The intensive care unit family meeting: Making it happen☆
Introduction
Among the most essential responsibilities of clinicians in the intensive care unit (ICU) is communication with patients and their families. Because ICU patients are usually unable to participate directly [1], complex discussions about diagnosis, prognosis, treatment plans, or patients' care preferences occur more often with families (a term used broadly to include individuals who may or may not be relatives but are important in the patient's life and may be legally authorized to make health care decisions). The “ICU family meeting” (or “family conference”) is generally understood to refer to this type of discussion, although the specifics of content, duration, venue, participants, and process may vary [2]. Frequently, the discussion addresses issues of pivotal importance—matters of life and death, literally—such as the benefits and burdens of intensive care therapies and the goals and values of the patient and family.
Evidence establishes the importance of the family meeting to critically ill patients and families. Over 3 decades of research, ICU families have consistently ranked communication as their preeminent concern, at least as important as caregivers' clinical skills [3]. A recent randomized, controlled, multicenter trial showed that, together with the use of printed informational materials, proactive, protocolized meetings by ICU physicians with families of patients dying in the ICU significantly reduced the prevalence and level of family member anxiety and depression and posttraumatic stress disorder as long as 3 months after the death [4]. In-depth analyses of transcripts of family meeting audiotapes illuminate the relationship between specific clinician statements and family satisfaction [5], [6]. It is also clear from a series of other studies that a scheduled and structured approach to family meetings can help to optimize efficient utilization of scarce and expensive ICU resources, as measured by length of stay in the ICU and hospital and duration of invasive treatments with limited clinical benefit [7], [8], [9]. Conversely, poor communication is associated with adverse outcomes for patients, families, clinicians, and health care systems [10], [11], [12].
Yet, research continues to reveal inadequacies in ICU communication [6], [13], [14]. One major problem is that family meetings fail to occur in a timely fashion; for many patients, no meeting is held at all, even during a prolonged ICU stay [9], [13], [15]. In a large, national survey of physician and nurse directors of ICUs, respondents affirmed the importance of regular meetings of clinicians with families but reported that such meetings were not conducted in two thirds of ICUs under their direction [13]. A minority few of ICU families in a leading academic medical center met with an attending ICU physician in the usual course of care [9]. Of 1500 patients in the multicenter Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments who were treated for more than 2 weeks in ICUs, fewer than 40% reported discussion with their doctor about prognosis or treatment preferences [16].
Why don't family meetings take place promptly for most ICU patients? With unambiguous data showing benefit, what explains the failure to integrate this essential, evidence-based practice into regular care more consistently? Although empirical and theoretical articles have addressed how to approach family meetings in terms of content and process [2], [5], [6], we are unaware of published literature about how to increase their frequency and regularity as opportunities for optimal discussions. In this article, we begin by examining factors that may serve as barriers to family meetings. We then discuss practical strategies that may be helpful in overcoming barriers and making family meetings happen.
Section snippets
Barriers
Factors related to clinicians, to patients and families, and to processes, structures, and systems of care may serve as barriers to the implementation of family meetings in a timely and consistent basis. Table 1 summarizes potential barriers, which are discussed more fully below.
Strategies that may be helpful
The Institute of Medicine has identified improvement of palliative care in the ICU, which includes effective communication with patients and their families, as a national health priority [28]. For all health care providers and fields, it has also prioritized “closing the gap” between current knowledge of optimal care and current clinical practice [29]. The ICU family meeting is known to be an effective strategy, positively associated with outcomes valued by patients, families, clinicians, and
Conclusion
We have suggested a series of strategies that may be helpful in making family meetings happen in the ICU. Some of these strategies will be more appropriate for certain ICUs than for others, and all would require adaptation to the needs, resources, clinicians, and “culture” of a specific ICU; each ICU has its own “ecosystem,” and the environments of different ICUs can be vastly different, even within a single institution. In this article, we have focused on approaches to address some of the
Acknowledgments
We wish to thank the very creative and dedicated ICU professionals involved in the TICU Program of the VHA who have skillfully translated knowledge into practice and improved palliative and other care for critically ill patients and families. Dr Nelson is the recipient of a K02 Independent Scientist Research Career Development Award (AG024476) from the National Institute on Aging (NIA). This work was supported in part by R21 AG029955 from NIA. The VHA sponsored the development of the Care and
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How to communicate with family members of the critically ill in the intensive care unit: A scoping review
2023, Intensive and Critical Care NursingCitation Excerpt :A total of 32 records (51 %) were included and further divided into four sub-categories: family meetings (n = 15), incorporating families into rounds (n = 7), communication navigators (n = 6), and bedside nurse-family communication (n = 4). To this sub-category, we allocated fifteen records that provided relevant information about ICU family meetings as a platform for family-clinician communication (Kerckhoffs et al., 2020; Kumpf et al., 2019; Briggs, 2017; Davidson et al., 2017; Seaman et al., 2017; Garrouste-Orgeas et al., 2016; Kynoch et al., 2016; de Havenon et al., 2015; Warrillow et al., 2015; Levin et al., 2010; Gay et al., 2009; Machare Delgado et al., 2009; Curtis and White, 2008; Lautrette et al., 2006; McDonagh et al., 2004). Due to the persisting lack of definitional distinctness between the terms “family conference” and “family meeting”, in the following the latter will be used only, while including both in meaning.
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2020, Critical Care Nursing Clinics of North AmericaCitation Excerpt :The Critical Care Nurse Communicator (CCNC) program is a primary palliative care ICU intervention at an academic, quaternary referral center designed to augment support for patients and surrogate decision makers facing serious, life-limiting illness. Family meetings serve as a critical forum for family and health care team members to discuss a patient's diagnosis, clinical course, prognosis, treatment preferences, and goals of care.5 These crucial conversations have been shown to improve the quality of communication and reduce family distress, particularly at the end of life.6
Communication with patients' families in the intensive care unit: A point prevalence study
2019, Journal of Critical Care
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Disclosure: Dr Nelson, Dr Pronovost, and Mr Bassett have served as Subject Matter Expert consultants for the Voluntary Hospital Association, Inc, Transformation of the ICU program, which sponsored the development of the Care and Communication Bundle of ICU Palliative Care Quality Measures.