In "Azoulay E, Chevret S, Leleu G, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000;28:3044–3049", it was found that less than half of the families knew what was wrong with their loved one or their prognosis 48 hours after admission to the ICU. About communication with families of critically ill patients, which of the following is not advised?
B. Decrease amount of conflicting information by having the same individuals meet with the family and/or decrease the number of providers who meet with the family
C. Attend to the psychological fact that stress, emotions and fatigue will decrease their understanding, so be more empathetic and develop written or computerized information.
D. For end-of-life communication, use direct and frank language, for example, when treatment is considered futile, tell them that "There Is nothing more to do". Clarify with them by saying "Would you like us to do everything possible?" to let them feel that we are respecting their wish, and to avoid ambiguity and future litigation, we should say "We will stop the breathing machine and the antibiotics and if his heart stops we won’t try to resuscitate", or concise language like "we will withdraw our care".
Answer: D
Nowadays, multiple factors are affecting our communications with families of critically ill patients, and we are actually in an unfavorable position when there are multiple instances that our decisions based on rationality and morality may not be supported by the popular media and were misunderstood by the general public. Many a time, we are approached by hostile families who have assumed that we have done wrong by default, until proven otherwise.
We are not required by any canon of ethics to render care that will not be beneficial to the patient or will not reverse the progression toward death. We are, however, required to do everything reasonable, including instituting palliative measures to avoid pain and suffering. In order to carry out what we believe is morally correct, blunt confrontation with family members is not the way out; we have to exercise our good communication skills.
It was advised that instead of say ing "there is nothing more to do", we should say with the caring statement, "I wish there were something we could do to cure your illness," as suggested by Quill and colleagues, followed with, "Let’s focus on what we can do to help you". Avoid saying "Would you like us to do everything possible?" otherwise the simple answer to you is just "yes, please, everything". It was suggested that it would be more effective to begin by asking, "How were you hoping we could help?" Avoid saying "We will stop the breathing machine and the antibiotics and if his heart stops we won’t try to resuscitate". Use the more tactful phrase of saying "To respect his wishes, we will stop the breathing machine and use medicines to make his breathing comfortable." It was advised that clinicians should avoid the shorthand "withdrawal of care," and instead say, "Withdrawal of mechanical ventilation and vasopressors and institution of comfort measures," which reflects that caring for the patient will continue and avoid giving them a feeling of abandonment.
References
1. David W. Crippen, MD (Editor). End-of-Life Communication in the ICU, A Global Perspective. Springer.
2. Steven Z. Pantilat, MD. Communicating With Seriously Ill Patients Better Words to Say. JAMA. 2009;301(12):1279-1281