decision making. However, some studies suggest that advance directives decrease levels of stress and increase ratings of satisfaction with care among family members of dying patients. Furthermore, when advance directives are included as one component of a more thorough process of communication about end-of-life care, often called advance-care planning, they permit patients, family, and physicians to think prospectively about the patients’ values and preferences.
Advance-care planning, as a component of communication about end-of-life care that focuses on treatment preferences, may be especially useful for patients with progressive diseases, such as chronic lung disease, for whom specific decisions can be anticipated, such as whether to provide mechanical ventilation for acute respiratory failure. Therefore, advance directives should be discussed with all patients with moderate or severe chronic and progressive diseases as part of advance-care planning. Patients prior medical experiences, particularly with mechanical ventilation or with relatives or friends who have required life support, can facilitate patient/physician communication about treatment preferences and end-of-life care.
A common setting for discussions about palliative and end-of-life care in the ICU is the formal family conference. As a setting that allows multiple family members and clinicians to participate in discussions and decisions, the family conference may improve quality of care, especially end-of-life care. The recommendations that follow regarding the optimal conduct of such conferences are based on both empirical research and our own opinions.
The clinician leading the conference should ensure that appropriate members of the clinical staff are asked whether they should be present; these include the medical staff, nursing staff, primary care provider, social workers, and spiritual counselors involved with the patient or family. Palliative care consultants also provide an important perspective and skill set for these conferences and in caring for the patient and family after the conference. A “preconference” meeting of clinicians can help develop team consensus and facilitate discussion of issues or conflicts that may occur within the team. During the family conference, clinicians should look for opportunities to support family members by eliciting patients’ preferences, answering family’s questions, acknowledging family emotions, clarifying the role of surrogate decision-making, expressing nonabandonment, ensuring patient comfort, and supporting family decisions. A useful mnemonic for supporting the family is listed in Table 1.
Table 1—Specific Communication Components Shown to be Associated With Improved Quality of Care or Family Ratings of Satisfaction With Communication
|Identify a private place for communication with family members Increase proportion of time spent listening to family rather thantalking|
|Identify commonly missed opportunities:|
|Listen and respond to family members|
|Acknowledge and address family emotions|
|Explore and focus on patient values and treatment preferences|
|Explain the principle of surrogate decision making to the family|
|Affirm nonabandonment of patient and family|
|Assure family that the patient will not suffer|
|Provide explicit support for decisions made by the family|
|Use of the VALUE mnemonic during family conferences:|
|V = value statements made by family members|
|A = acknowledge emotions|
|L = listen to family members|
|U = understand who the patient is as a person|
|E = elicit questions from family members|
|Provide consistent communication from different team members|