Communication is key to breaking bad news in the ICU, and intensivists need to learn to listen more when talking to families, said J. Randall Curtis, Professor of Medicine, Adjunct Professor, Department of Bioethics and Humanities, and Director, UW Palliative Care Center of Excellence at UW Medicine.
Even before breaking bad news, there is a 5 step approach to improving communication in the ICU with families, the VALUE approach.
The VALUE approach is:
Value family statements
Acknowledge family emotions
Listen to the family
Understand the patient as a person
Elicit family questions
When discussing prognosis with families, best practice is to provide prognostic information as a range, acknowledging uncertainty. Give honest, direct information acknowledge and explore emotions, don't give premature reassurances, don't give facts in response to strong emotions, explore emotions and allow silence, emphasised Curtis.
He cited a study by Stapleton and colleagues of clinician statements associated with increased family satisfaction with family conferences in the ICU. These were to assure the family that the patient would not be abandoned before death, that the patient would be kept comfortable and not suffer prior to death, and to provide support for the family around decisions to withdraw or continue life support.
For breaking bad news, Curtis recommended an approach developed by oncologists, that he has used successfully in his own hospital.
The SPIKES protocol has 6 steps:
- Setting up the interview
- Assessing the patient’s Perception
- Obtaining the patient’s Invitation (I have bad news, are you ready to hear it? [after a few times, it's more comfortable to use said Curtis, and he has never had anyone say no]
- Giving Knowledge and information to the patient
- Addressing the patient’s Emotions with empathic responses
- Strategy and Summary
Asked about handling emotions, Curtis recommended another mnemonic, NURSE, which stands for Naming, Understanding, Respecting, Supporting and Exploring. When expressing empathy, doctors should not say that they understand how the patient or family feel, but say they can only imagine how they feel, he suggested.