SCCM Resource Library-Challenging Palliative Critical Care Case: Skill Integration

Video Transcription

Welcome everyone to the next section of this talk. My name is Naomi George. I practice intensive care and emergency medicine at the University of New Mexico,  and I have no financial disclosures to share. In this section, we're going to discuss how and why you should develop high-quality family meetings in your ICU.  Dr. Oktober will pick up the thread to discuss communication strategies for family meetings. Our objectives today are to discuss the importance of the family meeting,  and then three aspects in terms of having a high-quality family meeting, forming a team, pre-meeting, and mapping out your strategy. Why is this important?  Well, imagine this scenario. Your patient has advanced cancer and is admitted to the ICU. He's really sick with sepsis. He's developed worsening arrhythmias and  multipressor shock and you think he's dying. You call a family meeting to talk about code status. You tell the family that the medical situation is  serious and that their loved one's health is tenuous. You ask if his heart stops, should we do CPR? The family says he's a fighter and they think he can pull through.  You're worried they're not getting it, and so you ask, but what if he doesn't? What then? The patient's son gets angry. You don't know him. He is a fighter.  The wife says, we talked to the oncologist. We just need to get him well enough for the next chemo. He can get through this if he gets to chemo. You feel stuck.  The family's expectations are unrealistic and you're worried that the patient is suffering. You can't meet the family's goals and the case is weighing on you,  and worse, you overhear the nurses avoiding the assignment. It doesn't have to be this way. We can do better, and the way to do so is through good, high-quality family meetings.  We'll get everyone on the same page as close as possible, ensure understanding the medical situation, and move the family and the team towards decisions around treatments  that match the patient's values and are clinically.  Let's first define what we mean when we talk about family meetings. First, family is meant broadly. Do not limit a family meeting to the patient's spouse  or parent or whoever that one assigned surrogate decision-maker is. The system may require you to have a single assigned decision-maker or may emphasize the importance of that.  Despite this, try to be as inclusive as possible. Many families make decisions collectively, whether or not you choose to recognize that. The more you include the important people  in the important decisions, the better the decision-making process is gonna be. Secondly, consider conducting family meetings more often. We often limit family meetings  to goals of care discussions, but family meetings can be an effective way of breaking bad news, sharing prognosis, establishing time-limited trials of aggressive treatment,  checking in during a difficult hospitalization. Regular family meetings can help engender trust and alignment between families and providers.  And let's be honest, family meetings can feel like a huge time suck when you have a busy ICU service. But before you go off to do the next central line  and forego the family meeting, consider that numerous trials have demonstrated that effective family meetings improve a myriad of factors important to the ICU experience,  and they're gonna be better for you and your staff, your patients, and their families. If we listen to patients and families, this is exactly what we'll hear.  In this landmark 2010 study, Nelson and colleagues recruited and conducted focus groups among ICU survivors and family members and asked participants,  what is high-quality care in the ICU? And asked, can you identify components with the greatest impact and that were the most valued during your ICU experience?  Several themes emerged, including that patients and families valued frequent meetings with the ICU clinicians, nurses, chaplains, and others.  They really did not value information sharing from multiple clinicians that was confusing or contradictory. They wanted to know who was in charge,  and they wanted to see good communications between doctors, nurses, and other team members.  Here are seven tangible action steps of an effective family meeting that you can implement or follow to improve the quality of family meetings in your center.  I'm gonna talk about the first four of these elements, and Dr. Oktober will cover the remainder. That is forming a team, pre-meeting, introductions, and assessing and updating.  First, you wanna form your meeting team. Be thoughtful about who you wanna involve. High-functioning teams are gonna improve interprofessional relationships,  they're gonna improve family communication and likely decision-making, and they're gonna help prevent conflict.  So what makes a team high-functioning? This is actually a really difficult task, particularly in medicine. Most teams that are good are good because they have a shared goal  and they practice together. They have durable relationships or bonds and know how to work with one another. The people you assemble together for your ICU family meeting  may be a pretty motley crew. They may include consultants you barely know, nurses and doctors who don't often work together, and so forth.  More than likely, your ICU family meeting team has never practiced together, and in many cases, team members may be at odds as to what the shared goals are.  So you need to work quickly to establish your team, the players on the team and their roles, the goals of the team, and try to create a sense of psychological safety  within the team so you can accomplish your goals. The best way to do this is to have a pre-meeting. If you can help it, do not skip this step. It's worth the extra 10 minutes.  A structured approach to team formation and structure of the team will help mitigate a lot of the myriad complexities inherent in family meetings. During the pre-meeting,  you want to establish a few things. First, who is the team leader? As we saw earlier, knowing who's in charge or who the team leader is can be very helpful to families and patients.  The team leader could be the intensivist.  It could be the palliative consultant. It could be the bedside nurse.  But just keep in mind that this person is not assigned the leader role so that they can do all the talking. In fact, the best way to be a good family meeting team leader  is to help facilitate talk time between the group, particularly allowing time for family and oftentimes facilitating time for your bedside nurses  to speak and share from their vantage point and from their expertise about the patient experience.  What are the important roles that you need to establish other than team leader? You need to know who is going to be breaking bad news if that's a task that needs to be undertaken,  who is going to be attending to the family's emotional needs, who is going to be providing support.  In addition, you also want to establish shared goals among the group members. This is an incredibly important task, particularly when working with consultants.  You need to get on the same page before you go in the room. A good way to do this without causing more conflict is to have everyone on the team share an estimate  for their best case, worst case, and most likely case outcome for the patient. This is a way to talk about prognostic estimates that doesn't require the team member  to become married to a specific outcome and rather to acknowledge the range or uncertainty that they hold in their mind. Oftentimes you'll find that people have more shared overlap  or more in common with their prognostic estimates when presented as a range than you would otherwise think. After you are able to assess this range,  you want to arrive at a consensus before the meeting about how this information or uncertainty is going to be presented. I've mentioned the importance of establishing a team  and pre-meeting in terms of reducing conflict. If you work in medicine, especially in the ICU, you may just think conflict is common and that's okay.  And you're right, that conflict is common, but it's probably not okay. In fact, conflict is incredibly common in the ICU, particularly around end-of-life care or goals of care.  And it leads to worse outcomes for patients. It negatively impacts team morale and it does contribute to healthcare and staff burnout.  To fully appreciate the degree of conflict in the ICU, the European Society for Intensive Care Medicine conducted a one-day cross-sectional survey  of all staff members in over 300 ICUs in 24 countries in their conflictus study. And not surprisingly, they found that conflict in the ICU was rampant. As the figure above shows,  the main sources of conflict were things that can be addressed in a high-quality family meeting, things like conflict between family and clinician and between clinicians.  The authors also quantified the magnitude of conflicts, noting that respondents, which were ICU providers, nurses, perceived more than 50% of the conflicts  they experienced in the last week as ones that were quote-unquote dangerous and over 80% of the conflicts they experienced in that past week is potentially harmful  to patients and families.  There's substantial evidence that conflict tremendously impacts the level of burnout  among both physicians and nurses. In this study, conflict and poor interprofessional relationships were a key factor in nursing burnout.  This is a 2006 study of nurses in French ICUs finding that over a third of nurses reported severe burnout symptoms. This is well before the COVID-19 pandemic.  And in a multivariate regression, they found that the strongest factors associated with burnout were in fact conflicts between patients and physicians and physicians and nurses.  So high-quality family meetings are an opportunity to align staff and families and reduce conflict, reduce burnout, and hopefully retain staff and improve quality across the ICU.  So you've established a team, you've gone through your pre-meeting. The next step of a high-quality family meeting is shockingly simple, and it just consists of good introductions  and laying the groundwork. It's surprising given how simple this task is, how often it's ignored. For good introductions, you want to do two steps,  sharing and learning or listening. In the sharing step, you want to share with everyone in the room who is on the team, what is their role, who's the captain of the team,  and what the agenda is for the meeting. You also want to learn. You wanna know who each person in the room is, and you want them to share how they are related to the patient  and what brought them to the room. You wanna know why each person in the room has come to the meeting, what they're hoping for out of the meeting,  and what their preferred language is, which is incredibly important when families have mixed language preferences. You also wanna find out how people wanna receive information,  particularly difficult information like bad news or poor prognosis. Some families or people hope for a direct receipt of direct information or blunt information.  Others prefer a more indirect or gentler approach.  Finally, you wanna follow some kind of guide or map or heuristic for how you're gonna move through the conversation. This is oftentimes called the talking map.  There are a lot of different maps. The common one is the spikes protocol, which I've set up here. Many of us learn this in med school. There are many, many others,  all of which tend to share overlapping elements, such as the serious illness conversation guide. They include a setup, which we've already covered, assessing family perspective  or knowledge and viewpoints, obtaining an information to share information, and responding to emotions. It's all fairly straightforward in terms of the elements,  but you do wanna develop more sophistication as you gain practice. I promise you, and research will show this as well, that if you just wing it without tools and practice,  without some kind of guide to keep you moored, the same thing will tend to happen every time, which is that the clinician will do most, if not all, of the talking.  And if there's not conflict,  the clinician may come out feeling quite good, like they've aced it, and the family won't perceive the meeting as being high quality whatsoever.  The decisions that come out of these types of meetings will not be as high quality as you think, and these have downstream effects on your staff, patients, and family.  Or there will be conflict, which we also explained previously is bad. This is not what you're hoping for. So have a talking map, practice it, get familiar with it,  and figure out how to help your talking map anchor you as you go through difficult conversations. And Dr. October will be talking a little bit more about these tools.  Finally, a few pointers about COVID-related family meetings. Hopefully most of us are able to allow more visitors in our ICUs and more in-person family meetings,  but I imagine the future is one in which we will always have COVID patients or patients with isolation needs, and thus remote meetings probably will not go away entirely.  For this reason, it's important to have some thoughtfulness about how to conduct a high quality family meeting remotely. And I recommend taking some time to do this  and setting it up for your unit or your institution. Ways you can set yourself up for success include getting the resources you need to make it work.  This might mean a dedicated space, a dedicated device for things like Zoom or video conference, accounts that allow you to quickly or easily connect with family,  and a few other pointers that I included on this slide.  Here's a list of references for this talk. Thank you for your time and I look forward to our discussion.

Video Summary

The speaker discusses the importance of developing high-quality family meetings in the ICU. They highlight the challenges faced during family meetings and the negative consequences of conflict. They provide practical tips for forming a team, conducting pre-meetings, and introducing the team members. They also emphasize the need for a structured approach and a talking map to guide the conversation. The speaker concludes by mentioning the importance of considering remote family meetings in the context of COVID-19 and provides recommendations for success. Overall, the talk highlights the benefits of high-quality family meetings in improving communication and decision-making in the ICU.

Asset Subtitle

Ethics End of Life, Patient and Family Support, 2022

Asset Caption

This session will cover challenging cases of primary palliative care in the ICU and best practices for integration with palliative medicine. Speakers will review causes of conflict and moral distress among the ICU team, family surrogates, and other medical consultants. The session will also cover communication strategies for optimizing family-centered meetings to discuss goals of care and minimize conflict, along with the differences and similarities in providing palliative care for adult versus pediatric populations through case-based presentation (diagnosis, treatment, and communication). Active small group workshops on communication skills for discussing goals of care, empathy, and conflict resolution will allow skills practice for clinicians.

Meta Tag

Content Type Presentation

Knowledge Area Ethics End of Life

Knowledge Area Patient and Family Support

Knowledge Level Advanced

Membership Level Select

Tag Palliative Care

Tag Ethics and End of Life

Year 2022

Keywords

family meetings

ICU

challenges

communication

decision-making

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