Daily News Boston CHEST 2024

October 6-9, 2024

How to navigate the ICU communications tightrope

Robyn Scatena, MD
Robyn Scatena, MD

Communicating effectively in the ICU is tough—the environment is stressful; time and resources are stretched thin; and patients and their families or surrogates are by turns worried, impatient, fearful and angry.

“You have to ask patients and family members how they want information to be shared,” said Robyn Scatena, MD, director of critical care at Norwalk Hospital. “That’s a hard question to ask and a hard question to answer.”

Dr. Scatena opened a CHEST 2020 prerecorded critical care session, How Do You Say It? The Communication Tightrope in the ICU. Clinicians want to share information and patients/surrogates want to get information. Ensuring that communication happens takes focused attention. The session is available for viewing on the virtual CHEST 2020 meeting platform through January 18, 2021, for registered attendees.

Two communication models have been widely adopted by hospitals. PEWTER was developed for school counselors and is used extensively in hospitals. SPIKES was developed to improve communication with cancer patients and is likewise being used widely in hospitals.

The two models are similar, Dr. Scatena said. The first step is to prepare to talk with patients or families, gathering information, asking if the patient/family is ready to talk, and taking them to a private area.

The next step is to evaluate how much they know about the illness. The best approach is to simply ask, “What do you know so far?”

Next comes a warning that you have some serious information to share to help prepare them for what is likely bad news.

When it comes to the actual message, simple is better. From the heart, no medical jargon, soft, sincere and compassionate tones. And let them react in their own way.

Damanjeet Chaubey, MD, MPH, FACP, SFHM
Damanjeet Chaubey, MD, MPH, FACP, SFHM

“The demonstrated reaction may, or may not, be reflective of the emotion the listener is feeling,” Dr. Scatena cautioned. “But don’t be judgmental. There is no right or wrong way to take bad news.”

The final step is to regroup and move forward with an action plan, whether it is scheduling follow-up meetings or sharing support resources. The key, she said, is to look ahead.

Looking ahead is how palliative care handles difficult conversations in the ICU. It all starts with understanding the patient and surrogate goals and preferences.

“If we know what they want, we can align care with patient goals,” said Damanjeet Chaubey, MD, MPH, FACP, SFHM, Andrew Cruz Endowed Chair in Palliative Care at Nuvana Health. “Understanding patient goals helps the health-care team provide the right care at the right time.”

The COVID-19 crisis has helped institutions recognize the need to hardwire patient and family goals into care systems, Dr. Chaubey continued. All patients at high risk for severe illness are asked about goals and preferences at admission, during their stay, and again at discharge.

Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN-K
Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN-K

“Understanding and documenting patient preferences is good for patients, good for their families, and good for the institution,” she said. “You have to capture what matters to the patient. And it is important that we, as clinicians, become good at responding to emotions. If we can do that well, we can make a difficult time more manageable.”

Talking with families and aligning care to meet their goals isn’t just a good strategy for palliative care. It can help improve care and satisfaction throughout the ICU.

“Families want as much information as they can get, particularly prognostic information,” said Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN-K, associate professor at the University of Wisconsin-Milwaukee College of Nursing.

“At the same time, families need to be heard themselves. We, as clinicians, must spend less time talking to families and more time listening to them. We can all learn from palliative care.”