Communication

Table of Contents
 Preface
 Communicating With Patients
 Introduction
 The physician patient relationship
 Acknowledging conscious and unconscious patients
 Overcoming communication barriers
 Considering the patient’s perspective
 Meeting the patient’s needs
 Dealing with ‘difficult’ patients
 Obtaining informed consent
 Helping the patient cope with the ICU experience
 Communicating With Families
 Introduction
 Providing information
 Involving the family in patient care
 Involving the family in decision making
 Handling differences of opinion
 Breaking bad news
 Discussing organ donation
 Family satisfaction with care
 Communicating With Co Workers
 Introduction
 Working in a multidisciplinary team
 Promoting cooperation and collaboration
 Improving the quality of care
 Dealing with problems Handling errors in the ICU
 Developing communication skills
 Introduction
 Effective communication strategies
 Communication skills
 Team communication
Communication

Current Status 2019

Completed
This module is updated and maintained by the (ETHICS) section

Latest Update
Update

Ethics
Chair
Rik Gerritsen MD, PhD, FCCM, Intensive Care Department, Medical Centre
Leeuwarden, The Netherlands; Past Chair Ethics Section, European Society of
Intensive Care Medicine

Deputy
Christiane Hartog MD, Department for Anesthesiology and Intensive Care, Jena
University Hospital, Jena, Germany

Section Editor
Andrej Michalsen MD, Consultant in Intensive Care Medicine , Department of
Anaesthesiology and Critical Care, Tettnang Hospital, Tettnang, Germany

ELearning Committee
Chair
Kobus Preller Dr., Consultant, John Farman ICU, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, UK

Deputy
Mo Al-Haddad MD, Consultant in Anaesthesia and Critical Care, Queen Elizabeth
University Hospital; Honorary Clinical Associate Professor University of Glasgow,
Glasgow UK

Project Manager
Estelle Pasquier , European Society of Intensive Care Medicine

Update 2019

Module Authors
 Charlotte van der Berg

Module Reviewers
Nancy Kentish-Barnes
Julie Bebenishty
Andrej Michalsen MD, Consultant in Intensive Care Medicine , Department of
Anaesthesiology and Critical Care, Tettnang Hospital, Tettnang, Germany

Section Editor
Hans-Ulrich Rothen , Dept. of Intensive Care Medicine, Bern University Hospital
and University of Bern Bern, Switzerland
B Lobo-Valbueno

CoBaTrICE Mapping Contributors

Cristina Santonocito MD, Dept. of Anesthesia and Intensive Care, IRCSS-
ISMETT-UPMC, Palermo, Italy
Victoria Anne Bennett MD, St George’s Hospital, London, United Kingdom

Co-Ordinating Editor
Joana Berger Estilita MD, Consultant in Anaesthesia and Intensive Care
Department of Anaesthesia and Pain Therapy, Bern University Hospital, University
of Bern, Switzerland

Executive Editor
Mo Al-Haddad MD, Consultant in Anaesthesia and Critical Care, Queen Elizabeth
University Hospital; Honorary Clinical Associate Professor University of Glasgow,
Glasgow UK

First Edition 2006

Module Authors
Jeannie Wurz , Dept. of Intensive Care Medicine, Bern University Hospital and
University of Bern Bern, Switzerland
Hans-Ulrich Rothen , Dept. of Intensive Care Medicine, Bern University Hospital
and University of Bern Bern, Switzerland
Geke Blok , Dept. of Education and Science, Reinier de Graaf Topclinical
Teaching Hospital Delft, the Netherlands
Alexander Kiss , Department of Psychosomatics University Hospital Basel Basel,
Switzerland

Module Reviewers
Graham Nimmo , ...
Janice Zimmerman Dr., Dept of Internal Medicine Division of Critical Care The
Methodist Hospital Houston, Texas, USA
Update Info

Intended Learning Outcomes

Communication Part I:
Communicating with Patients

1. Adequately approach conscious and

unsconscious patients
2. Deal with communication barriers
3. Correctly obtain an informed consent
from an ICU patient

Communication Part II: Communicating with

Families

1. Adequately provide information to family

members
2. Know when and how to involve the family in
decision-making and in patient care
3. Adequately transmit bad news

Communication Part III:

Communicating with co-workers

1. Have improved communication skills

within the ICU team
2. Perform a clear, succinct and
adequate handover
3. Correctly and openly communicate
about errors in the ICU
4. Explore the advantages and barriers
to good team-work
 Communication Part IV: Developing
communication skills

1. Have effective communication strategies

with patients
2. Adapt these strategies for team
communication enhancement

eModule Information

Relevant Competencies from CoBaTrICE

Communication Part I: Communicating with Patients

7.1 Comfort and recovery: Identifies and attempts to minimise the physical and
psychosocial consequences of critical illness for patients and families
12.1 Professionalism: Communicates effectively with patients and relatives
12.4 Professionalism: Involves patients (or their surrogates if applicable) in
decisions about care and treatment

Communication Part II: Communicating with Families

12.1 Professionalism: Communicates effectively with patients and

relatives
12.4 Professionalism: Involves patients (or their surrogates if
applicable) in decisions about care and treatment

Communication Part III: Communicating with co-

workers
 12.2 Professionalism: Communicates effectively with
members of the health care team
12.7 Professionalism: Collaborates and consults; promotes
team-working
12.8 Professionalism: Ensures continuity of care through
effective hand-over of clinical information
12.9 Professionalism: Supports clinical staff outside the ICU
to enable the delivery of effective care
12.10 Professionalism: Appropriately supervises, and
delegates to others, the delivery of patient care

Communication Part IV: Developing

communication skills

12.1 Professionalism: Communicates effectively with

patients and relatives
12.2 Professionalism: Communicates effectively with
members of the health care team

Faculty Disclosures:
The authors of this module have not reported any disclosures.

Copyright©2017. European Society of Intensive Care Medicine. All rights reserved.

ISBN 978-92-95051-82-9 - Legal deposit D/2005/10.772/29
1. Communicating With Patients

1. 1. Introduction

‘What we’ve got here is... failure to communicate ...’ Strother Martin in the film Cool
Hand Luke, 1967

The goal of communication is to convey information. Everyone communicates, but not

everyone communicates successfully.

There are many reasons for conveying information. Among them: to add to knowledge
of a subject; to motivate someone to act; to exchange ideas; to express emotions. All
these come into play in an intensive care unit. The ultimate goal of communication in
the ICU is to improve patient outcome and quality of care.

Most people think of communication only in terms of delivering a message, but

communication is bidirectional: it requires not only that a message be sent, but also
that a message be received. What’s more, effective communication requires that the
sender’s message is understood as it was intended to be understood.

Many factors influence comprehension of a message. Your tone of voice, word choice
and volume affect interpretation of a verbal message. There is a world of difference
between telling a co-worker: ‘I’m a little concerned about the fact that you didn’t give
Mrs Baker her medication this morning’ and ‘What do you mean you forgot Baker’s
meds!?!’ Likewise, an informed consent form that asks whether a patient ‘agrees to
undergo hemipelvectomy for extended neoplastic intervention’ won’t be very effective if
the patient

1. doesn’t have a medical background,

2. only speaks Spanish or
3. can’t read.

 Note

Give clear, honest, comprehensible information in a sensitive way

Your message must be adapted to the situation. Communicating your message

effectively requires that you:

Know what you want to say

 Are aware of the characteristics of your audience
Choose the most appropriate format for communication
Deliver a clear message
Verify that your message has been understood

Your goal as an ICU professional is to use your communication skills to enhance the
care of your patients. The more aware you are of the factors that influence
communication, the greater your chance of communicating effectively. In the following
pages we will clarify some of the factors that are important for successful
communication in the ICU.

1. 1. 1. The physician–patient relationship

In the past, physicians had only limited therapies and treatments at their disposal. With
so few options for treating patients, there was much more emphasis on the physician-
patient relationship. Over the course of the 20th century, however, the availability of
many treatment options from antibiotics and immunisations to mechanical ventilation
and computed tomography changed the face of medicine. Unfortunately, modern
medicine sometimes falls into the trap of emphasising technology at the expense of
good interpersonal relationships.

This is especially true in the ICU. Frequently, disease, medications and interventions
leave patients with only a limited capacity to interact with their physicians and nurses -
if they are able to interact at all. This does not mean that ICU professionals should be
satisfied with a lack of interaction. Outside the ICU, competent communication
between doctors and patients has been shown to enhance patient satisfaction,
compliance, and functional status. There is a significant association between patient
health outcomes and how physicians communicate. Furthermore, effective
communication may lead to less anxiety in patients and more trust in physicians.

In the last decades, healthcare policy in many countries has increasingly focused on
‘patient empowerment’. Also, there is a trend towards using less sedation in critically ill
patients. As a result of this, patients are more aware of their stay in the ICU. Nurses
and physicians should be aware of this and of the consequences this has on the way a
patient experiences the ICU stay. It has been shown that nurses have an important
role in ‘translating’ medical information to patients and families and that this lowers
feelings of depression and anxiety.

In text References
(Borza, Gavrilovici and Stockman. 2015; Chaitin et al. 2003; Laerkner et al. 2017;
Sustersic et al. 2018)

 References
Borza LR, Gavrilovici C, Stockman R., Ethical models of physician—patient
relationship revisited with regard to patient autonomy, values and patient
education., 2015, PMID:26204658
Chaitin E, Stiller R, Jacobs S, Hershl J, Grogen T, Weinberg J., Physician-
patient relationship in the intensive care unit: erosion of the sacred trust?,
2003, PMID:12771585
Laerkner E, Egerod I, Olesen F, Hansen HP, A sense of agency: An
ethnographic exploration of being awake during mechanical ventilation in
the intensive care unit., 2017, PMID:28704639
Sustersic M, Gauchet A, Kernou A, Gibert C, Foote A, Vermorel C, Bosson
JL, A scale assessing doctor-patient communication in a context of acute
conditions based on a systematic review., 2018, PMID:29466407

1. 1. 2. Acknowledging conscious and unconscious patients

As a first step in building a professional-patient relationship, you can start by
acknowledging all your patients - regardless of their capacity to respond. This relays
the message that you see each of them as a person, not a body in a bed.

If you are the physician treating the patient, introduce yourself to the patient and
family, explain your role, answer questions, find out how much your patient knows and
understands about his/her condition. As the leader of bedside rounds, always greet the
patient before beginning a discussion about him.


What might you say to your sepsis patient, Mrs Roth, at the start of
rounds?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 ‘Good morning, Mrs Roth, I’m Dr xxxx. I’m in charge of your care
today. The team and I are going to go over how you’ve been doing since
yesterday, and then we’ll be happy to answer your questions.’ And later:
‘Mrs Roth, can you tell me what you know about your illness?’
Often, patients are more aware of what is being said around them than healthcare staff
realise. Some patients have reported awareness of healthcare workers’ attempts to
communicate with them while they were unconscious, and others have reported
frustration and alienation over lack of such communication. In addition, patients may
be upset by staff discussions of the patient’s condition or care or by other inappropriate
conversation. As the patient’s doctor or nurse, you should give information and
explanations even to patients who are unresponsive.

 Note
Always talk to patients even if they are unconscious or unresponsive!

Several decades ago it was found that increased verbal communication with
unconscious patients leads to a proportional reduction in the incidence of fear, anxiety,
depression, hallucinations, and delirium. Yet on average, nurses spend only 5% of
their time communicating verbally with unconscious patients, and presumably doctors
spend even less.

The majority of comatose patients have normal brainstem auditory evoked responses
and may be able to hear. Sensory stimulation programmes have been used to
increase arousal and awareness in comatose patients and have not been shown to be
detrimental in any way.

In text References
(Laerkner, Egerod and Hansen 2015; Leung et al. 2018; Shaw et al. 2014; Walker,
Eakes and Siebelink 1998)

 Note
Encourage family members of unconscious or non-alert patients to announce
their presence and say hello to the patient when they begin a visit. Suggest that
they describe the ICU for the patient, relate what is going on in the world, or
read greeting cards that the patient has received.

 References
Laerkner E, Egerod I, Hansen HP, Nurses experiences of caring for critically
ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit:
a qualitative study., 2015, PMID:25743598
Leung CCH, Pun J, Lock G, Slade D, Gomersall CD, Wong WT, Joynt GM,
Exploring the scope of communication content of mechanically ventilated
patients., 2018, PMID:29102851
Shaw DJ, Davidson JE, Smilde RI, Sondoozi T, Agan D., Multidisciplinary
team training to enhance family communication in the ICU., 2014,
PMID:24105452
Walker JS, Eakes GG, Siebelink E, The effects of familial voice
interventions on comatose head-injured patients., 1998, PMID:10188435
1. 1. 3. Overcoming communication barriers
Although barriers to communication are common in unconscious patients, it may also
be difficult for conscious ICU patients to communicate with healthcare staff. The
barriers may include intubation, hearing difficulties, lack of a common language and
illiteracy.

1. 1. 3. 1. Intubation
For most patients, being intubated (orotracheal tube or tracheostomy) is an unfamiliar
and frightening condition. Being unable to talk can lead to feelings of panic and
insecurity, sleep disturbances and stress. Patients should be reassured that their
inability to speak is temporary and that they will be able to communicate again verbally
once the tube has been removed.

Anecdote
A patient who had been intubated in the ICU remarked later: ‘No one had told me that I
was unable to speak. Should I really have understood that myself?’

Nurses have reported that ‘the less communicative their patients were, the less
communicative they were in return.’ Most interactions between nurses and intubated
patients last less than 30 seconds, and consist of instructions, explanations,
information related to physical care, yes/no questions, and commands.

Failure to communicate, and frustration over not being able to understand the patient,
causes stress in caregivers. Stress leads to a reluctance to persevere and results in
caregivers minimising or avoiding interaction with intubated or tracheostomised
patients. Critical care nurses identified the following factors as limiting communication
with intubated patients: heavy workload, patient’s severity of illness, difficulty in lip
reading, patient’s inability to write, preoccupation with physical or technical aspects of
care, personality of the patient, and lack of appropriate communication skills training.

 Note
A Toronto study found that placing photographs of patients and their families at
the patient’s bedside increased the caregivers’ empathy for the patient and
helped make the highly technical environment more personal.

Although for most people speech is the preferred method of communication, there are
other ways to communicate. Non-verbal communication can include such behaviours
as gesturing, nodding, mouthing words, blinking, lip reading, and touch. Alternative
communication methods include pencil and paper, magic slates, felt-tip markers and
dry erase boards, picture boards, language cards, one-way speaking valves, computer
keyboards and electronic voice output communication aids (VOCAs, see video). A
one-way speaking valve may enable patients with a tracheostomy to communicate
vocally at a very early stage. Ten Hoorn et al. performed a systematic review of all
studies available on communication aids in conscious ventilated ICU patients and
suggested an algorithm for the selection of alternative communication methods. Next
to the alternative methods discussed in this review, newer methods are being
developed and should be tested in ICU patients (e.g.: tablet-based communication).

In text References

(Ten Hoorn et al. 2016; Girbes and Elbers. 2014)

1. 1. 3. 2. Hearing difficulties
Speech is not the only sense that may be affected in the ICU. A significant number of
critically ill patients - even those younger than 40 - fail auditory testing at thresholds in
the normal conversational sound level range.

Numerous factors can cause acute hearing difficulty in ICU patients. These can range
from cerumen impaction and middle ear fluid changes to trauma and electrolyte
abnormalities. Often, these will be reversible. The toxic effect of drugs such as
aminoglycosides and furosemide may not be reversible.

Not being able to hear properly may increase a patient’s confusion and disorientation
or lead to unnecessary fear. It may be a significant factor in patient agitation or
delirium. Since assessment of mental status requires an intact auditory processing
system, ICU professionals should verify that a patient can hear before coming to a
definitive conclusion about his/her mental state.

In text References

(Hamill-Ruth and Ruth. 2003)

1. 1. 3. 3. Foreign languages
Language barriers are a challenge for ICU professionals. Many hospitals serve
patients who have little or no ability to speak and understand the local language.

While translators may be useful, it may difficult to accurately translate the complaints
of patients or the information coming from medical/nursing staff - particularly if the
translator does not have specific training in this field. Multilingual family members or
hospital staff have the advantage of being continuously involved in the situation. They
can help with communication on a day-to-day basis. There is, however, also evidence
that family members may interpret or modify the information rather than merely
translate. Another option is to provide illustrated cards that translate commonly used
ICU phrases into other languages. In addition, most smartphones carry an application
which translate the speech and written words and can be then shown to the
patients/family.

 Note
A family may be from a different cultural background or have religious beliefs of
which you are not aware.
 Challenge
Charades and Pictionary™ are popular games that require a player to communicate a
concept to teammates without speaking. Charades uses pantomime and Pictionary™
uses drawing. Create a set of cards that list ICU devices, concepts, and procedures.
Then test the cards by playing charades or Pictionary™ with your coworkers. The next
time you encounter a patient with limited language abilities, apply what you learned.

1. 1. 3. 4. Illiteracy
Poor reading skills are associated with poor health, and are especially prevalent in the
elderly, the poor, members of minority groups and immigrants. However, because
many people who cannot read are very adept at hiding their inability, healthcare
providers need to be aware that every day they are likely to encounter patients and
family members with limited literacy skills.

Unfortunately consent forms, questionnaires and surveys, brochures and handouts,

and instructions for medications and self-care are often written in language that
patients and their families cannot fully understand. Materials such as audio- and
videotapes, slides, models and picture books can be used to provide healthcare
information with no or minimal reliance on text.

Above all, healthcare professionals should not assume that patients or their surrogates
understand information, just because they receive it. It is your job to check their
understanding.

In text References

(Bell et al. 2016; Volandes and Paasche-Orlow. 2007)


How might illiterate patients or relatives respond when confronted
with materials they are unable to read?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER


They may:

Claim they have forgotten their glasses

Glance at the papers and then ask for more time to read them at
home
If accompanied by a spouse or adult child, hand the materials to the
other person without looking at them
 Ask where to sign a document without reading it at all.

 References
Ten Hoorn S, Elbers PW, Girbes AR, Tuinman PR, Communicating with
conscious and mechanically ventilated critically ill patients: a systematic
review., 2016, PMID:27756433
Girbes AR, Elbers PW., Speech in an orally intubated patient., 2014,
PMID:24645961
Hamill-Ruth RJ, Ruth RA., Evaluation of audiologic impairment in critically ill
patients: results of a screening protocol., 2003, PMID:14501956
Bell SK, Roche SD, Johansson AC, O'Reilly KP, Lee BS, Sands KE, Talmor
DS, Brown SM, Clinician Perspectives on an Electronic Portal to Improve
Communication with Patients and Families in the Intensive Care Unit.,
2016, PMID:27700144
Volandes AE, Paasche-Orlow MK., Health literacy, health inequality and a
just healthcare system., 2007, PMID:18027287

1. 1. 4. Considering the patient’s perspective

One way that you can improve the care of your patients is to look at the ICU from their
perspective. Physicians who spend most of their time talking but not listening miss
important opportunities to allow patients to communicate their values and goals.
Clinicians should view the goals of treatment from the patient’s perspective and should
not assume that they understand their patients’ priorities.

Patients have a basic need to express themselves. Being allowed to communicate

may even be therapeutic. When possible ask your patients what is important to them,
and how you can improve their ICU experience. Patients in focus groups ‘invariably
provide suggestions different from those that group after group of clinicians and
administrators characteristically pursue.’

Sometimes ICU doctors have the difficult task to discuss plans with patients with
capacity about what to do when things go wrong. One of the options may be starting
palliative care. Under these circumstances, the best beginning of such a conversation
is an open question (e.g.: “How have you been coping with your disease?”). Most
patients will have thoughts about this subject and will express their opinion and wishes
without much further prompting.

 Note
 You never really understand a person until you consider things from his point of
view ... until you climb into his skin and walk around in it’: Character in the novel
To Kill a Mockingbird

In text References

(Acebedo-Urdiales et al. 2018; Darbyshire et al. 2016)

 References
Acebedo-Urdiales MS, Jiménez-Herrera M, Ferré-Grau C, Font-Jiménez I,
Roca-Biosca A, Bazo-Hernández L, Castillo-Cepero MJ, Serret-Serret M,
Medina-Moya JL, The emotion: A crucial component in the care of critically
ill patients., 2018, PMID:27113260
Darbyshire JL, Greig PR, Vollam S, Young JD, Hinton L, I Can Remember
Sort of Vivid People…but to Me They Were Plasticine. Delusions on the
Intensive Care Unit: What Do Patients Think Is Going On?, 2016,
PMID:27096605

1. 1. 5. Meeting the patient’s needs

Once a patient’s needs for survival and safety are met, his/her psychological needs
become most important. Among these are the need for the presence and support of
other people, information, honesty, compassion and hope. In order to meet these
needs, you must communicate - or make it possible for others to communicate.

1. 1. 5. 1. Presence
Positive reinforcement and encouragement from family and friends can strongly
influence the patient’s recovery. ICU patients who have companionship from loved
ones suffer fewer hallucinations, and flexible visiting hours allows family members to
provide emotional support. Although some health care professionals believe that
visitors are physiologically stressful for patients, there is no scientific basis for
restricting visitors to the ICU. Allowing patients to influence the timing and number of
visitors may have advantages for the patient in comparison with visits controlled by
staff.

 Note
Family relationships often include elements of conflict. Family members do not
necessarily view the patient’s situation in the same way that the patient does.
Always keep the patient’s best interests in mind.

1. 1. 5. 2. Information
Informed patients tolerate pain more easily, recover from surgery more quickly and
cooperate better with therapy. A patient’s failure to ask for information does not
necessarily mean that they do not want it. Many patients never ask their physicians for
prognostic information, yet most want to know their prognosis. However, it is a good
idea to ask a patient first: ‘How much do you want to know?’ Children should receive
age-appropriate explanations of their illness, treatment options, and - if they are
terminally ill - the concept of death.

Patients very often do not understand percentages or numerical data, and often they
are not as interested in statistics as they are in knowing the impact their disease will
have on their lives. This is in contrast to findings in a study on critically ill traumatic
brain injury (TBI) patients, where doctors ‘refused’ to give numbers while families
preferred to hear numbers when talking about prognosis
See the following references and the ESICM module on Clinical outcome  .

In text References

(Quinn et al. 2017; White et al. 2010)

1. 1. 5. 3. Hope and honesty

For physicians treating critically ill patients, it can be difficult to find the right balance
between being honest and offering hope. Most people do not want to be deceived;
they want ‘accurate information pertaining to their condition shared with them
candidly.’

Some ways to provide hope when communicating prognosis include:

Stress that numbers apply to groups rather than individuals.

When appropriate focus on outliers, and on positive and achievable goals.
Speak in terms of reaching goals or landmarks or overcoming hurdles.
Focus on the things that are controllable.
Highlight the aspects of the patient’s situation that might improve their chances.
Emphasise quality of life rather than life expectancy.

In text References

(Chiarchiaro et al. 2015)


Without using percentages, how would you communicate a
hopeful prognosis to a patient with a 75% chance of surviving to
ICU discharge and a 45% chance of completely regaining physical
function at the end of one year?
 COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER


‘Mrs Johansson, I think there’s a very good chance you’ll be able to
move back to the general ward if you continue to improve as you have
up until now. For every four patients in your situation, three become well
enough to leave the ICU, and you’ve shown a great deal of
improvement. First we need to get you breathing on your own, though.
That’s our goal over the next few days, and we need your help to reach
it. There is a fair chance that in a year from now you may even be back
to living a normal life. Nearly half the patients in your situation have
completely recovered by then.’

 References
Quinn T, Moskowitz J, Khan MW, Shutter L, Goldberg R, Col N, Mazor KM,
Muehlschlegel S, What Families Need and Physicians Deliver: Contrasting
Communication Preferences Between Surrogate Decision-Makers and
Physicians During Outcome Prognostication in Critically Ill TBI Patients.,
2017, PMID:28685395
White DB, Engelberg RA, Wenrich MD, Lo B, Curtis JR., The language of
prognostication in intensive care units., 2010, PMID:18753685
Chiarchiaro J, Buddadhumaruk P, Arnold RM, White DB., Quality of
communication in the ICU and surrogate's understanding of prognosis.,
2015, PMID:25687030

1. 1. 6. Dealing with ‘difficult’ patients

Every healthcare professional encounters ‘difficult’ patients. These are not necessarily
patients with complex medical problems but rather patients who may be demanding,
aggressive, dirty, rude, or violent. In 1978 Groves defined four types of difficult
patients: ‘dependent clingers’, ‘entitled demanders’, ‘manipulative help-rejecters’ and
‘self-destructive deniers’. These patients may evoke negative feelings in ICU staff
ranging from depression to anger to guilt.

 Note
Try not to feel personally attacked by reactions of anger and disbelief
Sometimes there may be conflicts in the ICU over whether to provide non-beneficial
treatments demanded by the patient. Other conflicts may arise from cultural gaps
between the physician and the patient. Sometimes ‘difficult’ behaviour can result from
coping strategies from the patient.

Regular communication can improve understanding, emphasise the limitations of

medical science, establish a trusting relationship, and diffuse anger and aggression.
Negotiating with, and educating, the patient can reduce conflicts. The frequency and
consequences of violent and abusive behaviour can be reduced through staff
awareness, recognition of the verbal and non-verbal signs of aggression, and training
in communication skills.

Some means of coping with difficult patients include:

Empathy
Non-judgmental listening
Patience and tolerance
Directness (‘I know you’re angry at us for not being able to cure your cancer...’)
Setting clear limits for an encounter (‘Over the next 15 minutes we will ...’)
Referral to consultants for mental health services
Involving the patient’s family

1. 1. 7. Obtaining informed consent

Informed consent, whether for treatment or for enrolment in a clinical trial, involves five
principles: disclosure of information, competency, understanding, voluntariness, and
decision making. The specifics of obtaining consent differ for adults and for children,
as well as by nation/jurisdiction.
A French study found that only 25% of patients were capable of making decisions in
the first 24 hours after their admission to the ICU. Trauma, disease, sleep deprivation,
various treatments, and stress may all be factors. If the patient is not competent,
someone else (a physician, a legal representative or, in some jurisdictions, a relative)
must make decisions on their behalf.

 Note
Admitting the initial uncertainty concerning results of the research (clinical
equipoise) is the ‘only honest way for proposing a clinical trial to a patient or
family.’ European Society of Intensive Care Medicine Statement, 2002

In text References

(Terry 2007; Matei and Lemaire. 2013; Modra, Hilton and Hart 2014)
 Anecdote
A four-year-old girl was asked to donate bone marrow to save the life of her baby
sister. Encouraged by her parents, she agreed. After the harvesting procedure, she
asked the doctor when she was going to die. It was only then that the doctor realised
that the little girl had assumed she would have to die in order to save her sister’s life.

 Think
How might obtaining consent differ for a competent adult and a 10month-old
child?

For a detailed discussion of the issues surrounding consent see the e-learning module
on Ethics 

1. 1. 7. 1. Consent forms
Unfortunately, many consent forms are written significantly above the reading level of
the average reader. To simplify your text you can do the following:

Use short, simple words and sentences

Limit the amount of technical jargon
Use parallel sentence structure
Present one idea per paragraph
Consider a question-and-answer format

Easy-to-read forms are associated with higher patient satisfaction and less consent
anxiety. If well written, this will not offend well-educated participants.

In text References

(Silverman et al. 2005)

Challenge
Adapt several paragraphs of a previously used consent form, using the suggestions
above to create simpler text. Prepare three questions that test the reader’s
understanding of key points in the paragraphs. Show the original text to four
nonmedical people you know e.g. friends, family and ask them to answer the
questions. Then show them the simpler text. Which test provoked the best answers?
Which version did they prefer?

 References
Terry PB, Informed consent in clinical medicine., 2007, PMID:17296662
Matei M, Lemaire F., Intensive care unit research and informed consent: still
a conundrum., 2013, PMID:23725612
 Modra LJ, Hilton A, Hart GK, Informed consent for procedures in the
intensive care unit: ethical and practical considerations., 2014,
PMID:24888290
Silverman HJ, Luce JM, Lanken PN, Morris AH, Harabin AL, Oldmixon CF,
Thompson BT, Bernard GR; NHLBI Acute Respiratory Distress Syndrome
Clinical Trials Network (ARDSNet)., Recommendations for informed
consent forms for critical care clinical trials., 2005, PMID:15818118

1. 1. 8. Helping the patient cope with the ICU experience

Many patients experience pain and anxiety during their ICU stay. Since the 1980s, the
practice of maintaining a personal diary for the patient during his/her ICU stay has
been adopted in numerous European countries. The purpose of the diary, which is
maintained by staff, relatives, or friends, is to provide ‘a framework to reconstruct a life
disrupted by illness and fragmented by loss of memory.’ Diaries can help ICU survivors
make sense of their experience and can help families of deceased patients cope with
their loss.

The transition to the the regular wards can also be stressful. Some patients may be
afraid that something will happen to them if they are not under constant surveillance.
Others develop long-term psychological problems such as post-traumatic stress
disorder in reaction to the ICU experience. As part of the discharge process , the team
should emphasise that the patient has clinical improved to such a state that he no
longer needs critical care, and he will attain more independence in a hospital ward as
well as, attempting to answer patients’ questions, provide reassurance and solicit input
on aspects of care that can be improved. In addition, a transfer letter written for the
patient can be a solution in solving any unanswered questions regarding the transfer.

 Note
One hospital that received high ratings in preparing patients for discharge
required patients and families to write down any questions they had. Only after
all questions were answered was the patient discharged.

In text References

(Ullman et al. 2015)

 References
Ullman AJ, Aitken LM, Rattray J, Kenardy J, Le Brocque R, MacGillivray S,
Hull AM, Intensive care diaries to promote recovery for patients and families
after critical illness: A Cochrane Systematic Review., 2015, PMID:25869586
2. Communicating With Families
Usually your ICU patients will be visited by relatives and perhaps close friends.
Interacting with families is an integral part of caring for a critically ill patient. Although
there is a temptation to feel that spending time with families takes you away from your
‘real’ job – patient care – you should remember that families are important to patients;
increasing your support of the family may indirectly improve your patient’s response to
treatment and thus his/her chances of leaving the ICU alive.

 Note
Looking after families is an integral part of our job

2. 1. Introduction
Delivering bad news is one of the most daunting tasks faced by physicians. For many,
their first experience involves patients they have known only a few hours. Additionally,
they are called upon to deliver the news with little planning or training. Given the
critical nature of bad news, that is, “any news that drastically and negatively alters the
patient's view of her or his future”, this is hardly a recipe for success.

Historically, medical education has placed more value on technical proficiency than
communication skills. This leaves physicians unprepared for the communication
complexity and emotional intensity of breaking bad news. The fears doctors have
about delivering bad news include being blamed, evoking a reaction, expressing
emotion, not knowing all the answers, fear of the unknown and untaught, and personal
fear of illness and death. This can lead physicians to become emotionally disengaged
from their patients. Additionally, bad news delivered inadequately or insensitively can
impair patients' and relatives' long-term adjustments to the consequences of that
news.

In this course we will explore some strategies to communicate with patients and
address the issue of how to “break bad news” in intensive care.

2. 2. Providing information
Usually your ICU patients will be visited by relatives and perhaps close friends.
Interacting with families is an integral part of caring for a critically ill patient. Patients
are part of a wider social patient-family network. Although there might be a temptation
to feel that spending time with families takes you away from your ‘real’ job - patient
care - you should remember that families are important to patients; increasing your
support of the family may indirectly improve your patient’s response to treatment and
thus his/her chances of leaving the ICU alive.

Intense feelings such as despair, fear, worry, anger, and exhaustion are common
among the families of patients being treated in the ICU. Families of critically ill patients
have many needs that continue or even intensify when the patient remains in the ICU
for a long time. Above all, relatives and close friends need information about the
patient and what is happening to him or her. The information should be clear, accurate,
honest, timely, and in language they can understand.

In text References

(Azoulay and Pochard. 2003)

2. 2. 1. Who should meet the information needs of families?

It is up to the ICU team to provide the family with information. As soon as possible
after admission there should be an initial meeting to explain the patient’s situation and
answer the family’s questions. This meeting will usually last a minimum of ten minutes
and should preferably be attended by the physician in charge. Family members want
more frequent contact with physicians (they often state that they have too little access
to physicians; they never say that they have too much). They prefer to receive all
information in person from the same physician each time. The problem of conflicting
information from more than one source should be recognised and addressed. It is
quite common that physicians, nurses and auxiliary treating team members have
completely different perspectives of how they predict the course of the patient's
disease will progress.

Anecdote
A few hours after Mr S was admitted to the ICU the surgeon spoke with his wife: ‘Hello
Mrs S, it’s nice to meet you. I wanted to let you know that the operation was quite
difficult but we were finally able to stop the bleeding and we’re confident that your
husband will recover soon.’ Less than an hour earlier, the physician in charge of the
ICU had told Mrs S that despite a successful surgical intervention there was a very
high risk that her husband would develop multiple organ dysfunction syndrome in the
next few days and die. Mrs S didn’t know who to believe, and had doubts about the
competency of the team.

2. 2. 2. What do families want and need to know?

The family is primarily interested in information about the patient’s status. What is
wrong with my mother? How is she doing? Are you going to stick tubes and needles
into my husband? When will he come home? Information helps families form
reasonable expectations and cope with their distress.

 Note
 Often, medical professionals give families the same information they give each
other - physiological data - rather than providing information in human terms.

You should:

Explain the primary diagnosis, and which organs are involved in the disease
process.
Give a balanced but cautious estimate of the patient’s chances of survival
(prognosis).
In simple terms, describe the treatments that you will use (‘We’re going to hook
him up to a machine that will help him breathe’).
Provide printed materials or links to online information about the procedures and
equipment in the ICU.
Briefly explain the roles of the members of the ICU and hospital teams.

 Warning

Half the families of ICU patients don’t understand the patient’s diagnosis,
prognosis, or treatment. Try to explain the medical condition of the patient in
such a way that both your 10-year old nephew and your grandmother will
understand. Try to avoid overloading families with unnecessary details, which
may be easily misinterpreted and distract families from more crucial information.

In text References

(Lee Char et al. 2010; Quenot et al. 2017; Wilson et al. 2015)


How would you translate the following statement into terms a lay
person can understand? ‘Your husband’s CT scan shows the
clinical signs of a pulmonary embolism, including obstructive
shock because of acute severe right ventricular failure. We’re
going to intubate him, treat the shock with fluids and inotropes or
vasopressors if needed, and see whether his vital signs improve
over the next 24 hours.’

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 ‘We’ve now looked at the pictures of your husband’s lungs. It

seems that a clot of blood has travelled to the lungs and blocked an
artery there. This makes it much harder for the heart to pump blood to
the rest of the body. Overall this results in a life-threatening situation for
your husband. We’re going to put a tube down his throat into the
entrance of the lungs to make sure he gets enough oxygen and try to
help the heart pump by giving him fluids and special drugs. Then we’ll
see whether he improves over the next 24 hours.’

2. 2. 3. How can you improve family comprehension?

Often information is communicated but not understood. Some factors that can
influence comprehension include:

Amount of time devoted to communication (the more the better)

Emotional state
Language (vocabulary, foreign vs native language)
Conflicting messages

People who are stressed and upset may have trouble concentrating and may hear but
not retain your message. Non-native speakers in particular have difficulty
comprehending information. Not only is it harder for them to understand your words,
but they may also have different values, expectations regarding healthcare, and rules
of etiquette.

 Note
Communication is only effective if it meets the needs of the audience

What you can do:

Communicate with the family on a regular basis, as often as possible.

Coordinate with your team so that all members are giving the same message or
designate one person to communicate with the family.
Choose one family member to be responsible for disseminating information about
the patient to the rest of the family.
Make sure your body language reflects the message you give verbally.
Provide translators and translated materials for speakers of foreign languages.
Ask the listener to restate your message in his/her own words (see ‘Checking
understanding’ in Task 4).
Give information in an organised and logical sequence, using signposting and
summarising (see Task 4).
Reinforce your message by using various communication methods like
summarising, reflecting and and asking the family what they understood from your
message.

You tell your patient’s husband: ‘We are planning to wean your
wife from the respirator today.’ He answers: ‘Yes’. What do you say
to make sure that he has understood?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 ‘I just want to make sure you understand what’s involved in

weaning your wife from the respirator. Can you describe what you think
will happen? If you’re not sure, I can explain it in more detail.’

2. 2. 3. 1. Using printed materials to aid comprehension

Often - especially at admission - families of ICU patients receive an overwhelming

amount of information at a time when they are emotionally unable to comprehend it.
One option for helping families process and retain information is to provide a family
information brochure that can be referred to repeatedly.

A brochure might contain the following:

The name of the physician in charge of the patient.

Titles and primary duties of the various ICU personnel.
Telephone number of an ICU team member who can provide daily updates.
Contact information for the hospital’s clergy/pastoral team and social workers.
A glossary of major equipment and procedures, described in simple terms.
Visiting hours.
A floor plan for the unit, including labelled restrooms and waiting rooms.

The brochure may also address patients’ and families’ information needs when the
patient is transferred out of the ICU.

You might also suggest that the family member use a small notebook in which
additional information can be recorded, including:

Telephone numbers of family and friends who need to be updated.

The patient’s diagnosis.
Information about treatment plans and goals.
Questions to ask the medical and nursing staff.
Answers to questions previously asked.
In a study of the impact of a family information leaflet, Azoulay et al. found that the
brochure reduced the proportion of family members with poor comprehension from
40.9% to 11.5%.

 Note
Policies designed to promote communication are only effective if they are used

In another study, relatives of patients who were dying in the ICU were randomised
either to receive a brochure on bereavement and be exposed to a proactive
communication strategy (longer conferences and more time for family members) or to
receive the usual treatment only. Three months later the psychosocial distress in the
relatives in the intervention group was significantly lower than in the control group.

In text References

(Dotolo et al. 2017; Francis et al. 2017; Furqan and Zakaria 2017; Lautrette et al.
2007)

Challenge
Develop a simple brochure for relatives that provides basic information about your
ICU. Then survey family members to determine their reactions to the brochure.

Hinsdale Hospital (Hinsdale, Illinois, USA) developed a structured communication

programme for families of ICU patients, consisting of a discussion with a nurse, an
information pamphlet and a daily telephone call. The intervention led to a significant
reduction in the number of incoming calls from family members, an increase in family
satisfaction with care and the perception among family members that their information
needs were better met.

2. 2. 4. Providing support for the ICU family meeting

Family meetings often fail to occur on a timely and regular basis in many ICUs. Gay et
al. suggested the following strategies to help ensure that family meetings take place:
identifying convenient blocks of time for the meeting, using print materials, including
the family meeting on checklists or daily goals sheets, including nurses, supporting
communication skills training, and relaxing restrictions on family presence in the ICU.

In addition, a toolkit designed to make family meetings simpler proposes using a family
meeting planner, a meeting guide for families, and a family meeting documentation
template.

In text References

(Au et al. 2018; Curtis and White. 2008; de Havenon et al. 2015; Bruce et al. 2017)

 References
Curtis JR, White DB., Practical guidance for evidence-based ICU family
conferences., 2008, PMID:18842916
Azoulay E, Pochard F., Communication with family members of patients
dying in the intensive care unit., 2003, PMID:14639077
Lee Char SJ, Evans LR, Malvar GL, White DB., A randomized trial of two
methods to disclose prognosis to surrogate decision makers in intensive
care units., 2010, PMID:20538959
Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Large A, Andreu P,
Rigaud JP, What are the ethical issues in relation to the role of the family in
intensive care?, 2017, PMID:29302596
Wilson ME, Kaur S, Gallo De Moraes A, Pickering BW, Gajic O, Herasevich
V, Important clinician information needs about family members in the
intensive care unit., 2015, PMID:26320406
Dotolo D, Nielsen EL, Curtis JR, Engelberg RA, Strategies for Enhancing
Family Participation in Research in the ICU: Findings From a Qualitative
Study., 2017, PMID:28438584
Francis L, Vorwaller MA, Aboumatar H, Frosch DL, Halamka J, Rozenblum
R, Rubin E, Lee BS, Sugarman J, Turner K, Brown SM; Privacy, Access,
and Engagement Task Force of the Libretto Consortium of the Gordon and
Betty Moore Foundation., A Clinician's Guide to Privacy and
Communication in the ICU., 2017, PMID:27922454
Furqan MM, Zakaria S, Challenges in the implementation of strategies to
increase communication and enhance patient and family centered care in
the ICU., 2017, PMID:28318678
Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C,
Barnoud D, Bleichner G, Bruel C, Choukroun G, Curtis JR, Fieux F, Galliot
R, Garrouste-Orgeas M, Georges H, Goldgran-Toledano D, Jourdain M,
Loubert G, Reignier J, Saidi F, Souweine B, Vince, A communication
strategy and brochure for relatives of patients dying in the ICU., 2007,
PMID:17267907
Au SS, Roze des Ordons AL, Parsons Leigh J, Soo A, Guienguere S,
Bagshaw SM, Stelfox HT, A Multicenter Observational Study of Family
Participation in ICU Rounds., 2018, PMID:29742590
de Havenon A, Petersen C, Tanana M, Wold J, Hoesch R, A pilot study of
audiovisual family meetings in the intensive care unit., 2015,
PMID:26100581
Bruce CR, Newell AD, Brewer JH, Timme DO, Cherry E, Moore J, Carrettin
J, Landeck E, Axline R, Millette A, Taylor R, Downey A, Uddin F, Gotur D,
Masud F, Zhukovsky DS, Developing and testing a comprehensive tool to
assess family meetings: Empirical distinctions between high- and low-
quality meetings., 2017, PMID:28780489
2. 3. Involving the family in patient care
Family members of critically ill patients have a strong need for proximity to the patient.
This need to be with or near the patient is most intense in the initial stages of the
critical illness and lasts until the patient shows signs of stabilisation, improvement or
recovery.

Allowing families to be present while you care for the patient or to help care for the
patient themselves is one way to meet their need for proximity. Being present during
rounds at the bedside allows them to contribute information about the patient and to
observe the complexity of care. This may, however, require modification of the
language used on the ward round to avoid misunderstandings or causing offence.
Telephone updates are a good addition to family meetings, however they cannot
replace face-to-face meetings.

In text References

(Seaman et al. 2017)

2. 3. 1. Daily care
Participation in daily care may give families a feeling of usefulness, thereby
contributing to the alleviation of negative feelings such as guilt. Some examples of
options for family involvement in patient care include feeding and bathing the patient,
swabbing the patient’s mouth, and possibly performing tracheal suctioning.

Although there is little reported evidence that participation benefits families, Azoulay et
al. noted that ‘performing some of the acts usually left to professionals may lead to an
awareness of the caring nature of interventions used in ICUs, which may otherwise
seem frighteningly aggressive.’ By involving families in daily care, healthcare
professionals communicate that family members are not outsiders but welcome
members of the ICU team.

In text References

(Azoulay et al. 2003)

2. 3. 2. Pain assessment
Patient comfort is one of the major concerns of family members. Compromised mental
status, mechanical ventilation and language barriers can inhibit communication with
patients, thus hampering health professionals’ ability to identify and treat pain. ICU
nurses are trained to assess patients for signs of pain, including restlessness,
hypertension and tachycardia. Family members, who know the patient well and are
often motivated to foster improvements in care, can provide an alternate source of
pain assessment. By helping to communicate the patient’s needs they can be an asset
to the healthcare team.

Your 83-year-old patient Mrs Henry, who is semi-conscious after
being struck by a car five days earlier, moans frequently. Mrs
Henry’s daughter spends a great deal of time at the bedside, and
has complained to another patient’s wife that the nurses are
ignoring her mother’s pain. The nurses are frustrated. How might
you take advantage of the daughter’s ongoing presence at the
bedside to improve the situation?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 Ask Mrs Henry’s daughter if she would be willing to help the

nurses keep track of her mother’s pain and response to pain
medications. Suggest that the daughter use a notebook to record
instances when she thinks her mother is in pain, how long the pain lasts
and whether the pain seems to go away soon after medications are
given. Ask the nurses to look at the daughter’s record after a period of
24 hours to see if their evaluation of Mrs Henry’s pain corresponds with
the daughter’s, and to consider whether pain medication should be
increased.

In text References
(Ovayolu Ö et al. 2015)

2. 3. 3. Family presence during resuscitation

The first time you meet your patients they may be in need of resuscitation.
Traditionally, family members have been excluded from resuscitation based on the
belief that seeing aggressive, invasive procedures would distress them and that their
presence would compromise the performance of the clinical staff. Several studies have
shown that allowing family members to witness resuscitations in emergency rooms or
before hospital admission might be advantageous in their coping with the
resuscitation. Many guidelines support family-witnessed resuscitation.

In text References

(Breach 2018; DeWitt 2015; Leske and Brasel 2010)

 References
 Seaman JB, Arnold RM, Scheunemann LP, White DB, An Integrated
Framework for Effective and Efficient Communication with Families in the
Adult Intensive Care Unit., 2017, PMID:28282227
Azoulay E, Pochard F, Chevret S, Arich C, Brivet F, Brun F, Charles PE,
Desmettre T, Dubois D, Galliot R, Garrouste-Orgeas M, Goldgran-Toledano
D, Herbecq P, Joly LM, Jourdain M, Kaidomar M, Lepape A, Letellier N,
Marie O, Page B, Parrot A, Rodie-Talbere , Family participation in care to
the critically ill: opinions of families and staff., 2003, PMID:12856124
Ovayolu Ö, Ovayolu N, Aytaç S, Serçe S, Sevinc A., Pain in cancer
patients: pain assessment by patients and family caregivers and problems
experienced by caregivers., 2015, PMID:25471183
Breach J, Exploring the implementation of family-witnessed resuscitation.,
2018, PMID:29583168
DeWitt S, Should Family-witnessed Resuscitation Become Our Standard?,
2015, PMID:26099911
Leske JS, Brasel K, Effects of family-witnessed resuscitation after trauma
prior to hospitalization., 2010, PMID:20234233

2. 4. Involving the family in decision-making

More than 90% of ICU patients are too ill or too sedated to be aware of what is
happening with regard to their care. Thus surrogates are often involved in the process
of decision-making regarding ICU treatment. Although it is the physician who is
ultimately responsible for determining care plans, he/she may wish to obtain input from
family members before making decisions that may have great significance for the lives
of many. The role of the family is dependent on cultural context, in some European
countries, it is the team who makes the decisions in line with the wishes of the family.
The role of the family is to represent presumed patient’s wishes, so the most
appropriate question to be asked is often “What do you think your mum would have
wanted?”. Remember that assignment of final responsibility varies across medical-
legal systems. It is very important to realize this variation, and to inform yourself how
this is arranged medically and legally where you practice.

 Important

Medical practice and legislation vary between countries and sometimes even
regionally. Inform yourself how this is arranged where you practice.

In text References

(Azoulay, Chaize and Kentish-Barnes 2014; Chao et al. 2016; Petrinec et al. 2015;
Sprung et al. 2014)
2. 4. 1. Seeking input from families
Healthcare professionals may feel that families are unable to comprehend the many
issues that affect medical decisions and thus should not be allowed to make those
decisions. Rather than excluding families from decision-making, healthcare providers
can and should educate patients and families on the risks and benefits of proposed
therapies so that there can be informed discussion of the best approach to the
patient’s medical care. This requires an emphasis on communication between
clinicians and families.

 Note
In the USA, families participate in 70-80% of medical decisions about their
critically ill relatives. In Northern Europe, families are significantly more closely
involved in end-of-life decision-making (88%) than they are in Southern Europe
(48%).

In text References

(Cunningham et al. 2018; Nelson et al. 2017; Oczkowski et al. 2016; White et al.
2018)

2. 4. 1. 1. Determining the patient’s preferences

The increasing emphasis on patient autonomy means that many families may expect
you to consider the patient’s wishes in planning your approach to care. If you did not
have a chance to talk with your patient before treating him or her, you can ask the
family for information (‘Can you tell me about your husband? What does he value most
about his life? How do you think he would feel about being hospitalised for a long
time?’). The key question is not what the relatives wish for but rather ‘What would the
patient say if he/she was able to talk to us?’

2. 4. 1. 2. Factors influencing relatives’ perspectives

Fewer than 2% of relatives reported that prognostic information provided by the
medical staff had the greatest influence on their beliefs about the patient’s prognosis.
Other factors cited by family members include the patient’s character, illness history,
and physical appearance; the relatives’ presence at the bedside; belief in God; and the
relatives’ own optimism, intuition and faith.

Although many surrogate decision-makers are doubtful of the accuracy of physicians’

prognoses, they highly value discussions about prognosis and use the information for
multiple purposes. Acknowledging that many factors play a role in patient and
surrogate assessments may help clinicians identify and overcome disagreements
about prognosis.

In text References

(Boyd et al. 2010; Zier et al. 2008)

2. 4. 1. 3. Educating the family and encouraging discussion

Families must have a reasonable level of comprehension of the patient’s problem if
they are to participate in decisions about care. A skilled physician should ensure that
family members have been informed but have not been overwhelmed by issues they
don’t understand. Written information may improve families’ decision-making
capacities.

In addition to scheduling regular meetings between family and staff members, you
should encourage family members to discuss issues among themselves. Since many
families make cooperative decisions, consider including extended family in major
discussions with staff.

 Note
One third of family members of ICU patients have post-traumatic stress
symptoms three months after the stay of their loved ones. Higher rates have
been found for family members whose relative died after end-of-life decisions
(60%) and who shared in end-of-life decisions (81.8%). This may indicate a risk
of creating a feeling of guilt among relatives who share the burden of decision-
making. The physician should avoid asking the family for a decision but rather
seek consensus.

In text References

(Cameron et al. 2016; Graef and Sieber 2018)

Challenge
The next time a decision must be made about whether to withdraw life support from
one of your patients, document the decision-making process. Who is involved? How
many individuals and categories of caregivers? Are the family consulted or informed?
How long does it take until a decision is made? Has consensus been reached? Do you
see aspects of the process in which communication could have been improved? If you
have suggestions for improving the process, share them with your team.

In text References

(Wong, Phua and Joynt 2018; Bosslet et al. 2015)

 References
Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, Curtis
JR, Ford DW, Osborne M, Misak C, Au DH, Azoulay E, Brody B, Fahy BG,
Hall JB, Kesecioglu J, Kon AA, Lindell KO, White DB; American Thoracic
Society ad hoc Committee on Futile and Potent, An Official
ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to
Requests for Potentially Inappropriate Treatments in Intensive Care Units.,
2015, PMID:25978438
Sprung CL, Truog RD, Curtis JR, Joynt GM, Baras M, Michalsen A, Briegel
J, Kesecioglu J, Efferen L, De Robertis E, Bulpa P, Metnitz P, Patil N,
Hawryluck L, Manthous C, Moreno R, Leonard S, Hill NS, Wennberg E,
McDermid RC, Mikstacki A, Mularski RA, Harto, Seeking worldwide
professional consensus on the principles of end-of-life care for the critically
ill. The Consensus for Worldwide End-of-Life Practice for Patients in
Intensive Care Units (WELPICUS) study., 2014, PMID:25162767
Azoulay E, Chaize M, Kentish-Barnes N, Involvement of ICU families in
decisions: fine-tuning the partnership., 2014, PMID:25593753
Chao YS, Boivin A, Marcoux I, Garnon G, Mays N, Lehoux P, Prémont MC,
Leeuwen EV, Pineault R, Advisory Committee, Canadian Medical
Association, College of Family Physicians of Canada; Canadian Bar
Association, Ministère de la santé et des services sociaux, International
changes in end-of-life practices over time: a systematic review., 2016,
PMID:27716238
Petrinec AB, Mazanec PM, Burant CJ, Hoffer A, Daly BJ., Coping
Strategies and Posttraumatic Stress Symptoms in Post-ICU Family
Decision Makers., 2015, PMID:25785520
Cunningham TV, Scheunemann LP, Arnold RM, White D, How do clinicians
prepare family members for the role of surrogate decision-maker?, 2018,
PMID:28716978
Nelson JE, Hanson LC, Keller KL, Carson SS, Cox CE, Tulsky JA, White
DB, Chai EJ, Weiss SP, Danis M, The Voice of Surrogate Decision-Makers.
Family Responses to Prognostic Information in Chronic Critical Illness.,
2017, PMID:28387538
Oczkowski SJ, Chung HO, Hanvey L, Mbuagbaw L, You JJ, Communication
tools for end-of-life decision-making in the intensive care unit: a systematic
review and meta-analysis., 2016, PMID:27059989
White DB, Angus DC, Shields AM, Buddadhumaruk P, Pidro C, Paner C,
Chaitin E, Chang CH, Pike F, Weissfeld L, Kahn JM, Darby JM, Kowinsky A,
Martin S, Arnold RM, PARTNER Investigators., A Randomized Trial of a
Family-Support Intervention in Intensive Care Units., 2018, PMID:29791247
Boyd EA, Lo B, Evans LR, Malvar G, Apatira L, Luce JM, White DB., "It's
not just what the doctor tells me:" factors that influence surrogate decision-
makers' perceptions of prognosis., 2010, PMID:20228686
Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, Luce JM, White DB.,
Doubt and belief in physicians' ability to prognosticate during critical illness:
the perspective of surrogate decision makers., 2008, PMID:18596630
Cameron JI, Chu LM, Matte A, Tomlinson G, Chan L, Thomas C, Friedrich
JO, Mehta S, Lamontagne F, Levasseur M, Ferguson ND, Adhikari NK,
Rudkowski JC, Meggison H, Skrobik Y, Flannery J, Bayley M, Batt J, dos
Santos C, Abbey SE, Tan A, Lo V, Mathur S, Parot, One-Year Outcomes in
Caregivers of Critically Ill Patients., 2016, PMID:27168433
Graef F, Sieber S, Cultural background, gender, and institutional status
have an effect on the evaluation of multi-disciplinary participatory action
research., 2018, PMID:29727460
Wong WT, Phua J, Joynt GM, Worldwide end-of-life practice for patients in
ICUs., 2018, PMID:29351142
2. 5. Handling differences of opinion
Sometimes you will not reach full agreement with the family on how to proceed with
care. Perhaps you will disagree over the goals of treatment, whether to continue with
treatments you consider inappropriate, or who has the right to decide.

 Important
Depending on differences in laws, ethical and professional guidelines, and local
practice, large differences exist throughout the world. As noted previously,
always consider such variability and respect laws, guidelines and rules relevant
for the specific circumstances.

There may also be differences of opinion between members of the clinical team.
These need to be handled sensitively, with respect for others, and may require a
detailed explanation to the family about the nature of probability and clinical
uncertainty. Handling differences of opinion requires an open mind and superior
communication skills.

 Note
Many disputes on medically inappropriate treatment begin with unrealistic
expectations on the part of the family resulting from the clinician’s failure to
communicate successfully.

2. 5. 1. ‘Difficult’ relatives
Relatives are perceived as ‘difficult’ when they create more work for the ICU team
members, e.g.: by telephoning frequently, when they are unable to comprehend
medical information, when they are aggressive, accusatory or threatening, and when
they are persistent in their demands for medically inappropriate treatment(s).

Many of these problems can be addressed with an emphasis on communication. As

seen earlier in this section, regular updates from the staff and the use of written
information and other aids can improve both the satisfaction and comprehension of
relatives. Aggressive family members should be treated with compassion; they may
simply be reacting to their feelings of helplessness and should be reassured that you
are doing everything in your power to provide optimal care. Often relatives who
demand medically inapproprate treatments either do not have sufficient awareness of
the extent or severity of the patient's illness or have been given an inaccurate picture
of the patient's chances of recovery.

2. 5. 2. Reaching consensus
Disagreements often occur when individuals or groups have different points of view.
Often these points of view are based on different belief systems, and neither system
can be described as ‘right’ or ‘wrong’. Reaching consensus requires that all parties
make an effort to see the problem from the other person’s point of view.

What you can do:

Keep calm.
Listen attentively to better understand the other point of view.
Know the laws and professional guidelines in your country regarding who has the
right to make decisions.
Involve people from outside your department (clergy, ethicists, specialists, friends
of the family) in the negotiations to reduce the emphasis on ‘us’ vs ‘them’.
Allow the family time to consider your point of view and to discuss your
recommendations among themselves.
Avoid proceeding with a controversial treatment until both staff and family agree
that your approach is the best one.
Be open-minded - it may be your opinion that needs to change!

See the following references and the E-module on Ethics  .

In text References

(Cook and Rocker. 2014; Curtis et al. 2012; Luckett 2017; Truog et al. 2008)

A study from Brigham and Women’s Hospital and Harvard Medical School in 2000
looked at using an intensive communication intervention to help patients, families and
the critical care team evaluate the use of advanced supportive technology. Regular
discussion of goals and care plans and greater interaction between caregivers,
patients, and families permitted an earlier transition to ICU-based palliative care when
technology was found to be ineffective. The intervention resulted in a significant
reduction of the median length of ICU stay from four days to three days.

 References
Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD,
Rushton CH, Kaufman DC; American Academy of Critical Care Medicine.,
Recommendations for end-of-life care in the intensive care unit: a
consensus statement by the American College [corrected] of Critical Care
Medicine., 2008, PMID:18431285
Cook D, Rocker G., Dying with dignity in the intensive care unit., 2014,
PMID:24963569
Curtis JR, Engelberg RA, Bensink ME, Ramsey SD., End-of-life care in the
intensive care unit: can we simultaneously increase quality and reduce
costs?, 2012, PMID:22859524
Luckett A, End-of-life care guidelines and care plans in the intensive care
unit., 2017, PMID:28328270
2. 6. Breaking bad news
Breaking bad news is one of the most difficult tasks you will face as a physician, but it
is a necessity in the practice of critical care medicine. Doctors and nurses may be
afraid to add to relatives’ distress, or to express their own emotions, or they may be
uncertain about whether they are capable of dealing with unexpected reactions from
relatives. They may experience feelings of inadequacy due to lack of training,
knowledge and the necessary communication skills.

2. 6. 1. Preparing families for the possibility of a bad outcome

It is surprisingly common for a family to have no idea that the situation is serious until
the doctor proposes moving from curative treatment to palliative care. If you don’t tell
the family about the seriousness of the situation until death is imminent, it may be
difficult for them to ‘catch up’. From the beginning of the patient’s ICU stay, you should
be cautious in making any promises about the patient’s recovery. Present a balanced
picture, highlighting the possibility of both positive and negative results. One way of
achieving this is by explaining the possible clinical pathways the patient’s course might
follow - death in ICU, death in hospital, death within a certain period after discharge
home, or long-term survival - and the emotional and physical burdens attached to
these outcomes.

In text References

(Hollyday and Buonocore. 2015; Kim et al. 2016)

2. 6. 2. How to talk with families

Once it is clear that there is little hope for survival, you should schedule a meeting with
the family, who should be informed in clear, easily understood language that their
relative is dying. Make a distinction between your capabilities and intentions: what you
want to do is cure the patient, but you are unable to do this. The family should be
allowed to absorb this information before you begin discussions of treatment
withdrawal.

 Note
Postponing the message worsens the situation for the patient and relatives

What you can do:

If the family comes completely unprepared, use “warning shot” tactics (e.g. “I have
bad news for you, we should sit down”).
Break bad news early and clearly. Use no more than a few introductory
sentences.
In the case of death of a patient, use the word dead or death.
 Show compassion.
Ask open-ended questions (beginning with ‘How’, ‘What’, ‘Where’ and ‘When’) that
allow the family to elaborate on their concerns.
Use time to reflect and identify/acknowledge what family members are feeling.
Summarise to demonstrate that you are aware of what relatives have
communicated.
Encourage the family to ask questions, and give them the information they ask for,
checking that your explanation has been understood.
After the family has had sufficient time to respond to the bad news, address what
will happen in the near future and solicit their preferences.
After the encounter, take a deep breath and, if possible, some time for yourself.

In general: talk less, listen more (increased time given to family vocalisation is
associated with increased satisfaction).

You may find the mnemonic BAD helpful:

Break the bad news
Acknowledge the reaction
Discuss the near future

 Note
Occasionally, a patient in the ICU must be told of the death of a loved one.
Breaking bad news in this unique situation is addressed by the Rev. Lisa
Watson in a review article (see below).

In text References
(McDonagh et al. 2004; Watson 2008)

2. 6. 2. 1. Where to talk with families

Bad news should be delivered to families in a private room whenever possible. The
lack of a comfortable, private space for discussions and conferences is a serious
drawback for families of critically ill patients. A room for families should have enough
space and chairs to accommodate several people; coffee and water; tissues, blankets
and a telephone; and a window and bed if possible.

Your 61-year-old patient with bacteraemia, Mr Swenson, dies just
as you are about to leave work for a weekend skiing trip. You meet
his wife in the elevator and tell her that it looks like her husband
has finally died. You explain that you have to leave the hospital on
important business, but the nurse will make the arrangements. Mrs
Swenson starts to ask a question, but you interrupt, saying that
the physician on call can help her. Name four things you did wrong
in handling this situation.

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER


1. You broke the news of the patient’s death in a public place.
2. You showed no compassion, and in fact treated the death as
inconsequential.
3. You left the follow-up to someone else without first briefing them.
4. You discouraged the wife from asking questions.

 References
McDonagh JR, Elliott TB, Engelberg RA, Treece PD, Shannon SE,
Rubenfeld GD, Patrick DL, Curtis JR., 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., 2004,
PMID:15241092
Watson LA, Informing critical care patients of a loved one's death., 2008,
PMID:18515608
Hollyday SL, Buonocore D., Breaking bad news and discussing goals of
care in the intensive care unit., 2015, PMID:25898881
Kim L, Hernandez BC, Lavery A, Denmark TK, Stimulating reflective
practice using collaborative reflective training in breaking bad news
simulations., 2016, PMID:27077393
2. 7. Discussing organ donation
Every patient dying in Europe should be considered as a potential donor. Regulations
differ throughout countries, though. For details refer to the following e-modules:

Ethics 
Organ donation and transplantation 

2. 8. Family satisfaction with care

Meeting the needs of patients’ families is an essential aspect of ICU care. Satisfaction
of proxies is a major criterion in the assessment of quality of care and of compliance
with accreditation requirements. Often relatives are not satisfied with the emotional
support they receive, with the provision of understandable, complete, and consistent
information, and with the coordination of care. Poor communication is frequently cited
as the main cause of dissatisfaction with care.

In a study by Stapleton, specific clinician statements during family meetings — such as

assurances that the patient will not be abandoned before death, will be comfortable,
and will not suffer — and the support for families’ decisions about end-of-life care, are
associated with higher family satisfaction.

Practical issues regarding conducting meetings with the family:

Choose a comfortable and private location

Know the patient’s name
Verify that you are speaking with the relatives of the right patient
Know the names of the other staff members attending the meeting
Introduce all people present
Provide enough chairs for all attendees
Ask all staff to turn off their pagers or cellular telephones
Know the topics you plan to discuss
Allow time for questions
Identify a person for the family to contact if further questions arise after the
meeting, and provide the contact information
End the meeting by summarising decisions made and further steps to take.

For family members, quality of care is not limited to merely treating the patient for an
acute illness. In a Canadian survey of relatives of patients who died in the ICU,
satisfaction with care correlated more significantly with how providers treated the
family than with how providers treated the patient. The authors inferred that, as it
becomes evident that a patient will die, more support and compassion need to be
directed to the family.

Meeting the needs of families does not guarantee that they will be satisfied with every
aspect of ICU care. However, it is very likely to improve the ICU experience for
everyone involved.

In text References

(Dall'Oglio et al. 2018; Frivold et al. 2017; Heyland et al. 2002; Jensen et al. 2017;
Kryworuchko and Heyland. 2009; Lam et al. 2017; Pagnamenta et al. 2016; Schaefer
and Block. 2009; Stapleton et al. 2006)

 References
Dall'Oglio I, Mascolo R, Gawronski O, Tiozzo E, Portanova A, Ragni A,
Alvaro R, Rocco G, Latour JM, A systematic review of instruments for
assessing parent satisfaction with family-centred care in neonatal intensive
care units., 2018, PMID:29239021
Frivold G, Slettebø Å, Heyland DK, Dale B, Family members' satisfaction
with care and decision-making in intensive care units and post-stay follow-
up needs-a cross-sectional survey study., 2017, PMID:29344389
Heyland DK, Rocker GM, Dodek PM, Kutsogiannis DJ, Konopad E, Cook
DJ, Peters S, Tranmer JE, O'Callaghan CJ., Family satisfaction with care in
the intensive care unit: results of a multiple center study., 2002,
PMID:12130954
Jensen HI, Gerritsen RT, Koopmans M, Downey L, Engelberg RA, Curtis
JR, Spronk PE, Zijlstra JG, Ørding H, Satisfaction with quality of ICU care
for patients and families: the euroQ2 project., 2017, PMID:28882192
Kryworuchko J, Heyland DK., Using family satisfaction data to improve the
processes of care in ICU., 2009, PMID:19730812
Lam JNH, Lau VI, Priestap FA, Basmaji J, Ball IM, Patient, Family, and
Physician Satisfaction With Planning for Direct Discharge to Home From
Intensive Care Units: Direct From ICU Sent Home Study., 2017,
PMID:28931361
Pagnamenta A, Bruno R, Gemperli A, Chiesa A, Previsdomini M, Corti F,
Merlani P, Cottini S, Llamas M, Rothen HU, Impact of a communication
strategy on family satisfaction in the intensive care unit., 2016,
PMID:26823125
Schaefer KG, Block SD., Physician communication with families in the ICU:
evidence-based strategies for improvement., 2009, PMID:19855271
Stapleton RD, Engelberg RA, Wenrich MD, Goss CH, Curtis JR., Clinician
statements and family satisfaction with family conferences in the intensive
care unit., 2006, PMID:16625131
3. Communicating With Co-Workers

3. 1. Introduction
Research in healthcare shows that patients frequently experience unnecessary harm
as a result of preventable medical errors. These events can result in the substantial
suffering of patients, as well as a high financial burden in terms of extended hospital
stays and litigation costs. In the intensive care unit (ICU), the complex and
multidisciplinary nature of intensive care medicine renders it particularly susceptible to
the occurrence of medical errors.
Effective team communication and coordination are recognized as being crucial for
improving quality and safety in the intensive care unit. Studies of communication
failures in medical teams have indicated the influence that hierarchical and social
factors have upon the behaviour of junior medical staff. Communication failures can
emerge from junior team members being reluctant to communicate openly with senior
team members because of a fear of either appearing incompetent, or of being
rejected, embarrassed, or reprimanded. Attitudinal research in the US has indicated
that ICU team members have divergent perceptions of their communication
behaviours, with more nurses than doctors reporting difficulties in speaking-up about
problems with patient care, and fewer nurses reporting that teamwork between nurses
and doctors is well coordinated. Not only do such factors increase the likelihood of
medical errors occurring, but also the extent to which communication in the ICU is
open may influence the degree to which patient care duties are understood. Through
the use of communication interventions that promote teamwork across role boundaries
(e.g. ICU daily goals sheets), making communication more inclusive and explicit has
been shown to increase team members' understanding of patient care plans in the
ICU.

3. 2. Working in a multidisciplinary team

In the ICU, although a single physician may have overall responsibility for a patient,
numerous staff members are involved in the patient’s care. In order to provide
optimum care, these team members have to communicate. Therefore, the etymology
of the word “communication” should be remembered: communicating means “sharing,
joining, uniting or making understanding common”; much of what means to function as
a team or be a good leader is linked with optimal communication strategies.
A multidisciplinary team may include not only physicians from a wide variety of
specialties and various levels of seniority, but also nurses, respiratory therapists,
pharmacists, dieticians, physical therapists, social workers, ethicists, and the
chaplaincy staff. In general, a physician leads the team.

3. 2. 1. Clearly assigning roles and tasks

Each member of the multidisciplinary ICU team has an important role to play. These
roles should be clearly defined, and team members, patients, and family members
should all be aware of the division of responsibility. The team leader has an important
influence on the interactions in the team; quality of leadership includes the ability to
establish a shared mental model, to coordinate tasks, to centralize the flow of
information, to establish structure and to stabilize emotions. (For further information
about leadership, see the e-module on Organisation and management  ).

 Note
Give one specific task to one person at one time

Although clarification of roles is an important aspect of daily work, it is particularly

important in stressful situations, such as resuscitations. It is known that, during crisis,
medical teams often fail to achieve a shared mental model: physicians often fail to
communicate what they are doing and why. Consequently, tasks should be clearly
assigned, and a single person should not be asked to perform multiple tasks
simultaneously. Practical strategies to enhance short-term medical communication
imply combating mitigating language (referent to language that de-emphasizes), use of
graded assertiveness (like the 5-step advocacy or SBAR) and use of closed-loop
communication (confirming task completion by demanding feedback). This coordinated
team approach should apply to all aspects of the patient’s ICU stay.

SBAR tool consists of a standardised prompt questions in four sections allowing

effective and consistent communication between healthcare professionals. It’s a
mnemotechnic word for:

Situation: identify yourself and patient, name the reason for your communication
and describe your concern
Background: patient’s reason for admission, significant medical history (patient’s
background)
Assessment: vital signs, clinical impressions or concerns
Recommendations: explain what you need, suggestions, expectations…

Using SBAR, important information can be transferred in a brief, concise and

predictable structure (as the structure is shared, it helps staff anticipate the needed
information). It was originally developed by the United States military for
communication on nuclear submarines and has been adapted for use in healthcare by
Dr M Leonard and colleagues (Kaiser Permanente, Colorado, USA).
Regarding other developed tools, teamwork in medical emergencies may be measured
using the TEAM tool, developed from an extensive review of the literature, and
validated through instrument testing. Primarily developed for cardiac resuscitation
teams, the TEAM tool has also been found to be a valid measure for teams managing
critically ill patients. In summary, TEAM is a training and/or assessment tool that is
made up of three categories (leadership, teamwork and task management);
encompassed within these categories are nine elements: leadership control,
communication, co-operation and co-ordination, team climate, adaptability, situation
awareness (perception and projection), prioritisation and clinical standards. The final
eleven items include applicable prompts to aid rating, whilst the twelfth item is a global
rating of the team’s performance.

Table 1: TEAM tool. Randmaa M et al, 2014.

Categories Elements
Items (11)
(3) (9)
The team leader lets the team know what is
Leadership expected from them through direction and
Leadership
control command
The team leader maintains a global perspective
Communication Effective communication within the team
Co-operation
The team worked together to complete the tasks
and co-
in a timely manner
ordination
The team acted with composure and control
Team climate
Positive morale within the team

Teamwork The team managed to adapt to changing

Adaptability
situations
Situation
awareness Monitoring and re-assessing the situation
(perception)
Situation
awareness Anticipation to potential actions
(projection)
Prioritisation Prioritising tasks
Task
Management Clinical The team followed approved standards and
standards guidelines
Global
On a scale of 1-10 give your global rating of the team’s non-
(overall
technical performance
rating)
In text References
(Randmaa et al. 2014)


What forms of communication could you use to ensure that team
members are aware of the division of responsibilities?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 Oral – Clarify jobs regularly in team meetings; explain your role

when introducing yourself to patients and families. Written – Post a job
diagram in the ICU; include job descriptions in a family information
brochure.

3. 2. 2. Advantages of teamwork
There are many advantages to working effectively as a team:

Improvements in efficiency, outcome, and the cost of care for ICU patients.
Error reduction (with a profound impact in patients’ safety).
Increases in morale, better job satisfaction, and less time missed from work
because of illness. Health team satisfaction requires feeling supported (e.g.:
administratively and inter-personally, respected, valued, understood, listened to,
with a fair compensation), with a clear understanding of one’s role.
Moderation of the detrimental effects of fatigue on performance.
Fewer and shorter delays.
Higher consent rate for organ donation.
Retention of high-quality committed nursing staff.

 Note

A study in the Netherlands found that nurses’ perceptions of their relationships

with doctors and hospital management were directly correlated with their
attitudes towards their patients and patients’ perceptions of the quality of care
received.

In text References
(Agency for Healthcare Research and 2018; Parker 2016)

3. 2. 3. Intra-team conflict
The observed majority of reported conflicts involve intra-team disputes, especially poor
communication within the ICU team.

Intra-team conflict implies barriers to working as a team, like:

Egos (leading to issues of control and competition)

Maintenance of a strict hierarchy
Different values, cultural norms, and beliefs
Different ideas of the proper focus of care
Disagreements over the major goals of therapy

As intra-team conflicts, whether among members of the ICU team or between the ICU
team and consultant specialists, send confusing messages to family members and
may lead to suboptimal management, they should therefore be resolved before they
are apparent to the patient and/or family.

In text References

(Van den Bulcke et al. 2016; Wujtewicz, Wujtewicz and Owczuk. 2015)

3. 2. 4. Improving patient handovers

It is important that the team members give consistent messages, especially during
shift changes. It should be clear which team member will take over responsibility for
communicating with the patient and family.

There is considerable recent literature on staff handover of patients. Handoff or

handover is defined as the information exchange that takes place when a new clinician
assumes control of, or takes responsibility for, a patient. In the United States, interest
in handovers has increased since 2006, when the Joint Commission on Accreditation
of Healthcare Organizations introduced a requirement for hospitals to Implement a
standardized approach to “hand off” communications, including an opportunity to ask
and respond to questions.(Joint Commission on Accreditation of Healthcare
Organizations  )

A handover is not a unilateral transfer of information, and if poorly conducted it may

degrade quality of care. Many studies describe negative effects on patient safety due
to loss of information or miscommunication during patient transfers. See Brindley et al
below.

Checklists and standardised processes have been developed to improve information

transfer and provide accurate transmission of key facts: background clinical
information, course of acute illness, tasks that need to be completed, uncertainty and
anticipation of events. Cohen and colleagues emphasize the effect of handoff
interaction on the mind of the receiver and their subsequent ability to make sense of
the patient’s unfolding episode of illness and treatment.
Simple mnemonic tools such as those listed below are unlikely to be sufficient, as they
have failed to show benefits in clinically relevant outcomes and may even decrease
physician accuracy:

SBAR (previously mentioned)

SOAP: subjective, objective, assessment, plan.
DeMIST: details, mechanism, injuries, signs/symptoms and observations,
treatment given)

In a systematic review performed by Van Sluisveld et al., effective interventions

(measured by an improvement of continuity of care and decrease of preventable
adverse events) included:

Implementation of liaison nurses to improve the communication and coordination

of care between ICU and ward healthcare professionals.
Handover forms to facilitate the timely handover of complete and accurate clinical
information for ICU to ward healthcare professionals.

In text References
(Cohen, Hilligoss and Kajdacsy-Balla Amaral. 2012; Brindley and Reynolds. 2011; Ilan
et al. 2012; Patterson and Wears. 2010; van Sluisveld et al. 2015; Taylor et al. 2014)

 References
Brindley PG, Reynolds SF., Improving verbal communication in critical care
medicine., 2011, PMID:21482347
Randmaa M, Mårtensson G, Leo, Swenne C, Engström M, SBAR improves
communication and safety climate and decreases incident reports due to
communication errors in an anaesthetic clinic: a prospective intervention
study, 2014, https://bmjopen.bmj.com/content/4/1/e004268
Agency for Healthcare Research and Quality, Team strategies and tools to
enhance performance and patient safety , 2018,
https://www.ahrq.gov/professionals/quality-patient-safety/index.html
Parker MM, Teamwork in the ICU--Do We Practice What We Preach?,
2016, PMID:26771780
Van den Bulcke B, Vyt A, Vanheule S, Hoste E, Decruyenaere J, Benoit D,
The perceived quality of interprofessional teamwork in an intensive care
unit: A single centre intervention study., 2016, PMID:27152533
Wujtewicz M, Wujtewicz MA, Owczuk R., Conflicts in the intensive care
unit., 2015, PMID:26401743
Cohen MD, Hilligoss B, Kajdacsy-Balla Amaral AC., A handoff is not a
telegram: an understanding of the patient is co-constructed., 2012,
PMID:22316097
Ilan R, LeBaron CD, Christianson MK, Heyland DK, Day A, Cohen MD.,
Handover patterns: an observational study of critical care physicians., 2012,
PMID:22233877
 Patterson ES, Wears RL., Patient handoffs: standardized and reliable
measurement tools remain elusive., 2010, PMID:20180437
van Sluisveld N, Hesselink G, van der Hoeven JG, Westert G, Wollersheim
H, Zegers M., Improving clinical handover between intensive care unit and
general ward professionals at intensive care unit discharge., 2015,
PMID:25672275
Taylor KL, Ferri S, Yavorska T, Everett T, Parshuram C, A description of
communication patterns during CPR in ICU., 2014, PMID:25010785

3. 3. Promoting cooperation and collaboration

As noted previously, modern healthcare is delivered by teams rather than individuals,
and requires the cooperation of healthcare professionals from multiple disciplines.
Failures in inter-professional teamwork and communication lead directly to
compromised patient care, staff distress, tension and inefficiency. Besides, ICU
professionals can benefit from each other’s strengths, knowledge, and experience.
Cooperation and collaboration require acknowledgment of the existence and value of
different perspectives and a willingness to solicit input from various members of the
team.

3. 3. 1. Being aware of different perspectives

How different healthcare professionals interact with each other and with patients can
influence attitudes about teamwork. When asked to rate the quality of interaction
between specialties, healthcare workers often have very different opinions of how well
they cooperate. In one study, only 33% of nurses rated the quality of collaboration and
communication with physicians as high or very high. In contrast, 73% of physicians
rated collaboration and communication with nurses as high or very high.

Challenge
Would you describe the relationship between healthcare professionals in your
department as hostile or collegial? Why? Ask some nursing colleagues what they think
and compare your perspectives. What effect does this relationship have on patient
care? Make a list of steps that can be taken to promote communication and talk to
colleagues or the clinical director about implementing them.

Physicians in different specialties may also have different perspectives. Research

indicates that communication across specialties is not as frequent as desirable. In a
study, 62% of surgical staff rated teamwork with anaesthesia staff highly, but overall
only 41% of anaesthesia staff rated teamwork with surgical staff highly. We need to
team together, to join forces, and avoid this particular situation. Effective information
between physicians reduces the risk of medication errors, unnecessary diagnostic
testing and re-hospitalization rates, and is also associated with an improved quality of
life for patients. Furthermore, successful communication strengthens relationships
among providers, and may increase referral rates across health care settings.

The perception of poor teamwork by one team member, even if incorrect, is enough to
change the dynamics within that team. Nurses and physicians may benefit from
training in conflict resolution, effective methods of asserting opinions and knowledge
and in listening skills. Standardized communication protocols have demonstrated a
significant increase in direct (interactive) communication events from acute care
providers to primary care providers. Moreover, primary care providers confirm that
interactive communication with ICU professionals is useful.This allows them to
participate in the care plan during the patient’s admission to the ICU. Follow-up care
assistance may also take place once the patient is discharged from the hospital.

In text References

(Ellis et al. 2015)


Some health care professionals uphold a ‘covenantal ethic’ - a
promise to the patient to battle death on their behalf - while others
subscribe to a ‘communal ethic’ - a commitment to the best
possible allocation of scarce resources. How might these different
perspectives affect communication between the two groups?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 These different perspectives can lead to confrontation and

miscommunication. For example, surgeons and intensivists are likely to
disagree when a surgeon requests and is denied an ICU bed for their
patient, when a patient is discharged from the ICU before the surgeon
feels the patient is ready, or when a decision must be made regarding a
shift from cure to comfort care. Because of their different perspectives,
surgeons and intensivists can give very different messages to families
as to the odds of a patient’s survival. This can lead to confusion,
distress and disagreement over whether a patient should receive heroic
or comfort care. Thus, it is very important that any decisions about
patient care are discussed by the whole care team, aiming at a
consensus within the team, and that communication with relatives is
well coordinated.
Finally, it is important that there is a formal agreement outlining who is principally
responsible for a patient, so that there is some sort of mechanism to follow in case of
disagreement.

3. 3. 2. Soliciting input from other team members

In the past, it was more common for the treating physician to be the prime decision-
maker, with little or no input from the patient or relatives, other healthcare workers, or
even colleagues. However, many intensivists now believe that difficult ICU decisions
should not be left to an individual physician but rather should be based on team
discussion, with input from all members of the team involved in the patient’s care.
Salaset al proposed a model of five key dimensions of effective teams: team
leadership, mutual performance monitoring, backup behaviour, adaptability and team
orientation. Team members must be willing to take other’s ideas and perspectives into
account; team’s goals must be aligned with what is best for the patient, and they are
more important than an individual’s goals.

An exchange of information between healthcare providers of different degrees of

status is particularly important for effective teamwork in the ICU because research
shows that individuals lower in a hierarchy are often not asked for relevant information
that only they have (Costa et al. 2016; Leonard, Graham and Bonacum. 2004).
Different professional groups have different expectations concerning the content,
structure and timing of information transfer, and may not understand the role and
priorities of other groups. This is why team members must respect and trust each
other in order to give and receive feedback on their performance; for example, nurses’
belief that physicians inappropriately exclude them from decisions about patient care is
one of the causes of intra-team disputes.

In text References

(Salas, Sims and Burke. 2005)


What kind of unique and valuable information might a
nonphysician team member provide? Give some examples.

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER


Nurse – The degree of pain the patient is experiencing, unique
understanding of patients’ experiences and wishes.
 Chaplain – Specific religious rules e.g. when dealing with dying
patients and death.
Social worker – Social background of a patient.

A survey of physicians working in Portuguese ICUs showed that fewer than 15% of
respondents involved nurses in decisions to withhold or withdraw treatment. (The
percentage increased among physicians with more than 10 years of clinical
experience.) Nurses’ belief that physicians inappropriately exclude them from
decisions about patient care is one of the causes of intra-team disputes.
When reviewing working relationships and interactions, remember that local culture
and customs may determine the approach to patient care.

Anecdote
A nurse involved in the care of a young terminally ill patient was not included in
doctors’ ethical discussions of the patient’s care. As a consequence, she was not able
to understand the reasoning behind the decision to continue treating the patient.
Further members of the nursing team agreed with her opinion, leading to a major
dispute among members of the ICU team. The conflict was finally settled when a
formal discussion was organised with the help of a mediator. Early involvement of the
nurse in the ethical discussions might have prevented much animosity.

 References
Ellis KA, Connolly A, Hosseinnezhad A, Lilly CM, Standardizing
communication from acute care providers to primary care providers on
critically ill adults., 2015, PMID:26523007
Costa DK, Dammeyer J, White M, Galinato J, Hyzy R, Manojlovich M, Sales
A, Interprofessional team interactions about complex care in the ICU: pilot
development of an observational rating tool., 2016, PMID:27538395
Leonard M, Graham S, Bonacum D., The human factor: the critical
importance of effective teamwork and communication in providing safe
care., 2004, PMID:15465961
Salas E, Sims D, Burke CS., Is there a “big five” in teamwork? , 2005,
https://journals.sagepub.com/doi/abs/10.1177/1046496405277134

3. 4. Improving the quality of care

3. 4. 1. Profiting from rounds
Besides having educational value, rounds in the ICU are used to communicate the
patient’s status to the entire team and to establish goals and care plans.
Communication during rounds is system-based. Bedside presentations should proceed
in the same order for each patient, covering the major physiological systems. An
explicit approach to clinical and educational responsibilities and reporting during
bedside rounds could be implemented. Components of successful rounds could be:

Timely, succinct and accurate exchange of information

Consistency of information
Explicit short-term and long-term plans
A balance of teaching and clinical service
A problem-oriented approach

Decreased length of stay, earlier identification of problems, increased collaboration

and improved communication have all been associated with interdisciplinary rounds.

3. 4. 2. Setting goals
Care in the ICU is goal-oriented: when the goals have been met, the patient is well
enough to be transferred to a less intensive level of care. However, there is not always
consensus between physicians and nurses regarding the specific goals of care in the
ICU. Pronovost et al (reference below) reported on an intervention designed to shift
the focus of rounds from provider-centred to patient-centred care. A daily goals form
was developed to facilitate communication by requiring that the care team explicitly
define the goals for the day. At baseline fewer than 10% of residents and nurses
understood the daily goals, but after implementation of the form, the percentage had
risen to greater than 95%, and ICU length of stay decreased from a mean of 2.2 days
to 1.1 days.

In text References

(Pronovost et al. 2003)


What role might communication play in reducing ICU length of stay
through implementation of daily goals?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 By promoting communication between ICU staff members and

between staff and families, the goals form could enable staff members
to streamline their care by clarifying tasks, care and communication
plans. It could also lead to earlier agreement in decisions to change
from interventive to comfort care.

3. 4. 3. Creating guidelines for care

Clinical practice guidelines have been documented to increase treatment
effectiveness, healthcare provider accountability, order standardisation, evidence-
based decision-making, and resource use efficiency. They increase the satisfaction of
healthcare professionals, contribute to improved clinical outcomes, and encourage
clinician cooperation within the ICU.

A multidisciplinary team in Minneapolis, Minnesota, developed guidelines for resolving

disagreements over plans of care between healthcare providers, among family
members, or between providers and family. The policy outlined principles for resolving
disagreements, the chain of command to follow, and a list of ‘triggers’ that signalled
the potential need for a conference (Tracy et al below).

Additionally, guidelines for family-centred care in neonatal, paediatric and adult ICU
have recently been published, emphasizing critically ill patient care as an approach to
healthcare that is respectful and responsive to individual families’ needs and values.

In text References

(Davidson et al. 2017; Tracy and Ceronsky. 2001)

 References
Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.,
Improving communication in the ICU using daily goals., 2003,
PMID:12800116
Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, Cox
CE, Wunsch H, Wickline MA, Nunnally ME, Netzer G, Kentish-Barnes N,
Sprung CL, Hartog CS, Coombs M, Gerritsen RT, Hopkins RO, Franck LS,
Skrobik Y, Kon AA, Scruth EA, Harvey MA, Lewis-N, Guidelines for Family-
Centered Care in the Neonatal, Pediatric, and Adult ICU., 2017,
PMID:27984278
Tracy MF, Ceronsky C., Creating a collaborative environment to care for
complex patients and families., 2001, PMID:11759357

3. 5. Dealing with problems: Handling errors in the ICU

‘To err is human’- Alexander Pope

Healthcare errors occur frequently in hospitals and although not all result in actual
harm, those that do are costly. Safety programs have been implemented in the last
decade, providing a strong and visible attention to safety, implementing non-punitive
systems for reporting and analysing errors and incorporating well-understood safety
principles, incorporating all these topics in training programs.

An estimated 85% of errors across industries result from failures in communication

(see reference below; US Institute of Medicine).Communication may be impaired
between patient and healthcare team, between family and healthcare team, in the
shift-to-shift report, between units, e.g.:with patient transfers, between medical
services and physician staff, and between members of the healthcare team.

A twofold increase in preventable adverse events has been demonstrated in patients

being covered by on-call physicians belonging to a team different from the daytime
care team. Handoffs were implicated in 28% errors; Starmer et al demonstrated a
decrease of 23% of medical-error rate and preventable adverse events (form pre-
intervention to post-intervention period) after the implementation of a handoff
programwithout a negative effect on workflow.

Furthermore, ambiguous verbal or written communication is especially common in

connection with medications. There may be illegible handwriting, orders missed by
doctors, nurses, or other staff, or verbal orders. In a system with several distinct
processes - ordering, transcribing, dispensing, administering, and monitoring - there
may be several steps that could fail.

In text References

(Starmer et al. 2014; Institute of Medicine (US) Committee on Quality of Health Care in
America; Kohn, Corrigan and Donaldson. 2000; Vande Voorde and France. 2002;
Wachter et al. 2002; Wu et al. 2009)

Discussing errors is therefore crucial. Yet, there are a number of reasons why ICU
professionals may be hesitant to discuss errors. These may include personal
reputation, threat of malpractice, high expectations of the patient’s family or society,
threat to job security, expectations or egos of other team members, and possible
disciplinary actions by licensing boards.

In order to promote patient’s safety and avoid medical errors, we may highlight some
principles for effective teamwork:

First of all, encourage discussions of safety and establish a confidential reporting

system.
Voice specific findings: the team member assuming the leadership role should
encourage information sharing and ask questions as opposed to suggesting
diagnoses
 Think out loud: all members of the team are encouraged to verbalize on-going
observations; effective leadership can facilitate this process by querying the team
for observations
Perform periodic review of quantitative information: noted changes should be
verbalized by the team, highlight the change in the status of information
Focus on solutions, rather than placing the blame
Double-check crucial data: all members of the team are encouraged to double-
check crucial data and tasks, and verbalize any doubts

In text References

(Bion, Abrusci and Hibbert. 2010; Hunziker et al. 2011)

Proactive planning may reduce problems and errors, but it cannot eliminate them.
Healthcare leaders should encourage their workers to openly discuss patient safety
issues. Team members recognising a problem should be able to communicate their
concerns to persons in authority.


How can discussion of mistakes help improve safety in the ICU?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 Awareness of a problem is the first step to solving it. By discussing

mistakes without placing blame, ICU team members can pool their
knowledge of a situation and identify potential solutions for processes
and procedures in need of improvement. For more details, refer to Crisis
Resource Management e-module.

 References
Institute of Medicine (US) Committee on Quality of Health Care in America;
Kohn LT, Corrigan JM, Donaldson MS., To Err is Human: Building a Safer
Health System., 2000, PMID:25077248
Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD,
Noble EL, Tse LL, Dalal AK, Keohane CA, Lipsitz SR, Rothschild JM, Wien
MF, Yoon CS, Zigmont KR, Wilson KM, O'Toole JK, Solan LG, Aylor M,
Bismilla Z, Coffey M, Mahant S, Blankenburg R, Changes in medical errors
after implementation of a handoff program., 2014, PMID:25372088
Vande Voorde KM, France AC., Proactive error prevention in the intensive
care unit., 2002, PMID:12400625
Wachter RM, Shojania KG, Saint S, Markowitz AJ, Smith M., Learning from
our mistakes: quality grand rounds, a new case-based series on medical
errors and patient safety., 2002, PMID:12044134
Wu AW, Huang IC, Stokes S, Pronovost PJ., Disclosing medical errors to
patients: it's not what you say, it's what they hear., 2009, PMID:19578819
Bion JF, Abrusci T, Hibbert P., Human factors in the management of the
critically ill patient., 2010, PMID:20511333
Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell MD,
Marsch S., Teamwork and leadership in cardiopulmonary resuscitation.,
2011, PMID:21658557
4. Developing communication skills

4. 1. Introduction
The gap between the importance of communication skills in critical care and the lack of
structured educational programs to improve any critical care health professional’s
comfort and skill in these areas is a reality that must be recognized.

Recent guidelines (see reference below) recommend that:

Routine interdisciplinary family conferences be used in the ICU to improve family

satisfaction with communication and trust in clinicians and to reduce conflict
between clinicians and family members(grade 2C).
Healthcare clinicians in the ICU should use structured approaches to
communication, such as that included in the “VALUE” mnemonic, when engaging
in communication with family members, specifically including active listening,
expressions of empathy, and making supportive statements around non-
abandonment and decision making. In addition, we suggest that family members
of critically ill patients who are dying be offered a written bereavement brochure to
reduce family anxiety, depression, and post-traumatic stress and improve family
satisfaction with communication (grade 2C).
ICU clinicians receive family-centered communication training as one element of
critical care training to improve clinician self-efficacy and family satisfaction (grade
2D).

In text References

(Davidson et al. 2017)

Few healthcare professionals are naturally talented communicators; the majority have
to learn. This learning does not just occur through sheer experience or by being told
what to do; it is usually acquired through extensive training and deliberate practice.
Hence, communication skill programs give the opportunity for skills practice and
feedback and must be integrated into critical care training programs.

Simulation and debriefing come into play. Increasing published references

demonstrate that both strategies help promote the integration of skills learned in the
simulated setting into the clinical environment and ongoing skills development.
Structured debriefing of the clinical team after a potentially traumatic event can lead to
process improvements and better patient focused outcomes.

In text References
(Chiarchiaro et al. 2015; Couper et al. 2013; Curtis et al. 2013; Hope et al. 2015; Roze
des Ordons et al. 2017; Zante and Schefold. 2019)

 References
Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, Cox
CE, Wunsch H, Wickline MA, Nunnally ME, Netzer G, Kentish-Barnes N,
Sprung CL, Hartog CS, Coombs M, Gerritsen RT, Hopkins RO, Franck LS,
Skrobik Y, Kon AA, Scruth EA, Harvey MA, Lewis-N, Guidelines for Family-
Centered Care in the Neonatal, Pediatric, and Adult ICU., 2017,
PMID:27984278
Chiarchiaro J, Schuster RA, Ernecoff NC, Barnato AE, Arnold RM, White
DB., Developing a simulation to study conflict in intensive care units., 2015,
PMID:25643166
Couper K, Salman B, Soar J, Finn J, Perkins GD., Debriefing to improve
outcomes from critical illness: a systematic review and meta-analysis.,
2013, PMID:23754132
Curtis JR, Back AL, Ford DW, Downey L, Shannon SE, Doorenbos AZ,
Kross EK, Reinke LF, Feemster LC, Edlund B, Arnold RW, O'Connor K,
Engelberg RA., Effect of communication skills training for residents and
nurse practitioners on quality of communication with patients with serious
illness: a randomized trial., 2013, PMID:24302090
Hope AA, Hsieh SJ, Howes JM, Keene AB, Fausto JA, Pinto PA, Gong
MN., Let's Talk Critical. Development and Evaluation of a Communication
Skills Training Program for Critical Care Fellows., 2015, PMID:25741996
Roze des Ordons AL, Doig CJ, Couillard P, Lord J., From Communication
Skills to Skillful Communication: A Longitudinal Integrated Curriculum for
Critical Care Medicine Fellows., 2017, PMID:28351063
Zante B, Schefold JC., Teaching End-of-Life Communication in Intensive
Care Medicine: Review of the Existing Literature and Implications for Future
Curricula., 2019, PMID:28659041

4. 2. Effective communication strategies

Being aware of one’s own strengths and weaknesses with respect to communication,
combined with insight into how best to learn new practices and critical self-reflection
on performance, will lead to improvements in communication.

See the e-module on Teaching and learning 

4. 2. 1. Awareness
The ability to sense messages from our store of emotional memory - our own reservoir
of wisdom and judgment - is the basis of self-awareness, and self-awareness is the
vital foundation for three emotional competencies (Goleman 1998).

Emotional awareness (the recognition of how our emotions affect our

performance, and the ability to use our values to guide decision-making)
Accurate self-assessment (a candid sense of our personal strengths and limits, a
clear vision of where we need to improve, and the ability to learn from experience)
Self-confidence (the courage that comes from certainty about our capabilities,
values and goals)
Cultural awareness- (knowledge of how our culture influences health decision
making, stereotyping and assumptions


Self-awareness and reflection enhance the quality of
communication. Give reasons for this.

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 Through reflection and self-awareness you will become more

aware of what is happening in consultations with patients and families.
Understanding your own strengths and weaknesses as a communicator
will enable you to keep the lead in discussions and to avoid panicking
when something unexpected happens. You will more quickly evaluate
situations and come up with possible solutions.

4. 2. 2. Intuition and empathy

Intuition or ‘gut feeling’ is an important aspect of communication. In order to have a
real relationship with your patients, their families, and colleagues you need to be able
to sense their feelings, understand their perspectives and take an active interest in
their concerns. The ability to empathise with others is strongly related to our self-
concept, our self-esteem, our self-awareness and our self-control. Besides, effective
communication requires not only mastery of communication skills, but also the ability
to adequately interpret a situation and to recognise which skills will be effective with a
particular person at a particular time.

4. 2. 3. Types and levels of communication

Communication involves both sending and receiving information. Every message has
two levels of information: the content level and the context level. The content level
refers to the verbal information contained in the message. The context level guides us
in interpreting the information once it is received; it is the extra information that allows
us to read between the lines.

Intonation, volume, choice of words (paralinguistic aspects), facial expression and

body posture are the channels through which we can read the information on this
second (context) level. If both levels are in accordance, behaviour is congruent. Lack
of congruence promotes confusion and erodes trustworthiness.

 How can lack of congruence erode trustworthiness?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 80%-90% of human communication is non-verbal. You cannot hide

body language. Patients and their families will pay far more attention to
the context of your message than to its content. If you say something
different from what you really mean, this will be evident in your non-
verbal behaviour. The result is that other people will question the truth of
your words.

4. 2. 4. Communication styles
There are two distinct styles of communicating with patients or families: the doctor-
centred (‘directive’) approach and the patient-centred (‘explorative’) approach. Both
styles are necessary, but the order in which they are used can be quite crucial.

In the directive style, the doctor gathers information to test his/her hypotheses, gives
explanations or provides information he/she thinks is important for the patient. In the
explorative style, the patient’s perspective - his/her thoughts, emotions, attitudes and
behaviours - is the focus of attention. In order to find out about the preferences,
values, thoughts and feelings of patients or family members, the explorative style is
more appropriate. Physicians should choose the style with which they are most
comfortable or with which they are most experienced, based on their personal
preferences and skills.

(Warrillow, Farley and Jones 2015) summarised all these aspects into ten practical
skills for effective communication with relatives:

1. Ensure access for relatives to be with the patients, demonstrate

compassionate care through non-verbal cues
2. Provide regular updates and outline prognosis early on (no surprises)
3. Try to avoid conducting a family meeting on your own and involve other
healthcare professionals, such as the bedside nurse and/or trainees.
 4. Ensure you have plenty of time free of interruptions available for
communication with relatives
5. Start the conversation; prepare by knowing the patient’s history and clinical
details, never forgetting to ask relatives what they know
6. Avoid technical language
7. Avoid providing excess numeric data, such as prognostic statistics and
laboratory results
8. “It’s OK to show emotion”
9. Allow relatives to speak freely
10. Outline a plan, focusing on actual treatment and management

 References
Goleman D, Working with Emotional Intelligence, 1998, ISBN:0553104624
Warrillow S, Farley KJ, Jones D, Ten practical strategies for effective
communication with relatives of ICU patients., 2015, PMID:25904186

4. 3. Communication skills
There are a number of communication skills from which the physician can choose.
Among them: attentive listening, asking questions, paraphrasing, reflecting, explaining,
checking understanding, summarising, concreteness, and structuring. Most of these
skills are basic to every interaction; some are needed in specific situations to ensure
that communication is effective.

In text References

(Engel 2010; Ley. 1988)

4. 3. 1. Attentive listening
Attentive listening is one of the so-called non-selective listening skills, which means it
needs to be used throughout the encounter, creating an atmosphere in which the other
person is encouraged to speak freely. Attentive listening consists of verbal and non-
verbal behaviours: ‘hums’, short attentive silences, and so-called minimal verbal
encouragers (Yes ... ? So ... ? And ... ?); a relaxed posture, slightly bent towards the
other person; an interested facial expression; stimulating eye contact; minimal non-
verbal encouragers such as nodding; supportive gestures.

4. 3. 2. Asking questions
There are two kinds of questions: open-ended and closed. Both types of questions are
necessary in communication.
 Open-ended questions are best used when you want to explore. They give others
freedom to formulate an answer in their own words,e.g.: “How are you feeling
today?”
Closed questions can be used to acquire specific information. e.g.: “Is there any
shortness of breath?” or “How high was the fever?” They originate from the frame
of reference of the person who is asking the questions. This poses the risk that
they may be suggestive, and also that the person asking the questions will pay
less attention to the answers because they are busy thinking of follow-up
questions. In order to avoid sounding like a cross-examiner, closed questions
should be used sparingly.

4. 3. 3. Paraphrasing
Paraphrasing is restating, in your own words, the most important issues in the verbal
message the other person has given you. Paraphrasing has several goals: to show
understanding, to check if you have correctly understood what you have been told,
and to present the other person’s information in a more concise manner. You can also
occasionally literally repeat what has been said, but this should not be done often, in
order to prevent ‘parroting’.

4. 3. 4. Reflecting feelings
Reflecting is used to draw out the unspoken feelings underlying the words or
behaviour of another person. It is important to use your own words when reflecting
feelings, and to express them in a tentative way‘, for example “It sounds to me like you
are disappointed with what Ive just told you about your fathers condition".

The aims of reflecting feelings are to communicate understanding, to invite the other
person to elaborate on their feelings, and to show the other person that you are
listening. If used too often, reflection may either be threatening or give the impression
that you are employing a technique.

4. 3. 5. Checking understanding
You should not only check if information has been received, but also how it has been
received. Observe the impact of your words. Always check non-verbal signals. It may
often be necessary to repeat information, and to summarise what you have been
saying. It can be helpful to ask the patient or family to repeat what you have told them.
Ask for feedback about the comprehensibility of your information and encourage
questions.

4. 3. 6. Summarising and Concreteness

The purpose of summarising is to structure what the other person has said. Subjects
are ordered in a logical way or based on assumed priorities. Summaries give an
overview of both cognitive and emotional aspects; they are to the point, formulated in
your own words, and ideally communicated in a tentative mode. They often mark the
transition from one stage of the interview to another, or to a new subject.
Concreteness is a skill in which listening, encouraging, asking questions, reflecting
feelings and summarising are combined. It is used to ensure that you have the
personal, concrete and specific information you need for a full understanding of a
situation the other person has described.

4. 3. 7. Structuring
A structured interaction is more productive, keeps the participants focused, and
guarantees that important issues are addressed. Structuring is especially helpful for
interactions in which important issues have to be discussed, such as breaking bad
news, end-of-life decisions, and requesting organ donation.

In text References
(Awdish et al. 2017; Roze des Ordons et al. 2015; Salmon and Young 2017; Zante and
Schefold. 2019)

A communication curriculum could therefore start with knowledge about human

relationships. Learning about attachment processes and adult attachment styles could
help clinicians make sense of the variability of patients’ presentations and appreciate,
for example, that some patients’ difficulties with trust can lead to detachment or
hostility that is easily mistaken for self-sufficiency. Knowledge about relationships will
provide information for practically-focused learning. Good communication needs
clinicians to transcend generic knowledge and be curious about their patients; they
must be motivated to find out about their patients’ individuality. Clinicians should also
be able to focus their attention on their own behaviour instead of the patient.


Describe some ways you could use the communication skills
outlined in this task to develop a relationship with your patient in
the ICU.

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 Attentive listening - Spend some time at your patient’s bedside

before rounds. Asking questions So, how do you feel about being in the
ICU?’; ‘What can we do to make you feel more comfortable’.
Reflecting - ‘I can see that you’re very uncomfortable with the tracheal
tube.’ Explaining - ‘The tube down your throat helps you to breathe at a
regular rate. You can’t talk at the moment, but after it’s taken out you’ll
be able to talk again.’
 Challenge
Over a period of several weeks, watch the following interactions and make
notes about what you see and hear:

Television interviews in which people are invited to speak about their experiences
or about their specialty
Television interviews with politicians
Your colleagues, in consultations with patients or with families

Write down the main differences between these interactions in terms of the skills
described in this Task. What can you say about the structure of these interactions, the
kinds of questions being asked, the options for answering? Note the non-verbal
behaviour of both parties in the interaction: what happens on the content and the
context level? Which of the people do you consider good communicators
(interviewers/interviewees), and why? What can you learn from their behaviour? Make
a list of dos and don’ts for yourself.

 References
Zante B, Schefold JC., Teaching End-of-Life Communication in Intensive
Care Medicine: Review of the Existing Literature and Implications for Future
Curricula., 2019, PMID:28659041
Engel M, I'm Here - Compassionate Communication in Patient Care (Third
Edition). , 2010, ISBN-13:9780972000024
Ley P., Communicating with patients. Improving communication, satisfaction
and compliance, 1988, ISBN-10: 9780709941743
Awdish RL, Buick D, Kokas M, Berlin H, Jackman C, Williamson C, Mendez
MP, Chasteen K, A Communications Bundle to Improve Satisfaction for
Critically Ill Patients and Their Families: A Prospective, Cohort Pilot Study.,
2017, PMID:28042074
Roze des Ordons AL, Sharma N, Heyland DK, You JJ, Strategies for
effective goals of care discussions and decision-making: perspectives from
a multi-centre survey of Canadian hospital-based healthcare providers.,
2015, PMID:26286394
Salmon P, Young B, A new paradigm for clinical communication: critical
review of literature in cancer care., 2017, PMID:27995660

4. 4. Team communication
Regarding team communication in healthcare, many of the strategies mentioned
above may be used, contingent upon the situation.
Nevertheless, we can describe several actions to overcome barriers to team
communication in healthcare:

Teach effective communication strategies (structured methods of communication

such as SBAR handovers).
Train teams together, especially using simulation (as a safe way to practice new
communication techniques, allowing an increase in interdisciplinary
understanding). Immersive simulation can be a powerful intervention to trigger
discussion about roles, responsibilities and information sharing around patient
management.
Simulation (with appropriate debriefing) provides insights into how other
professional groups think and feel, and a better understanding of how to support
each other and maximise everyone’s input to patient care.
Define inclusive teams.
Create democratic teams (each member of the team should feel valued; flat
hierarchies encourage open team communication).
Hierarchies can create barriers to information exchange and action (e.g.: if
nurses perceive themselves as lower status team members, they may be
less likely to initiate action, despite being highly competent, because the
legitimacy of their action in the situation may be questioned).
Support teamwork with protocols and procedures that encourage information
sharing among the whole team
Develop an organisational culture supporting healthcare teams, overcoming the
geographical and temporal challenges often faced by healthcare teams where
patients and team members are spread across the hospital and belong to a
number of different teams (we must recognise the imperative inter-professional
collaboration for safety)

In text References

(Weller, Boyd and Cumin. 2014)

 References
Weller J, Boyd M, Cumin D., Teams, tribes and patient safety: overcoming
barriers to effective teamwork in healthcare., 2014, PMID:24398594

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