Improving Communication Between ICU Physicians and Families of Dying Patients

Key Point

A specific communication technique used by ICU staff—which can be remembered through use of the mnemonic VALUE—can reduce symptoms of depression, anxiety, and stress experienced by patients’ family members. In this study, the technique was enhanced by dissemination of bereavement handouts.

PARIS—Posttraumatic stress, anxiety, depression—these are conditions common to family members of ICU patients, particularly when the time comes to make important end-of-life decisions for loved ones who are unable to do so for themselves. However, after years of research, a strategy has been shown to make the experience easier. Reporting in the New England Journal of Medicine, Alexandre Lautrette, MD, and colleagues quantified the effect of an intervention designed to improve communication between clinicians in the ICU and family members of dying patients.¹ The study, funded in part by the National Institute of Nursing Research, showed that a family conference with a specific structure allows family members to express their emotions and arrive at realistic expectations of outcomes.

The cornerstone of the intervention is the mnemonic VALUE, which serves as a reminder for the ICU staff to do the following:

• Value and appreciate what family members say
• Acknowledge the family members’ emotions by using reflective summary statements
• Listen
• Understand who the patient was as a person by asking open-ended questions
• Elicit questions from the family members.

Prior Research Informs New Study

The seeds for the VALUE system of communication were planted several years ago. In an article that appeared in Critical Care Medicine,² J. Randall Curtis of the University of Washington in Seattle and colleagues outlined the specific steps to facilitate the family-clinician conference. The researchers recognized that for patients’ families, unrealistic expectations—including the notion that the ICU staff will be able to cure the patient—might make an already difficult conversation even harder. It is likely that families may have been unprepared for the acute illness or exacerbation that brought their loved one into the ICU, as well as for the unexpected poor prognosis, the investigators said.

In a subsequent study, the same group illustrated how the lines of communication in the ICU can be crossed.³ They reviewed audiotape transcripts of 51 family conferences during which the attending physician, along with nurses, social workers, and/or religious figures, delivered bad news or discussed withdrawal of life-sustaining therapy. The most common type of poor communication—or “missed opportunity”—occurred when a family member’s question was avoided or a different question was answered instead. Another type of missed opportunity occurred when hospital staff did not acknowledge family members’ verbal or physical (eg, crying) expressions of emotion. In other instances, clinicians missed opportunities during the discussions to correct family members who showed a lack of understanding of advance directives.

"Landmark" Trial Shows Measurable Benefits

The current study—a randomized controlled trial conducted in 22 ICUs—involved the family members of 126 critically ill patients. When an ICU physician believed that the death of the patient was likely to occur within a few days, a proactive family conference was called to decide whether life-sustaining measures, such as mechanical ventilation, be continued or withdrawn.

In half the cases, the family conference proceeded under the customary ICU practice. In the other half, the physicians conducted the conferences in accordance with the VALUE guidelines. At the end of their conference, intervention families were given a brochure on bereavement.

Three months after the patient’s death, the researchers conducted a telephone interview with one of the patient’s family members, primarily to assess symptoms related to posttraumatic stress disorder (PTSD). PTSD was measured via the Impact of Event Scale (IES), with scores ranging from 0 (no PTSD-related symptoms) to 75 (severe symptoms). Anxiety and depression symptoms were assessed by the Hospital Anxiety and Depression Scale (HADS) subscale scores (range, 0 [no distress] to 21 [severe distress]).

On average, the customary-practice conferences involved two family members and lasted 20 minutes, with the family speaking roughly five minutes; the intervention conferences involved three family members and lasted 30 minutes, with the family speaking for more than 13 minutes. All conferences resulted in a decision to forego further life-sustaining treatment.

IES scores in the intervention group were lower than those in the control group (median scores, 27 vs 39, respectively), “indicating that 25 family members in the intervention group (45%) were at risk for PTSD as compared with 36 (69%) in the control group,” the investigators noted. HADS scores also were significantly lower in the intervention group than in the control group (median scores, 11 vs 17, respectively).

“This study is groundbreaking in its demonstration of a statistically and clinically significant improvement in symptoms of anxiety, depression, and PTSD among family members,” said Craig M. Lilly, MD, and Barbara J. Daly, PhD, RN, in an accompanying editorial.⁴

“All providers of critical care should receive training that will allow them to offer the kind of support that they would want if they had a family member who was facing death in an ICU,” they contended.

—Adriene Marshall

Reference
1. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356:469-478.
2. Curtis JR, Patrick DL, Shannon SE, et al. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. Crit Care Med. 2001;29(2 suppl):N26-N33.
3. Curtis JR, Engelberg RA, Wenrich MD, et al. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med. 2005;171:844-849.
4. Lilly CM, Daly BJ. The healing power of listening in the ICU. N Engl J Med. 2007;356:513-515.

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