Key to Cultural Awareness and Ethical Decision-Making in the ICU: Effective Communication

2014 - 4 August - Ethics in Critical Care
Jose L. Pascual, MD, PhD, FRCS(C), FACS; Joshua A. Marks, MD
Two experts look at what it takes to deliver culturally sensitive, ethical care.

Bombarded on rounds by complex questions stemming from deranged physiology and rerouted anatomy, the intensivist is challenged to construct treatment plans focused on reducing morbidity and mortality, maintaining organ function and restoring health. Yet, when directing care using a patient-centered approach, one realizes a great variability in patients’ responses to care depending on their culture, mores and beliefs. Ethical, moral, religious, and cultural viewpoints may differ broadly with regard to available treatment modalities, desires for autonomy, determinations of medical futility, and especially, goals of care and end-of-life decision making.

Common examples that highlight cultural perspectives to routine intensive care include: the patient with a low hemoglobin level who could be treated with a transfusion but refuses; the patient’s son who requests that his father not be told that he has a terminal condition; and the family that demands that “everything” be done despite knowing a condition is terminal. Not being able to heal patients with treatable conditions or being forced to treat those who cannot be cured stresses the intensivist and can impact the quality of care delivered. Several approaches exist to help understand and mitigate these conflicts and aid in rendering optimal, culturally sensitive, ethical care for critically ill patients.

The majority of the literature on incorporating patients’ cultural perspectives focuses on heightening provider awareness and increasing communication.(1,2) Much is related to end-of-life care. Exploring patients’ beliefs and outlooks on life by listening to their fears and preconceived ideas allows the intensivist to better inform and educate them about treatment options and risks. Additionally, the dialogue offers an opportunity to investigate together any reasonable alternatives congruent with their wishes.

In the United States and most European countries, the culture of medicine promotes patient autonomy and self-determination over paternalistic determinations of care.(3) Patient expectations and wishes are considered paramount, and the medical team is charged with providing accurate information to inform patient decision making.  In the Ethicus study, a prospective trial performed in European intensive care units (ICUs) to determine the frequency and types of end-of-life practices, it was found that patient wishes were known by the medical team in fewer than 20% of cases and that end-of-life decisions were only discussed with 68% of families.(3) The ETHICATT study sought to assess the attitudes of Europeans to end-of-life decisions and found that quality of life was universally more important than value of life, but that this was more important for healthcare providers than for patients and families. In contrast to patients, health professionals preferred fewer ICU admissions, less cardiopulmonary resuscitation and ventilator use and a more rapid transition to home or hospice when faced with terminal illness.(3) The ABCDs of dignity-conserving care -- attitudes and assumptions can affect practice; behaviors should always enhance patient dignity; compassion is sensitivity to the suffering of another and the desire to relieve it; and dialogue should acknowledge personhood beyond the illness -- provide a framework for respect of patients’ autonomy and preferences.(4)

Because most critically ill patients lack the capacity to make decisions, especially at the end-of-life, family often acts as the surrogate decision maker. As a result, clinician-family communication becomes a central component of medical decision making in the ICU.  Invariably, relatives report wanting a greater role in decision making in order to communicate their loved one’s unique values and preferences.(3) To participate in the process, families need unambiguous communication and honest information. Effectively discussing prognosis and assessing spiritual needs may help to address cultural differences and barriers.

Communication in the ICU is frequently inconsistent and complicated by time constraints, lack of communication skills training, unclear goals and processes and, at times, complex family dynamics.(2)  A review of randomized controlled trials of interventions to improve ICU communication found that the use of printed information and structured communication by the ICU team and an ethics or palliative care consultation improved family emotional outcomes and reduced ICU days.(2) However, a study examining a proactive ethics intervention for all patients in an ICU prior to any recognized ethical conflict found that this was ineffective in reducing overall length of stay, ICU days, nonbeneficial treatments and costs; furthermore, it did not improve patients’ and providers’ perceptions of quality of care.(5) On the other hand, regular conferences in which patients, families and care providers addressed diagnosis and prognosis, patient values, and family understanding and clarified the goals of care reduced family distress, improved comprehension and decreased the use of intensive treatments. Including family on daily rounds may also allow the multidisciplinary medical team to listen to families and convey their thoughts about the care rendered and its trajectory.(6) Families perceive daily communication of routine medical information to be highly important, and care team members’ direct contact with patients and families is more likely to improve care than educational interventions and training for caregivers alone.(7)

Many health systems have adopted the AIDET service model (acknowledge, introduce, duration, explanation, thank you) for delivering patient-centered care.(8,9) The AIDET philosophy can support successful communication even when participants are nervous, anxious and feeling vulnerable. Another tool to improve clinician-family communication in the ICU is VALUE (value family statements, acknowledge family emotions, listen to family, understand the patient as a person, elicit family questions).(1) VALUE has been shown to significantly reduce family feelings of anxiety, depression and posttraumatic stress disorder three months after a patient’s ICU death.(1) Additional communication tools  associated with increased quality of care, decreased family psychological symptoms and increased family ratings of communication include: conducting a private family conference within 72 hours of ICU admission; providing consistent communication from the various healthcare team members; acknowledging family emotions; exploring patient values and treatment preferences; and assuring the family that the patient will not suffer.(1) Obtaining a spiritual history (using the SPIRIT mnemonic: spiritual belief system, personal spirituality, integration with a spiritual community, ritualized practices and restrictions, implications for medical care, terminal events planning) may also assist in providing sensitive care that addresses patients’ cultural perspectives and core beliefs.(4)
Acknowledgment of the unique cultural perspectives of ICU patients and their families is key to providing optimal patient-centered care and improving satisfaction. Clinician failure in eliciting patient values and goals and in providing patient-centered recommendations remains an important target of one of the five Critical Care Societies Collaborative Choosing Wisely Campaign® initiatives.(10) Ultimately one must determine what an individual patient is willing to undergo for a given probability of survival and anticipated quality of life.(4) Incorporating the patient’s beliefs, culture and values into daily ICU care requires adequate provider training, good communication between clinician and family and the collaboration of a well-functioning interdisciplinary team.


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