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Educational Modules for the Critical Care Communication (C3) Course - A Communication Skills Training Program for Intensive Care Fellows Written by the C3 investigators (Robert Arnold, Judith Nelson, Thomas Prendergast, Lillian Emlet, Elizabeth Weinstein, Amber Barnato, and Anthony Back), based on modules from Oncotalk (by Anthony Back, Robert Arnold, Walter Baile, James Tulsky, and Kelly Fryer-Edwards) Module 1: Fundamental Communication Skills Module 2: Giving Bad News Module 3: Determining Goals of Care for Patients Who are Not Doing Well Module 4: Talking about Resuscitation Preferences Module 5: Conducting a Family Conference Module 6: Discussing Forgoing Life-Sustaining Treatment and the Dying Process Module 7: Navigating Conflict with Families A Guide for Conducting an ICU Family Meeting Bibliography Copyright © 2010, Robert M. Arnold, MD CRITICAL CARE COMMUNICATION (C3) MODULE I: FUNDAMENTAL COMMUNICATION SKILLS These learning modules for intensivists have been developed based on the success of communications skills modules for oncologists, which are available through Oncotalk at http://depts.washington.edu/oncotalk/learn/modules.html In this module the term ‘family’ is used to refer to all the people who are emotionally intimate or biologically connected to the patient. Thus a patient’s ‘family,’ for our purposes, may include an unmarried partner, a close friend, and/or a second cousin—in addition to a spouse, children, or parents. Learning Objectives After reading this section, participants should be able to do the following: 1. List four fundamental principles for better intensivist-family communication. 2. Describe the "Ask-Tell-Ask" principle. 3. Describe the "Tell me more" principle. 4. Describe the "Respond to emotion" principle and the mnemonic NURSE. 5. Describe the differences between "monitors" and "blunters," and identify techniques to best address their information needs. Why This Course? Communication between physicians and patients and their families is “consistently identified as the most important and least accomplished factor in quality of care” in the intensive care unit (ICU). Each year, over half a million people in the United States die in an ICU or following treatment in an ICU during their final hospital admission. ICU patients are able to participate in their own end-of-life discussions less than 5% of the time, and they frequently have no advance directives available. Thus, intensivists turn to surrogates. Family members are conventionally recognized as surrogate decision-makers because they are presumed to know the patient’s preferences and to act in the patient’s best interests. Intensivists, not only need to inform the patient and/or family members about the diagnosis, prognosis, and treatment, but also, in most Copyright © 2010, Robert M. Arnold, MD cases, must help the family to make decisions that reflect the patient’s goals while at the same time attending to the family’s emotional needs at a time of severe stress. Multiple studies suggest that communication with family members in the ICU is inadequate. One study reported that half of family members, 48 hours after admission, did not understand even basic information about the patient's diagnosis, prognosis, or treatment. Malacrida et al. (See Readings and Resources List.) interviewed 123 relatives of patients who died in the ICU, 17% of whom said that they received insufficient or unclear information on their loved one’s diagnosis. During the ICU stay, anxiety and depression among family members was magnified when they felt excluded from decision making. Curtis et al. (See Readings and Resources List.) found that in family meetings, physicians spoke over two-thirds of the time, and that in 29% of the meetings, physicians missed opportunities to listen, acknowledge, and address families’ emotions; explore patient preferences; explain surrogate decision making; and affirm families’ concerns of non-abandonment. Abbott et al. (See Readings and Resources List.) investigated sources of conflict with family members of patients who died in the ICU. About half of the families reported conflicts with medical staff, usually involving poor communication. Finally, post-traumatic, stress-related symptoms in family members 90 days after their loved one’s discharge or death were more common among those who thought that information they received was incomplete, who shared in decision-making, and whose family member died in the ICU. Clinicians also report dissatisfaction with family communication. For example, over 70% of clinicians report perceived conflicts with other staff or family, typically surrounding decision- making for patients at high risk of dying. These conflicts were often severe and were significantly associated with job strain. Many intensivists will say that communication with families is the most stressful part of their job. Worries about “futility” and feeling overwhelmed by “demanding” families, may be part of the reason that one third of physicians and one half of nurses report being burned out. The common element among these deficiencies is poor communication skills. A recent survey of pulmonary and critical care fellows documents scant formal teaching on communication about death and dying, a lack of explicit feedback about basic communication skills, and an absence of 2 Copyright © 2010, Robert M. Arnold, MD role models with such expertise. A separate survey of physician and nurse directors of 600 ICUs across the United States identified inadequate training and the absence of clinician-experts in communication as a major barrier to better end-of-life care for patients dying in ICUs. Physicians report lacking the skills needed to communicate complex medical information or to address families’ emotional needs. Although physicians frequently regard the ability to communicate as an inborn talent, physicians can learn these skills if evidence-based methods are used. A variety of studies of internists and family medicine physicians show that communication skills training leads to more discussion of psychosocial issues with decreased patient distress, more inquiry about patients’ views, greater physician ability to elicit patient values and feelings, and greater confidence in communicating bad news. Finally, a Cochrane systematic review of communication skills training for health care professionals working with cancer patients and their families concludes that: (1) it is clear that communication skills do not reliably improve with experience alone, and (2) training programs using appropriate educational techniques are effective in improving skills. However, fewer data exist regarding the impact of these improved communication skills on patient or family outcomes. Fundamental skills that will help In teaching clinicians to improve their communication skills, we have found five fundamental principles that help physicians deal with many clinical situations. These principles summarize a great deal of the communication literature written by empirical researchers and master clinicians. These are not, of course, the only principles around, and other respected experts use teaching aids that are somewhat different. However, we, as the clinicians who developed this training, use these principles frequently ourselves and consider them “road-tested.” Note that the principles emphasize what physicians should actively do in trying to communicate better—not what physicians should avoid doing. When improving any skill, it is easier to try to do something rather than to try not to do something. So even though this learning guide includes barriers and pitfalls, we recommend that you focus on the principles. A series of principles for action is likely to be more useful to take away from this training than a list of barriers. 3 Copyright © 2010, Robert M. Arnold, MD Communication between patients and/or family members and intensivists is the bedrock of the therapeutic relationship, and a physician’s working model for how this relationship should function frames all of his/her efforts at communication. While much of the communication literature aimed at other specialties addresses interactions between a doctor and patient, much of the communication in the ICU occurs with a family member. Regardless of whether the communication occurs with the patient or the family member, the fundamental principles remain the same. Therefore, the rest of this module will talk about “intensivist-family communication” simply because this is the most common situation. Note: in this module, the term “family” is used broadly to mean both biological relatives and friends who are at the patient’s bedside in the ICU. Four models of surrogate-physician communication have been empirically validated. A common model for an intensivist-patient relationship is the directive model, in which the intensivist (the expert) take responsibility for what should be done to the patient and dispenses it to the family as required. At the other end of the spectrum are consumer theories, in which the family "buys" what s/he requires from the intensivist. In the informative model, for example, the physician provides information but does not discuss the patient’s values with the family. However, the theory that underlies our curriculum recognizes that medicine and the patient-physician relationship is essentially a moral enterprise that is grounded in trust. This view of communication fosters shared decision-making in which the intensivist brings his/her expertise about critical care to bear on

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