Ashish Khanna, MD, FCCP; Lillian L. Emlet, MD, MS, FACEP, FCCM
“Your son has . . . a poor neurological prognosis,” the fellow stuttered again and again. He could not say the word “die,” despite being asked repeatedly by the distraught family member if the patient was going to die. The fellow knew that this patient was going to die but did not deliver this message when prompted in a heated and intense family discussion. Fortunately, this was a simulated scenario, one meant for teaching and learning. Certainly, it was one that taught the fellows participating in the training program a strong and unforgettable lesson.1
We spend years progressing through medical school, residency, and fellowship training. At the end of this long road wait the titles of staff physician and intensivist. To prove our competency for these new roles, we pass various board examinations and meet criteria set by specialty societies and institutions. Yes, we know what we are doing correctly with the medicine aspect of critical care medicine. However, much is deficient when it comes to the nonmedical aspect of critical care medicine. This space is occupied by the art of talking to the patient and the patient’s loved ones, and not just talking, but talking effectively, so this may be more aptly labeled “communication.”
The journey from resident to fellow and onwards is also a journey from being supervised to being a supervisor.2 The Society of Critical Care Medicine’s (SCCM) In-Training Section helps and supports trainees as they pass through these critical phases. In this process, SCCM helps to foster career development during this transition. How much of a challenge is patient- and family-centered communication for a brand-new intensivist? We surveyed the audience at the In-Training Section’s sessions during SCCM’s Critical Care Congress over the last three years. Effective communication as a part of an end-of-life discussion featured as a consistent concern for the in-training community.3,4
Why is communication an essential skill in the intensive care unit (ICU)? A patient struggling for life in the ICU places family members under immense anxiety and burdens them with high-stress situations. Very few critically ill patients can actually participate in ICU decisions.5 In this setting the family becomes the major target for all communication. In actuality, families rate this skill as more important than clinical skills, especially because patient outcomes depend on what and how we communicate. McDonagh et al recorded 51 family conferences in four different hospitals. They found that for family conferences with a mean duration of 32 minutes, the percentage of time family members actually got a word in was only about 29%.6 We, the ICU physicians, end up speaking for a majority of time during all family communication sessions and hence family satisfaction at the end of these sessions is barely anything to speak of. We are also not very cognizant of what we say. Stapleton et al identified certain statements associated with increased family satisfaction during such meetings. These included assurances that the patient will not be abandoned prior to death, will be kept comfortable, will not suffer, and importantly, that the physician in charge will provide support and will help the family with decisions to withdraw or continue life support.7 The University of Washington’s Palliative Care Center of Excellence promotes the VALUE five-step approach to improving family communication in the ICU. This simple acronym stands for: value family statements, acknowledge family emotions, listen to the family, understand the patient as a person, and elicit family questions.8
How can we improve our communication skills with families in the ICU? Practice can make performance better. Using simulation to improve communication skills has been shown to improve provider comfort, reduce physician burnout, and decrease distress of families and long-term psychological impact by providing empathic emotional support.9–12 Using simulation to improve communication skills of other physician/provider groups has been demonstrated to be effective and has resulted in an increased number of empathic statements and increased time that the family spends talking in family meetings. In 2012, IntensiveTalk trained 10 pairs of critical care and palliative care physicians at institutions across the country in how to teach communication skills for critically ill populations, resulting in an increase in simulation-based communication skills training for critical care providers.12–15 The program VitalTalk provides training and resources for providers of all disciplines, including videos, handouts, an app, and intensive train-the-trainer courses on facilitating communication training sessions for a wide variety of disciplines. VitalTalk training programs have taught physicians from a wide variety of specialties for the last 10 years in empathic, patient-centered communication surrounding serious news and end-of-life care.
How can patient-centered exploration of goals be achieved by the young intensivist? Instead of coming into a family meeting with the medical team’s agenda, come with a desire to be curious about what the illness has meant to the patient and family. Being curious allows you to explore which activities, people, spirituality, recreation, and work the patient and family find meaningful. Listening to the hopes for the future allows the medical team to understand and join in those goals. Supporting the surrogates in their role of speaking on behalf of the patient is crucially important; no one is prepared for the surrogate role, and the mix of emotions and interfamily conflict and stress is the norm, not the exception. Normalizing the stress and offering that the care team walk the journey with the family will build trust so that the family can be guided together to make a plan of care that is reasonable yet realistic. After good exploration, understanding, and emotional support, the foundation of trust is built so that the medical team can provide a recommendation for patient-centered care. The art of communication is the vehicle by which we support patients and their families and is so integral to our practice that here is where we often find meaning in being an intensivist.
Trainee yesterday, trainer today, also known as the 30th of June phenomenon, happens to all of us as we pass through the ending of fellowship and the beginning of staff membership (on June 30). Without realizing it, we have not just moved into a new office, new scrubs, new name badge, better paycheck, etc., but we have also knowingly or unknowingly transitioned from a trainee to a trainer. Of all the skills on which we have to train our trainees, the art of effective communication with the ICU patient’s family probably ranks as one of the most challenging. The brand-new intensivist is thus faced with several challenges as he/she walks into a family meeting. On the one hand the intensivist has to deal with the family and their emotions and a difficult situation but, on the other hand, he/she has to use this as a training or teaching moment for the trainee. The time has come when we truly start working on our trainees’ skills with family-centered communication during the fellowship year itself, and that we give it as much emphasis as the knowledge and practice of clinical critical care medicine. Only then will we ease the transition through the in-training period, and only then will we do justice to the anxious family member who sits in the family lounge waiting to hear from us.
1. Society of Critical Care Medicine. Learning to say the word “die.” Critical Connections. Mt. Prospect, IL: Society of Critical Care Medicine; 2015. http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Learning-to-Say-the-Word-.aspx. Accessed May 24, 2017.
2. Frankel HL, Syed M, Khanna A. Fellow as a resident teacher: the journey from supervision to supervisor. Critical Connections. Mt. Prospect, IL: Society of Critical Care Medicine; 2016. http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Fellow-as-a-Resident-Teacher---The-Journey-from-Supervision-to-Supervisor.aspx. Accessed May 24, 2017.
3. Sreedharan R, Bhalala U, Khanna A, et al. My biggest concern: transitioning from fellow to faculty. [Critical Care Congress abstract 658]. Crit Care Med. 2015 Dec;43(12):166.
4. Kitagawa M, Beesley S, Sreedharan R, Peters N, Bhalala U, Khanna A. Concern over clinical competency during transition from critical care training to the first job. [Critical Care Congress abstract 925]. Crit Care Med. 2016 Dec;44(12):307.
5. Davidson JE, Jones C, Bienvenu OJ. Family response to critical illness: postintensive care syndrome-family. Crit Care Med. 2012 Feb;40(2):618-624.
6. McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med. 2004 Jul;32(7):1484-1488.
7. Stapleton RD, Engelberg RA, Wenrich MD, Goss CH, Curtis JR. Clinician statements and family satisfaction with family conferences in the intensive care unit. Crit Care Med. 2006 Jun;34(6):1679-1685.
8. Curtis JR, Engelberg RA, Wenrich MD, et al. Studying communication about end-of-life care during the ICU family conference: development of a framework. J Crit Care. 2002 Sep;17(3):147-160.
9. Back A, Arnold RM, Baile W, Fryer-Edwards K, Tulsky JA. A framework for enhanced doctor-patient communication: Oncotalk learning modules. 2002. https://depts.washington.edu/oncotalk/learn/modules.html. Accessed May 24, 2017.
10. Barth JL, Lannen P. Efficacy of communication skills training courses in oncology: a systematic review and meta-analysis. Ann Oncol. 2011 May;22(5):1030-1040.
11. Bonvicini KA, Perlin MJ, Bylund CL, Carroll G, Rouse RA, Goldstein MG. Impact of communication training on physician expression of empathy in patient encounters. Patient Educ Couns. 2009 Apr;75(1):3-10.
12. Arnold RM, Back AL, Barnato AE, et al. The Critical Care Communication project: Improving fellows’ communication skills. J Crit Care. 2015 Apr;30(2):250-254.
13. Chasten K, Awdish R, Mendez M, Buick D, Kokas M. Clear conversations: a comprehensive curriculum to facilitate translation of skills learned in simulated settings to improve communication in real clinical encounters. [Annual Assembly of American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association Abstract FR482E]. J Pain Symptom Manage. 2016 Feb;51(2):384-385.
14. Berns S, Hurd C, Carl J, Roshal A, Lindenberger E. Practice makes permanent: VitalTalk techniques for drilling communication skills. [Annual Assembly of American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association Abstract FR482F]. J Pain Symptom Manage. 2016 Feb;51(2):385-386.
15. Choi D, Allen C, Oropello J, et al. Effectiveness of an intensive program to teach communication skills to critical care fellows. [Critical Care Congress abstract 388]. Crit Care Med. 2016 Dec;44(12):173.