AACN News—October 2008—Practice

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Vol. 25, No. 10, OCTOBER 2008


Practice Resource Network


Q What tips or guidelines does AACN have for patient and family care conferences?

A Nurses have seen the stress and anxiety that family members face when loved ones are critically ill. The anxiety-laden environment of an intensive care unit can produce difficult, varied emotional responses during crucial decision-making times.

In a study by Auerbach, et al, the two most common unmet needs of families were not enough information about the patient’s condition and treatment, and lack of explanation about the medical equipment being used.1 Another study found that 30 percent of families were not satisfied with the communication they received while their loved one was critically ill.2 In a study designed to assess levels of family stress associated with withdrawal of life support, Norton, et al exposed a series of unmet communication needs that included: the need for timely information, the need for honesty, the need for clinicians to be clear and the need for clinicians to answer.

So how can nurses, and the healthcare team at large, increase positive interaction and skilled communication with our patients’ families?

Let’s look briefly at what skilled communication is. Skilled Communication, as defined by AACN’s Healthy Work Environment Standards, is “more than the one-way delivery of information; it is a two-way dialogue in which people think and decide together,” further stating that “a culture of safety and excellence requires that individual nurses and healthcare organizations make it a priority to develop professional communication skills – including written, spoken and nonverbal – that are on par with expert clinical skills.”4 Critical elements of Skilled Communication include: focusing on finding solutions and achieving desirable outcomes; seeking to protect and advance collaborative relationships among colleagues; inviting and hearing all relevant perspectives; calling upon goodwill and mutual respect to build consensus and arrive at a common understanding; demonstrating congruence between words and actions; holding others accountable for doing the same.”

The following information is a summarized excerpt from resources produced by the 2007 AACN Ethics Work Group.

Calling a family conference can be an ideal time for the healthcare team to interact with the family, facilitate communication, provide information regarding the plan of care and address any specific questions or concerns the family may have. Family conferences can be called for any number of reasons such as a change in patient status, miscommunication or conflict, mistrust of caregivers, boundary conflicts, unusually long length of stay, end-of-life discussions or transfer/discharge resource planning. Any member of the healthcare team or family member should be able to request a family conference.

Planning and preparation for the family conference will include discussions with the patient (if he/she is capable) regarding legal decision making and advance directives as well as discussing with the family the desire of the healthcare team to touch base with them. In addition, identify the key players and coordinate the team. Key players can include physicians, nurses, advanced practice nurse, physician’s assistant, social worker, case manager, chaplain, pharmacist, respiratory therapist, dietitian, physical therapist, palliative care team, etc. The meeting may be coordinated by the bedside nurse, charge nurse, case manager, social worker, clinical director or another involved person. Prior to meeting with the family, it is advantageous if the key players review any pertinent issues and discuss the goals and purposes of the meeting with one another. Identify who will facilitate the meeting. The facilitator could be any of the key players depending on the group facilitation skills of the attendees and the relationship with the patient and family. Coordinate a private location where interruptions will be minimized. Those who have cell phones or beepers should either turn them off during the meeting or arrange coverage whenever possible. The facilitator should strive to achieve an atmosphere that encourages respectful, collaborative discussion.

Keeping the elements of Skilled Communication in mind, start the meeting by having everyone introduce themselves. Then clarify the family’s understanding of the current clinical situation. Ask the family to describe in their own words their understanding of what is happening with their loved one. Discuss and clarify any misconceptions or misinformation. Next, update the family on the current plan of care and overall prognosis including the possibility of death. Encourage the family to take notes if they’d like.

Continue the meeting by asking the family about the patient’s values and wishes. Questions such as: “Did you ever talk about what the patient would want if things did not go the way the patient had hoped?” or “Based on your knowledge of the patient’s values and beliefs, what do you think the patient would want in this situation?” can open a dialog between the healthcare team and the family while maintaining the focus on the patient. Guide the family so that decisions are made based on patient wishes or what the family thinks the patient would want. For example, “Sometimes we have to make decisions for others and these decisions may have an impact on us. We need you to think about what you think your loved one would want, and what is best for him/her.” Let the family know the healthcare team will help with the decision-making process. Discuss treatment options and offer a recommendation with the rationale. Seek confirmation that the recommended option fits with the patient’s values and wishes. Provide the family with the time they may need to discuss and process the information and the treatment options.

End the meeting by asking the family to summarize their understanding of decisions that were made or need to be made. Clarify any misunderstandings. Thank the family for meeting with the healthcare team and for helping to make these difficult decisions. Discuss a follow-up plan. Give the family contact information for the key member (point person) on the healthcare team. Finally, document the meeting and follow up as appropriate.

Remember: The family’s greatest needs are access and information.

References

1. Stephen M. Auerbach, Donald J. Kiesler, Jennifer Wartella, Sarah Rausch, Kevin R. Ward, and Rao Ivatury. Optimism, Satisfaction With Needs Met, Interpersonal Perceptions of the Healthcare Team, and Emotional Distress in Patients’ Family Members During Critical Care Hospitalization. Am. J. Crit. Care., May 2005; 14: 202 - 210.

2. Baker R, Wu AW, Teno JM, et al. Family satisfaction with end-of-life care in seriously ill hospitalized adults. J Am Geriatr Soc. 2000;48(5 suppl): S61 - S69.

3. Sally A. Norton, Virginia P. Tilden, Susan W. Tolle, Christine A. Nelson, and Susan Talamantes Eggman. Life Support Withdrawal: Communication and Conflict. Am. J. Crit. Care., Nov 2003; 12: 548 - 555.

4. http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf accessed August 15, 2008

5. http://www.aacn.org/WD/Practice/Content/ethicmainpage.pcms?pid=1&&menu= accessed August 15, 2008