October et al1 add valuable new insights into ways in which communication with families around important medical decisions can be improved in the pediatric intensive care unit (ICU). October and colleagues found that physicians responded to a family’s emotional cues with an empathetic statement 74% of the time. Of these, 62% were unburied (ie, there was a pause that allowed the family to respond), while the other statements were buried (ie, continuation of medical talk, interruption by another physician, or a closed-ended question). This qualitative study looked at how often physicians were able to identify emotional cues from the family, respond with an empathetic statement, and then leave space in the conversation for the family to respond. When the clinicians behaved in this way, families were more likely to share further information about their fears, values, and motivations.
How does this research inform our understanding of communication in the pediatric ICU? One notable background feature of the study was that 24 (80%) of the physicians were classified as white and 43 (64%) of the patients were classified as black.1 In my experience, this type of difference between physicians and families is not uncommon in large urban hospitals, often compounded by an increasing proportion of international patients, each with their own language, culture, and beliefs. In addition to improving communication skills, greater awareness, knowledge, and sensitivity toward how race, ethnicity, and culture affect the relationship between clinicians and families are essential to improving the care that we provide.
Another important feature of the study was that it focused specifically on family conferences around important medical decisions. To my knowledge, most of the communications research that has been done in both adult and pediatric ICUs has focused on family conferences for several reasons. In addition to the perception that decision making actually “happens” during family conferences, they are typically planned, occurring at a discrete time and in a predictable, formal setting. All of these features make family conferences both accessible and amenable to research. However, family conferences are not necessarily the most important venue for communication.2 Families interact with clinicians, gather information, and make decisions in many settings other than family conferences. Nurses may spend hours with a family at the bedside during a shift, with many opportunities for long and unpressured conversation. Bedside rounds are becoming increasingly popular, and families have an opportunity to hear the entire medical team discuss and debate the plan for the day. Specialists come by at unpredictable times, often giving their independent opinions without coordinating their views with other clinicians. And families are surfing the internet, talking with each other, and comparing notes about the care that their children are receiving.
We should be cautious in extrapolating from these relatively rare team meetings to the totality of the family experience in the ICU or even assuming that it is the communication with the physicians that matters most. While the physician certainly has an authoritative role in informing families about their children’s condition and options for care, families are often processing that information with bedside nurses, social workers, chaplains, and other friends and family members.
The authors reported that every family conference included nonphysician team members, but bedside nurses were present only 35% of the time.1 Even with the best of physician communicators, many families will feel too intimidated, overwhelmed, or unwilling to infringe on the physician’s time to ask all of the questions they need answered. Often, nurses play a critical role in debriefing with families at the bedside after a family conference, reviewing and explaining what the physician said, and helping the family work through their options for care. One possible way to improve communication with families might be to place more importance on having the nurse present for these meetings.
At these family meetings, nonclinicians spoke only 5% of the time.1 Nevertheless, when they did speak up, they were more likely to use unburied empathetic statements offering support to families. As the authors observed, this suggests that nurses and other nonphysicians are an untapped resource in communicating with families.
In modern ICUs, delivering health care is truly a team sport, and the team cannot perform at its highest level unless each member is empowered to contribute to the fullest of his or her potential. The notion that family conferences are primarily a conversation between physicians and families, with others invited mostly to observe, is not an optimal use of everyone on the team. Systems that place a high priority on ensuring that nonphysician clinicians are able and expected to attend and that use proactive huddles before meetings to encourage the participation and involvement of everyone on the team are likely to do a better job of supporting families overall.
How do we translate the findings from this study into better communication skills? Findings by October et al1 certainly ring true with my own experience. But, how to translate this wisdom into improved performance by physicians is not obvious. Simply telling a physician, “Listen for the family to provide you with an emotional cue, make an empathetic response, and then pause,” is unlikely to be successful.
As we have learned in so many areas of medicine, simulation training is one of the most powerful tools for improving clinical performance, and I think that the teaching of communication skills is no exception. Opportunities to interact with trained simulated patients and to receive feedback from the patients, faculty, and other learners is an invaluable way to become a better communicator.3,4
October et al1 have given us a gift of new insights into some of the ways in which we can improve our ability to communicate and care for patients and families. It is up to all of us to take this information and incorporate it into our own practices and into our educational programs.
Published: July 6, 2018. doi:10.1001/jamanetworkopen.2018.0352
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Truog RD. JAMA Network Open.
Corresponding Author: Robert D. Truog, MD, MA, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Bader 6, Boston, MA 02115 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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