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Vincent G Valentine, MD
University of Texas Medical Branch, Galveston, TX

vincent valentineSomewhere along the line, many heart and lung transplant specialists as well as intensivists—in their painstaking eagerness to restore the most critically ill patients with the latest innovations and unprecedented therapies—seem to have forgotten that underneath the severely sick patient is a human being, desiring comfort, compassion, and dignity.

Also, there is a family or significant other waiting their turn for time, attention, and an explanation from the attending specialist during the treacherous course of their loved one's confinement to the ICU.

This physician must remember that the worst offense he or she could be guilty of, under these trying times, is to ignore and not communicate to the patient or loved-one the events in the ICU. However, it would be more disagreeable to explain vividly and accurately in the most scientific fashion the diagnosis and prognosis which could be seemingly esoteric to most lay individuals, leaving the patient and their loved ones confused and frustrated.

Therefore, it is of utmost importance for us specialists to communicate a clear and plain explanation of the day-to-day interventions and forecast what might evolve over time in a firm and direct yet sensitive and compassionate manner which will require repetition. Unfortunately for many attending physicians and surgeons caring for patients in their final stages of heart or lung afflictions in the ICU, this necessary communication is difficult and time consuming, and to be effective, it must be delivered in a humane and unscientific manner, hence it is a literary art.

Over the last half century, not only have ICUs become ubiquitous in nearly all acute care hospitals in the United States, but also they have evolved from severe polio, burn, trauma, other sudden catastrophic injury, and post-surgical recovery units. Today, these units have become havens equipped with a bewildering array of complex appliances, particularly for transplantation and other forms of replacement therapies. Some of these machines with their own noise-makers (alarms!) include ventilators, computerized vital sign and cardiac monitors, sequential compression devices, and a variety of machines for dialysis, intra-aortic balloon counter pulsation, delivering nitric oxide, extracorporeal membrane oxygenation, cardiopulmonary bypass, mechanical heart devices, and plasma exchange. Moreover, these modern machinations require a myriad of flexible and rigid tubes emanating from the sufferer and demand a variety of health care providers adept at maintaining the function of these external devices without losing sight of the humanity of the patient.

It's a matter for wonder that even without postoperative and overdose patients in need of time to convalesce in the ICU, the mortality rates in the ICU remain below 50% despite the need for everything mentioned above to be in perfect harmony. Perhaps, only one mistake can drastically alter the course of events such that it becomes public knowledge and the health care system held accountable and for good reason. In effect when someone requires such critical care, this patient and their loved-ones will be introduced to an intimidating area where the potential for complications abound, death is all too common, and care is extremely expensive. These factors will further add to the grief and may come across rather sudden and unexpected to loved-ones that have not been properly prepared for this adventure. How can one possibly attend to the sufferer and their loved-ones in this environment? The one-word answer is: communication. Maybe two words: constant communication.

The importance of communication, which underlies the complete management of the critically ill and their loved ones, cannot be emphasized enough. For without communication critical care management is incomplete. Without communication, we would not know if we are providing any relief from pain or other distressing symptoms in the sufferer. Without communication, we would not know the patient's and/or loved-ones wishes regarding how aggressive we should be or when dying is ok, thus establishing the "do not resuscitate" order. Without communication, we would not know when it would be most appropriate to withdraw the care that could be prolonging death and shredding the fabric of human dignity in the dying. Of all available treatment strategies in the ICU, communication is perhaps the most economical therapy we have to offer.

How could we apply science without the art of communication? We must help the patient and their surrogates to face and embrace death. One study pointed out that families expect physicians to initiate end-of-life discussion; therefore, isn't it obvious for us to initiate end-of-life conversation? Once a patient has been admitted to the ICU and stabilized, the attending intensivist must provide a plan to the patient and/or loved ones. When death seems imminent upon admission, it is best to be candid and clear about the bad news including the diagnosis and plan of action. Under these trying times, most of the conversation will be with loved ones as the patient more than likely will be mentally incompetent. Useful tips for the initial discussion when death is imminent vs. when the outcome is uncertain is provided below. Most of the time, the ICU physician is meeting with the family for the first time. This first encounter is the most important. Any minor infraction is going to break any establishment of trust that will determine the overall effectiveness of communication.

A few sensible approaches gleaned from the critical care literature to improve communication for such difficult situations include:

  1. Have a dedicated conference room
  2. Identify the surrogate in charge
  3. Ask the surrogate about special needs:
    - Other key family members that must be present
    - Available interpreters for foreign languages and the deaf
    - Determine a preference to sit or not, sitting most of the time is more comfortable

Nonverbal Cues

  1. Adjust to eye level, sit with listeners, standing over and looking down is condescending.
  2. Maintain eye contact
  3. Position oneself away from door (do not stand or be seated with opening next to you or behind you) a nonverbal motion towards the door is misinterpreted
  4. Beware of swaying and backpedaling

Verbal Cues

  1. Speak slowly, deliberately, and decisively with the agreed plans
  2. Even though uncertainty abounds, must make a decision that everyone agrees with
  3. Pause frequently and ask if they are any questions.
  4. Ask the surrogate to explain their understanding

Other Important Points

  1. Expect to repeat the plan
  2. Set goals with time
  3. In time 24, 48 or 72 hours we will know more about possible outcomes
  4. Offer what would be most helpful

Important Don'ts

  1. Don't say the patient or your loved one is stable (who is truly stable in the ICU?)-if you are having this sort of conversation, the patient is usually critically ill and could possibly die
  2. Don't say, "We are doing everything ..."
  3. Don't say, "We know how you feel ..."

Important Dos

  1. Do ask the loved ones, "What do you think [the patient] would want under these circumstances, if they could communicate?"
  2. Are there any other questions you have?

Encourage families when in the room with their suffering loved ones to verbally and physically communicate with them. Even though we may be providing sedation and analgesia, assume they can hear, feel, and sense our presence. Be cautious about careless conversations in the presence of the patient and remind the families of this. Encourage the families to spend more time comforting the patient with hugs, hand-holding, wash cloths to the forehead and perhaps soft music. Discourage focusing on the monitors. Tend to the humanity, not the pathophysiology.

Disclosure Statement: The author has no conflicts of interest to disclose.