Chapter 140. The Family Meeting in the ICU

1. When should the ICU clinicians meet with the family of a critically ill patient and how should these meetings be conducted?

2. Who should be included in an ICU family meeting?

3. What are the elements of shared decision making?

4. How should ICU clinicians discuss prognosis with ICU patients and their families, and specifically, how should the clinicians break the bad news?

In the United States, approximately 20% of all deaths occur in the intensive care unit (ICU) each year. Critically ill patients frequently lack decisional capacity and the ability to express their preferences for treatment, and thus decisions regarding goals of care often involve family members. In these circumstances the concept of surrogate decision making is enacted, which generally involves a person, often a family member, who knows the values and preferences of the incapacitated patient and who is willing to serve as a surrogate decision maker. However, prior studies have reported poor communication and conflicting goals of care between ICU clinicians and patients' families. Communicating effectively and compassionately with families will help improve medical decision making for the patient and improve family outcomes after the critical illness of a loved one. The ICU family conference is a central component of this communication. This chapter provides a framework of how to plan, structure, and lead an effective meeting with families of critically ill patients.

Medical Decision Making

Relatives, partners, and friends often provide support and care for a patient, which for some will include the responsibility of surrogate decision making. Surrogate decision makers bear an enormous amount of emotional stress, and decision making during these circumstances can be difficult. In addition, one study revealed that despite discussions with ICU physicians, only half of families of critically ill patients adequately understood their relatives' diagnoses, prognoses, or treatments. Despite this, clinicians and health systems often neglect the care of the family as part of the overall care of a patient.

The American Medical Association endorses an interdependence of families and physicians, and their partnership must be established in order to make good medical decisions and provide optimal care for the patient. High quality ICU care depends on effective clinician-family communication to improve the family members' level of understanding and their ability to provide surrogate decision making that accurately reflects the wishes of the patient.

Family Outcomes: Anxiety, Depression, Posttraumatic Stress Disorder

Up to 25% of families report dissatisfaction with their communication with ICU caregivers. Furthermore, the approach to communication may cause anxiety, depression, and posttraumatic stress disorder among family members. Many physicians who work in critical care units conduct family meetings only after ICU patients are actively dying. However, critical ...