Should Families Be Invited Into the Healthcare Team Treating ICU Patients?

The way I see it, as chair of my local community hospital’s ethics committee, is that most of the conflicts between patient/family and the medical care staff has as its basis the need for better communication. The problem is that patients and families don’t know and understand what the doctors are knowing, understanding and communicating with their colleagues and the doctors don’t know what the patients/families want to know or how they feel because they are not told or, in fact, the doctors are not listening. It seem that there are two distinct groups involved: the patient and family on one side and the healthcare team on the other. A solution to the problem would be that the patient and family could all be together on the same team, meeting together, communicating together, all being aware of the current status and changes and finally making decisions together, in essence working together to the benefit of the patient,

It is in the hospital intensive care unit where many of the conflicts arise. It is there where the patient is usually critically ill and may be dying, unresponsive or poorly responsive to communicate wishes or make decisions and where the family plays an important role of a surrogate in understanding the clinical situation and decision-making. And it is here where often the conflicts arise which comes to the ethics committee.

An important article in the February 2007 issue of Critical Care Medicine titled “Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical
Care Medicine Task Force 2004–2005” is summarized by Medscape Internal Medicine. The consensus of the task force was supported by reviewing evidence-based studies in the literature. The conclusion was that "Including and embracing the family as an integral part of the multiple-professional ICU team are essential for the timely restoration of health or optimization of the dying process for critically ill patients …Support for the psychological and spiritual health of the family is an essential component of patient-centered care for the critically ill.” Some 43 recommendations were presented and Medscape noted the following examples:

Endorsement of a shared decision-making model rather than unilateral decision making by the clinician, which might decrease family stress and help families to cope.

Early and repeated care conferencing to reduce family stress and improve consistency and cultural sensitivity of communication, using terms that the family can understand. Improved communication may also increase the use of advanced directives.

Honoring culturally appropriate requests for truth telling and informed refusal.

Spiritual support, encouraging and respecting prayer and adherence to cultural traditions, which help many patients and families to cope with illness, death, and dying. In addition to formal spiritual counseling by a chaplaincy service, educated members of the ICU staff might help to accommodate the spiritual traditions and cultural needs of patients and families.

Education and debriefing of staff to minimize the effect of family interactions on staff health.

Family presence at both rounds and resuscitation, which might help families cope with the death of a loved one in the ICU.

Open, flexible visitation.

Way-finding and family-friendly signage.

Waiting rooms that are close to patient rooms and that include family-friendly amenities.

Family support before, during, and after a death.

Symptom management and family involvement in palliative care processes to improve ICU care.

I know that the suggestion of integrating the family into the healthcare team with participation in clinical rounds (where the multidisciplinary clinical members gather together near the patient to evaluate and discuss the patient’s current condition and further management) and observation of resuscitation is controversial amongst the physicians and other hospital staff. I wonder what are my visitors opinions about the conclusion of the task force and the need to implement the suggestions that were made. ..Maurice.