Critical Care Communication (3C)
Dr Mohan, Intensivist
Module 1 - FUNDAMENTAL
1. List four fundamental principles for better intensivist-family communication.
2. Describe the "Ask-Tell-Ask" principle.
3. Describe the "Tell me more" principle.
4. Describe the "Respond to emotion" principle and the mnemonic NURSE.
5. Describe the differences between "monitors" and "blunters," and identify techniques to best address their information needs.
Futility
"When doubts haunt me, when disappointments stare me in the face, and I see not one ray of hope on the horizon, I turn to Bhagavad-Gita and find a verse to comfort me; and I immediately begin to smile in the midst of overwhelming sorrow. Those who meditate on the Gita will derive fresh joy and new meanings from it every day."
- Mahatma Gandhi
कर्मण्येवाधिकारस्ते मा फलेषु कदाचन । मा कर्मफलहेतुर्भुर्मा ते संगोऽस्त्वकर्मणि ॥
You have a right to perform your prescribed duty, but you are not entitled to the fruits of action. Never consider yourself to be the cause of the results of your activities, and never be attached to not doing your duty.
- Bhagavad Gita, Chapter II, Verse 47
Demanding families
Cochrane systematic review of communication skills
(1) it is clear that communication skills do not reliably improve with experience alone, and
(2) training programs using appropriate educational techniques are effective in improving skills.
Intensivist-patient relationship
directive model
consumer model
informative model
shared decision-making: facilitative and collaborative
Principle 1: A Central Skill "Ask-Tell-Ask."
Ask the family to describe their current understanding of the issue. Asking permission prior to giving information also serves to help build a relationship.
Tell the family in straightforward language what you need to communicate
Ask the family whether they understand what you just said.
Principle 2: When You Are Stuck, Ask for More Information: "Tell Me More."
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Principle 3: Use reflections rather than questions to learn more
SON: I know he is really sick but I can not give up hope.
Dr: You can not give up hope.
SON: I have to be hopeful. I am not sure what I will do if he gets sicker or does not
make it.
Principle 4: Skills for Responding to Emotion.
When families are Emotive
they are less able to hear cognitive information.
people find it hard to make decisions.
feel that their situation and emotions are heard and appreciated.
You Show empathy –
being able to recognize and then show that you are trying to recognize what the other person is going through. Being empathic is associated with family satisfaction and trust.
Principle 4: Skills for Responding to Emotion.
‘NURSE’ - mnemonic
NAMING: naming an emotion as a way of noting for yourself what is happening in the encounter; showing that you are attuned to what they are experiencing.
UNDERSTANDING: A sensitive appreciation of the family's predicament or feelings is an important prerequisite for responding in a way that builds the relationship.
RESPECTING: Acknowledging and respecting a family's emotions is an important step in showing empathy.
SUPPORTING:
EXPLORING:
Principle 5: Assess the Other Person's Informational, Decision-making and Coping Style.
“Would it be useful if I gave my view?”
problem-focused coping have been termed "monitors." (NURSE).
emotion-focused coping are termed "blunters." -> "ask-tell-ask."
The best you can do is try something – either cognitive information or empathy and see the impact on the family.
Pitfalls/Common Barriers to Good Communication
Giving pathophysiology lectures:
Ignoring the context of the communication encounter:
Not finding out the family’s information needs and styles:
Launching into your agenda first without negotiating the focus of the interview:
Offering reassurance prematurely:
Pushing the family to make a decision, before they have had a chance to grieve the loss: