Rule 1 - Trust matters
If you need to tell people something big (especially something they don’t want to hear), they need to trust you. Advised Warrillow, “Give them reasons to trust you”. For example, allow them to be with their loved one as much as possible, let them attend ward rounds, and allow them to see your evaluation and decision-making process.
Rule 2 - No surprises
No one should ever be blindsided. Regular updates are needed, especially if things are not going well.
Rule 3 - No solo acts
Never speak to families on your own. It is crucial to have the bedside nurse present as a witness and support for the family, as very often patients or families ask the nurse for feedback afterwards. Families trust the nurses and talk to them a lot. The nurse is the family support. Families may not say very much during a family meeting, so intensivists should ask the nurse for feedback afterwards. If you are taking part in a meeting with a colleague, it is important to understand each other’s views and have clear agreement on the purpose of the meeting and the issues to discuss.
Rule 4 - Take your time
Make time. Use an interview room, and try to avoid bedside discussions unless for a short, simple update of good news.
Rule 5 - Start the conversation
Be prepared - know the patient and their journey. Ask them what happened, even if you know. It’s helpful to them to tell it. You can gently correct any errors or misinterpretations.
Rule 6 - Plain speaking
Speak plainly, concisely and clearly. Avoid using medical, technical or scientific language. Don’t patronise - use correct medical terms, but always provide interpretation.
Rule 7 - Avoid statistics
Don’t play the ‘percentage chance of survival’ game. You don’t really know the numbers anyway, and a one percent chance may be seized as a chance to carry on with non-beneficial treatment. Warrillow suggested real world honesty, for example:
“I’ve never seen a person in this situation survive”, “Despite a lot of high level treatments, things are now worse than when he first came to the ICU”.
Rule 8 - It’s OK to show you are human
If you misspeak, or your voice cracks it shows we are human, and families appreciate our efforts. If you say something not quite right, apologise and start again.
Rule 9 - Talk less, say more
If there is nothing to say, it may be best to say nothing. Silence is OK, and can be very helpful. Let them cry and do not feel a need to move on quickly. Warrillow acknowledged that is not easy.
Rule 10 - Tell them the plan
Detail the management plan in all aspects. Do not detail what treatments will not be offered, but offer only reasonable options that are actually meaningful.
Warrillow closed by advising intensivists not to neglect self care. Occasionally we need to ask each other “Are you OK?”
Managing Editor, ICU Management