Abstract and Introduction
Good, effective communication among critically ill patients, their families, and providers is often challenging and complex. The concerns and dissatisfaction about poor communication with providers from patients facing a life-limiting illness and their families are well known. Often, patients cannot speak for themselves; thus, family members become the surrogate spokesperson for the critically ill patient. Successful interventions have been identified to improve communication such as the team approach to communication, the formal family meeting, a bundled checklist approach, and use of advanced practice nurses. However, in large part, the bedside intensive care unit (ICU) nurse's role has been diluted in those interventions. Developing ICU nurses' mastery of communication skills using palliative care principles is gaining momentum as an effective strategy. The ICU nurse can be a strong leader for good, effective communication for ICU patients and their families when palliative care strategies are utilized.
The intensive care unit (ICU) is a complex environment in which all providers are trained to implement standard interventions and treatments to reverse serious illness. Patients and their families have identified good communication as a critical component of quality care while in the ICU. Frequently, the critically ill patient may require intensive support that renders patients unable to express their goals of care or make decisions about the care. Family members often find themselves as surrogates for communication when the patient is unable to participate. Despite the aggressive focus of the ICU, one comprehensive epidemiological study demonstrated that one of five Americans die in and around an ICU stay. Death is a common phenomenon in the ICU and usually occurs after a treatment approach of aggressive and supportive interventions. However,many patients survive their critical illness. In either situation, good communication between providers, patients, and their families is imperative. A recent trend in ICU settings has been to implement palliative care strategies to improve communication. As bedside caregivers, the ICU nurses are the professionals who have the most interaction with patients and their families in formal and informal ways. Armed with knowledge and skills of effective palliative care strategies, such as proactive communication, the ICU nurse is poised to be a major advocate to improve communication in the ICU with patients and their families.
The purpose of this article was to review the issue of communication in the ICU, highlight palliative care strategies that may improve communication in the ICU, and further stimulate the discussion about integrating palliative care strategies that the ICU nurse can use to improve communication in the ICU.
A select review of relevant literature in palliative care nursing and critical care nursing using CINAHL and MEDLINE databases was conducted to elicit specific activities of the bedside ICU nurse in improving communication. The search focused primarily on the topic of the nurses' role in ICU communication in qualitative and quantitative studies conducted in the past 10 years and included physician-based literature that focused on multidisciplinary communication strategies in order to determine the nurses' role in effective communication. Finally, the Center to Advance Palliative Care practice guidelines for effective communication were reviewed to highlight the process of integrating palliative care into the ICU as a tool for the ICU nurse to improve communication.
Communication in the ICU
Good communication with patients who are critically ill and on artificial life support is likely to be challenging at best and probably nonexistent at worst. In many of these situations, providers turn to family members as surrogate decision makers for their critically ill loved one. Yet for many family members, decision making can be fraught with anxiety and negative emotions, especially if family members do not know the patient's wishes about artificial life-support interventions.
The premise of effective communication is paramount in ICU environments. Effective communication is a theme in the American Association of Critical Care Nurses (AACN) Synergy Model for practice and in AACN's Healthy Work Environment advocacy initiative (www.aacn.org). In a recent editorial,Munro and Savel stated that communication with families is now recognized as an essential component of end-of-life (EOL) care. Effective communication is also a priority for the Society of Critical Care Medicine (SCCM). In fact, SCCM published ICU clinical practice guidelines for EOL care in 2001 and again updated in 2008.Among those guidelines, SCCM highlighted communication with families as an important intervention for ICU patients. Family satisfaction improved and psychological distress decreased when ICU clinicians utilize communication skills that inform and support patients and families. Despite this evidence, communication with patients and their families continues to be sporadic and limited.
In a qualitative study using focus groups of randomly selected patients, families of survivors, and families of patients who died in the ICU, Nelson et al used open-ended questions to obtain perceptions of what constitutes high-quality intensive care. The authors reported that a shared definition of high-quality intensive care among the respondents included timely, clear, and compassionate communication and other issues such as decision making focused on patients' preferences and values and access and proximity to patients.
Hinkle and Fitzpatrick utilized the Critical Care Family Needs Inventory (CCFNI) tool to determine priorities for care of families whose loved one was in the ICU. The CCFNI is a 45-item questionnaire that elicits priorities about information, support, comfort, and proximity to the patient. Issues surrounding communication were ranked within the top 5 needs by relatives of 101 patients. Although the study found significant differences among relatives, physicians, and nurses in the mean subscales scores for family needs, three needs most highly rated occurred in the top five among all three groups. The three needs included (1) to have questions answered, (2) to be assured the best care possible, and (3) to feel that hospital personnel cared about the patient.[5(p223)] Furthermore, consistent use of CCFNI during the study helped nurses empower families to speak up about their perceived needs, especially around the topic of information and communication with physicians and other providers.
In a systematic review of determinants of decision making about EOL decisions for families for critically ill patients in the ICU,Frost et al explored various factors that influenced those EOL decisions. Despite the heterogeneity of the samples and methods in their review, the authors highlighted the complexity of the decision-making process and underscored the role of good communication, information exchange, and deliberation among family members and providers.
Peigne et al conducted a multicenter study to explore questions asked by relatives about their critically ill loved one. Using qualitative methods, the researchers used thematic analysis to arrive at 21 questions that were deemed important for family members of patients in the ICU. Of those 21 questions, all but 6 questions had to do with communication and information sharing about diagnosis, treatments, and general communication.
Good communication in the ICU is an expectation from patients, their families, and professional societies. Good communication is also an important concept in family-centered care that warrants deliberate ongoing communication. The ICU nurse is poised to be a key contributor of efforts to improve communication with patients and families in the ICU because they have always been strong advocates to meet the patients' needs. Indeed, because of the time spent in constant attendance at the bedside of the critically ill patient, ICU nurses build relationships with patients and their families. Often, the ICU nurse has in-depth knowledge of the patients' or families' concerns that has not been realized by other providers.
Interventions to Improve Communication
The complex nature of the ICU environment challenges health care providers to utilize any moment of contact with families to have meaningful discussions about the patient as a person. Communication is challenging as each new participant, whether family member or health care provider, adds to the complexity by bringing in his/her own set of values and preferences to the situation.
Formal Family Meetings
The formal family meeting has gained prominence as an intervention designed to enhance communication in the ICU. In fact, in the field of palliative medicine and palliative nursing, the formal family meeting has been referred to as a ''procedure'' much like a central line insertion in the ICU. When a central line is inserted, the multidisciplinary ICU team ensures that essential steps have been completed during the procedure to ensure optimal patient outcomes. Likewise, the formal family meeting has become a much studied and refined phenomenon. Furthermore, the formal family meeting is the forum of choice when patients and families are facing difficult decisions about limiting life-sustaining treatment.
Delgado and colleagues implemented a structured family meeting format that included multiple disciplines, physician, nurse, chaplain, and families of patients who were on artificial ventilator support for 5 days or greater with repeated family meetings held every 3 days thereafter or earlier if requested by the family. The study outcomes included favorable responses from family members in regard to their understanding of the patient's condition and the ability to arrive at a plan of care that was consistent with the patient's known wishes. Furthermore, the researchers were able to demonstrate that a proactive structured family meeting was feasible and improved communication with family members of ICU patients.
An important attribute of family meetings is the proactive and structured format. Mosenthal and colleagues implemented a structured communication intervention—a family meeting—for all patients within 72 hours of admission to the ICU. Their prospective, observational study design measured outcomes before and after the structured communication intervention was integrated into standard ICU care for all patients admitted to a trauma ICU. One of the outcomes of the structured communication intervention was that integrating palliative care principles, such as good communication about goals of care early in the patient's ICU stay, was helpful in achieving consensus around patient-appropriate use of artificial life-support technology and EOL care. The structured intervention also demonstrated that early structured communication about resuscitation led to more timely EOL decisions such as withdrawal of artificial life support and decreased length of stay in ICU for patients who were dying. An important outcome of this study was the change in the ICU culture because of standardizing a protocol for early structured family meetings into practice. Specifically, the change in culture was that family meetings occurred for all patients in the trauma ICU, not based on patients' prognosis or physicians' preference for family meeting.
Formal Family Meetings
Previous studies of palliative care integration into ICU care emphasize the need to develop a checklist to ensure completion of critical steps to improve communication in the ICU and therefore quality of care in the ICU. The ''Care and Communication Bundle''[15,16] is a systematized set of activities that culminates in a structured proactive family meeting. This intervention is targeted for ICU patients who are at high risk for death or for patients whose ICU length of stay is greater than 5 days. The Care and Communication Bundle entails several strategic steps, with suggested time frames, that have been validated as crucial to improving family communication in the ICU. These steps include that by day 1, health care providers will (a) identify the patient's appropriate surrogate, (b) determine whether the patient has an advance directive, (c) clarify the patient's code status, and (d) assess and manage pain regularly; by day 3, they will (e) offer social work support and (f ) offer chaplain support; and by day 5, they will (g) initiate and conduct an interdisciplinary family meeting.[15–17]
Penrod et al used the bundle approach to evaluate their pilot program to improve communication and care in their ICUs. Using a quality improvement format, they evaluated what percentage of patients with lengths of stay of more than 5 days received the structured steps of the Care and Communication Bundle before and after the implementation of the intervention. Of interest to note is that the ICU nurses were successful at documenting the completion of the bundle steps in the process, but there was no measure of whether patients or families achieved satisfaction about communication after implementation of the Care and Communication Bundle. Similarly, Daly and colleagues used a before-after design to implement their Intensive Communication System intervention. The Intensive Communication System included a structured formal family-meeting format run by two advance practice nurses (APNs) within 5 days of ICU admission and weekly thereafter. Each meeting addressed medical updates, values, and patient's preferences for treatment, goals of care, and milestones of patient condition for determining effective treatment. Although the outcome results of ICU length of stay and time to tracheostomy were inconclusive between the before and after groups, the APN-facilitated family meetings demonstrated two unintended benefits: (1) increased participation of bedside nurses and social workers in the family meetings and (2) longer time duration for family meetings. Nelson et al report that successful implementation of the Care and Communication Bundle is dependent on the ICU and institutional culture that values and supports the integration of palliative care principles into the ICU setting.
From these studies, one can infer that a structured, proactive approach to family communication is beneficial to improve communication in the ICU. However, in the previous studies, the ICU nurse role has not been clearly defined. In fact, one can argue that the role of the ICU nurse has been diluted and even relegated to monitoring of process activities. Given that the ICU nurse is at the bedside actively engaging in informal communication with patients and families, the nurse has a valuable role in improving communication in the ICU.
The Nurses' Role
There is little research on the specific role of the nurse to improve communication in the ICU. In an early research study, Medland and Ferrans used a two-group, pretest-posttest, quasi-experimental design to determine if structured communication with an information brochure and daily telephone calls to family members of ICU patients would have an effect on family satisfaction in the ICU. Their results showed no difference in satisfaction levels between the two groups. However, the ICU nurses were able to incorporate into their daily ICU patient care routines the seemingly simple proactive interventions of daily phone calls or daily bedside updates without difficulty.
Lowey conducted a systematic review of the literature for communication between nurse and family caregivers within the context of EOL care. However, her review was not specific to nurse interactions with families in the ICU. Furthermore, of the 30 articles in her review, only 2 articles dealt with nurse communication and families, and both were in the context of advanced cancer.
Bloomer et al conducted a retrospective observational study of documentation in patients' medical records to determine the degree of nurse involvement in family meetings. Their results from retrospective documentation review demonstrated that nurses neither initiated nor participated in family meetings. The researchers admitted to their weak study design from the focus on documentation, which is often prone to gaps. Nevertheless, they opine that the role of the nurse is significantly underrepresented in the literature.
Slatore and colleagues used a qualitative approach to analyze ICU nurses' communication behaviors within the theoretical framework of patient-centered care. Two themes emerged from their analysis: (1) nurses felt that one of their key roles was serving as translator or intermediary between physicians and patients and the patient's families and (2) nurses determine what they are willing or not willing to discuss with patients and families.[23(p414)] In fact, nurses often felt limited or constrained in their ability to communicate with patients and families especially around topics of code status or consequences of aggressive therapies such as use of vasopressors or renal replacement therapy.[23(p415)] Although ICU nurses spend a majority of their time communicating with patients and families and with physicians, this study demonstrated that nurses may feel marginalized in their ability to communicate with patients and families about difficult topics.
White and colleagues conducted a single-arm interventional study involving the addition of a specially trained family support specialist, a nurse, to the ICU team. The role of this nurse was to provide four types of support: (1) emotional support, (2) communication support, (3) decision support, and (4) anticipatory grief support to families of patients critically ill in the ICU. This novel role was feasible and accepted by the clinicians' and patients' families.Moreover, the specially trained nurse helped to increase the quality of communication and the family's ability to articulate the patients' values within the patient-centered model of care. Although this study utilized a specially trained nurse to provide the interventions based on the four supports, one can argue that ICU nurses already undertake some of these behaviors in informal ways on a daily basis.
The Advanced Practice Nurse
The role of the APN regarding family communication in the ICU has been diverse. On the one hand, the role of the palliative care APN is recognized as a critical member of the consulting team for patients and families in the ICU.[25,26] However, increasingly, APNs are being utilized as primary providers for critically ill patients in the ICUs in many settings. In a small longitudinal study comparing ICU APN versus physicians in training (residents), Hoffman and colleagues  demonstrated that the APN spent more time in care coordination and less time in nonunit activities compared with residents. The time availability of the APN at the bedside for family communication is unknown but is a potential resource to enhance good communication with patients and families in the ICU.
Journal of Hospice and Palliative Nursing. 2014;16(2):93-98. © 2014 Lippincott Williams & Wilkins