ICU: The New Hospice
There are many ways to ameliorate emotions, such as normalization (“It is normal to be upset…”) and paraphrasing and repeating back (“So, what you are saying is that…”), but critical care physicians seem to find silence or listening difficult. Silence represents understanding and sharing in the pain of suffering. Video feedback can demonstrate the value of timely silence. Physicians who tend to lecture patients or families are often not aware of this until they view themselves on video feedback. Doctors who talk less and listen more are perceived as being more empathic.
Communication training often addresses double-talk—physicians saying one thing when they mean another. For example, discomfort talking directly about dying often drives physicians to use metaphors. “Would you like everything done?” is actually an attempt to say, “If you were close to death, we physicians would like to avoid futile resuscitation.”
The problem is that patients and families understand “everything” to mean a comprehensive approach. The opposite of “everything” is understood to be a halfhearted approach. Communication training can unpack the metaphor “everything,” clarifying the real underlying issue, that CPR in dying cancer patients has almost zero efficacy.
“Heroic measures” is another metaphor for futile CPR that is understood in divergent ways. Would you prefer physicians to use “heroics” or the opposite, “cowardly” measures? I would select heroic measures—it reminds me of the movie “Saving Private Ryan.” But the real issue is physician discomfort discussing futile CPR and dying. Communication training helps physicians add better lines to their end-of-life communication scripts, to more accurately reflect their good intent.
I was shocked recently when training a group of Eastern European palliative care physicians. One broke down in tears during role-play—he had never told a patient that he or she was dying. “Truth telling” is an old story in the West, so imagine my dismay when, a week later, I heard of a ventilated, brain-dead patient being kept alive for weeks at a top U.S. hospital. Earlier communication would have helped the patient and family find their respective peace.
The physicians involved in this case were competent and caring, yet they found it difficult to initiate a conversation about withdrawal of life-extending treatment. A desire not to disappoint the family, fears of litigation, a communication skill deficit, or cultural divergence may have impeded communication. Nevertheless, earlier initiation of this painful negotiation would have helped the patient and family find peace.
The need for ICU communication training is ubiquitous, even in the most prestigious medical institutions, because discussing death is intrinsically difficult, even among kind-hearted, experienced critical care physicians. Although it seems obvious that communication training would be beneficial in the ICU setting, the challenge remains to demonstrate that improved skills lead to better clinical outcomes. Currently, critical care medicine communication training is at an early, but exciting, stage of development.
