1. Improving Communication with Families in the ICU
Deborah Kasman MD, MA – Southern California: Baldwin Park
RESEARCH TEAM:
Hooman Mobassery MD – ICU Director
Fran Izzo LCSW – Social Work Director
Deborah Kasman MD, MA- Bioethics Director
Michelle Martinez RN – ICU Nurse
Jennifer Corado LCSW – ICU Social Worker
Ayae Yamamoto MD - Statistician
PURPOSE
BACKGROUND
RESULTS
Improve communication with families in the ICU
Improve communication between various providers in the ICU
Promote consistency and continuity in communication with families in the ICU
Decrease stress by improved support for providers working with distraught ICU families
TRUST / UNCERTAINTY / MORAL DISTRESS
Surrogate Stress Explore values, expectations & decision-making preferences Systemic approach to family meetings Systemic support for emotional needs of families
Provider Stress
Training to address uncertainty in prognosis
Debriefs as appropriate
Communication training for Providers
Systems Issues
Primary source (concierge) to support families & HC team
Rapid response- Palliative Care teams
Standardize comprehensive family approach
FAMILY SATISFACTION ‘COMMUNICATION’
“1” is best; Likert scale 1 to 5
* P < ** P < 0.05
FAMILY SATISFACTION “QUALITATIVE”
More positive in
Clinical Aspects
Communication
Sensitivity
Friendly; Kind; Caring
Supportive; Helpful
Attentive; Comforting
Professional; Polite; Joy
Compassionate; Gentle; Love
Stay Sweet; Great Attitude
You Made it Bearable
+ Sensitivity
Hurtful; Cruel
Excluded; Upset; Scared
Overwhelmed; Frustrated
Lost respect; Smile more
Don’t Ridicule or underestimate
You make it Difficult
- Sensitivity
MEASUREMENTS
Family Satisfaction in ICU Survey
Pre N = 35 (36.8% return)
Post N = 103 (41.0% return)
Communication with ICU Family Survey
Pre N = 23 (54.8% return)
Post N = 26 (53.1% return)
Physician Qualitative Questions
Pre N = 6 of 7
Post N = 5 of 7
* DESIGNATED SOCIAL WORKER:
Continuity & support for families in ICU
Help assess family readiness for decision-making
Support ICU providers with stressors
P < 0.05 on one-tail t-test for
“Honesty” and “Consistency”
FAMILY SATISFACTION “SUPPORT”
“5” is best score, Likert scale 1 to 5
“Surprise” results
“At the end of the day people won't remember
what you said or did they will
remember how you made
them feel” Maya Angelou
MD comment Pre: Different family members get fragmented information
MD comment Post: There are fewer misunderstandings allowing a practitioner less familiar with family to gain insight
INTERVENTION
Designated SW* in ICU
Education Sessions for MDs/RNs
Coding Schema defines Family Needs level “C’” families having highest needs
Family Meetings in < 72 hours of admit for level “C” families:
Family Friendly Materials Intro to ICU pamphlet & Patient storyboard
NURSES: DAY & NIGHT SHIFT
Communication with Families in ICU Survey
Items with greatest improvement in scores: P <
CONCLUSIONS
Communication with Families improved during the intervention
First time families to ICU felt supported in the trial
Return to ICU families felt less control & less included in care of their loved one
Nurses in day & night shifts improved in all measures in survey
Physicians felt improved support from SW, consistency in communication & better understanding of families
Discuss goals of care in face of uncertainty
Include ethnic/cultural aspects of care
Team members aware of patient/family goals
Improve Communication with Families
Team interacts well making plan of care
Values for decisions discussed openly & honestly
Sum Score for “Current Work Situation” questions
Improve Communication Between Providers
Improved “titrating meds to control dyspnea” & “withdrawing life sustaining treatments”
Information about dying & bereavement support
Sum score for “Knowledge and Abilities”
Promote Consistency & Continuity for Families
Improved Support in “social work support/access” & “ethics consultation” & “resources to plan”
Decrease Sum Score for “Contributing to Overall Stress”
Decrease Stress for Providers through increased Support
“Average of 3 questions” P< 0.05 Modifier Effect
“Prior ICU experience” families felt less supported, & less control during the trial
MD comment Pre: There is a disconnect between MD and patient understanding of the clinical situation
MD comment Post: Conferences for “C” families had a big impact on communication/relationships with patients/families
FUTURE PLANS
Reproduce precise elements social worker added to ICU care team
Build trust with ‘Prior ICU experience’ families & include them in care of loved one
Nurses to design strategies to enhance family-centered ICU care
Prepare families for uncertain clinical course -- include palliative care earlier