April 24, 2019

Communication and Self-Awareness in the ICU

If you ask critical care specialists, most would say they communicate well with families, especially when it comes to goals of care, and determining the limits of aggressive treatment and therapies. However, data is suggesting otherwise.  In a recent study published online in JAMA Internal Medicine, researchers set out to determine the extent to which ICU clinicians and surrogates incorporate critically ill patients’ values and preferences into treatment decisions.

Two-way communication between families/patients and clinicians is paramount. As our patients’ families need to understand what treatments and procedures are planned, doctors also need a strong understanding of what the family prefers when the patients themselves are unable to express clearly.

In the study, Clinician-Family Communication About Patients’ Values and Preferences in Intensive Care Units, “249 clinician-family intensive care unit conferences were analyzed for statements about incapacitated patients’ treatment preferences and health-related values and applied them to deliberation and treatment planning. Most conferences lacked adequate communication, particularly in terms of deliberating about patient values and preferences and applying them to treatment decisions.”

Among the 249 conferences that addressed a decision about goals of care, 25.8% contained no information exchange or deliberation about patients’ values and preferences. Clinicians and surrogates exchanged information about patients’ values and preferences in 68.4% of the conference; however, patients’ values were applied to the treatment decision in only 44.3% of those conferences. Important end-of-life considerations, such as physical, cognitive, and social functioning or spirituality were each discussed in 35.7% or less of the conferences; surrogates provided a substituted judgment in 13.5%, and clinicians made treatment recommendations based on patients’ values and preferences in 8.2% of conferences.

I was taken aback that in only 13.5% of the conferences did surrogates make a substituted judgment, and that patients’ values and preferences were taken into consideration for treatment recommendations in only 8.2% of the conferences. This data was quite eye-opening. It got me thinking about how I, in my goals of care discussions with families, would fare if my conversations were analyzed. This study shows that we can do much better when it comes to making sure we include the values and preferences of our patients when making treatment decisions.

A technique that I’ve found to be very effective is to ask the family, “If Mom (for example) was standing outside of the ICU room right now and looking at herself, what would she say?” This question does two things at once: it takes into account what the patient wants, and it also lifts the burden of guilt from the family members making the decision. When framed this way, the responsibility of the decision becomes more the patient’s with the family only representing what the patient can’t say on his or her behalf.

Regarding our perception of how effective our ICU family meetings are, it’s often human nature to assume that we’re doing well with activities we do routinely. This important study in JAMA Internal Medicine shows that ICU doctors have room to improve in their communications and decision making. While, of course, we place the interests of our patients first, this study should give us pause to reflect in making sure that whatever we recommend for our patients, we consider what they would say, if they were able.

For study details, please click here.

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