A multidisciplinary team of nurses, doctors, and pharmacists join a conversation with 93-year old Max Rubenstein and his grandson, Ira Tytel, at left, during rounds in the Coronary Intensive Care Unit at the Peter Munk Cardiac Centre in Toronto, June 20, 2014. Dr. Christopher Overgaard, the cardiologist involved, is at left in the white coat.Peter Power/The Globe and Mail
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Working in a cardiac intensive care unit populated by men and women with life-threatening heart issues, I have witnessed many patients and their families sit on the edge of darkness and despair, hoping for a miracle.
I have had to relay difficult news to many families over the years. There have also been many astonishing recoveries and modern-day marvels. Thankfully, these occurrences happen often. They are what we strive for each and every day.
For patients and their families, the single most important human element that can make or break their experience is effective communication between themselves and health care providers.
When a life hangs in the balance (and saving that life is the collective goal), communicating clearly and consistently is an absolute necessity.
Many patients have told us that getting face-time with their loved ones' medical team to discuss the patient's prognosis and health care plan is their lifeline.
In reality, the medical staff of most hospital units are usually pulled in a dizzying number of directions - continually investigating treatment options and reviewing medical procedures - all while trying to maintain effective communication with the patient and concerned family members. When emergencies arise, the necessary updating of worried family members can sometimes take a back seat. The addition of language barriers, or various cultural issues involving the relatives or friends of a cardiac patient in our care can further complicate what is already a difficult, emotionally-wrenching scenario.
When we have surveyed family members and patients regarding their experience in our Coronary Intensive Care Unit (CICU,) we sometimes hear that family members occasionally feel out-of-the-loop with regard to a patient's treatment plan.
To address this, we recently introduced a novel pilot project using a family-centred approach to medical communication. Since the beginning of 2014, we have invited families of patients to accompany us - the medical team - on rounds so that these relatives can hear the health care teams' detailed discussion about their loved one.
Here's how it works: When a family first meets the medical team, they are briefed on how the process works, and how we will discuss their loved one's condition. We invite willing family members to join us daily to listen in on the detailed medical discussion taking place. When running through a patient's medical issues, we use typically use a "head-to-toe" format reviewing the condition of the brain, heart, lungs, intestines, kidneys, skin and the status of the lines used to monitor the patient and to introduce medications to them. Then, we let family members know what further investigation needs to be done, and describe the treatment plan for the day. When this plan changes, families are informed. During these "rounds," at least 10 medical professionals are present, including a staff physician, four resident doctors, two nurses, a pharmacist, and a patient care co-ordinator.
Including family members in a patient's medical briefing allows them to get a realistic perspective of their loved one's condition, educates them about medical terms, provides them an opportunity to ask questions, keeps them abreast about updates and changes, and allows them to better understand the decisions that health care staff make while treating the patient.
It also affords family members the chance to share this information with the rest of their relatives, and even the patient themselves. Furthermore, if language is a barrier, medical briefings through a family-centred approach allow relatives to convey information directly to the patient in their native tongue. This approach also enables family members to develop relationships with the health care team, giving them the sense that the team is approachable in the care of their loved one.
For the nurse or doctor doing the briefing, this approach means maintaining a balance between giving the family member a realistic portrait of the prognosis without conveying too much optimism or pessimism about the fragile road ahead. This becomes most challenging when a family member is perhaps not realistic or is unable to cope with the dire nature of their loved one's situation. This is both understandable and common. If the patient is dying, the doctors, nurses and medical staff will share in the range of emotions that follow.
What we have found is when a patient's family witnesses first hand how things are progressing, when they see how hard we are trying to help that patient, they become more confident with the care their relative is receiving, even if the prognosis is not good.
A family-centred approach also enables greater accountability. It keeps us, the medical staff on our toes, enhances the information-sharing between us and further supports the importance of the multi-disciplinary approach that we practice --- different medical specialties collaborating on a single patient to ensure the best outcome possible.
We are in the infancy of the family-centred approach to critical care in our CICU, and its continued evolution will involve a shift in the culture of our unit. However, the feedback we've received from families has been most heartening. Those included have been extremely appreciative of being able to attend family-centred rounds and to hear the medical information first hand.
Ultimately, this approach to communication speaks to transparency and trust between the medical team, patients and families --- even if and especially when the critically ill patient may not survive.
Dr. Christopher B. Overgaard is an interventional cardiologist at the Peter Munk Cardiac Centre in Toronto. He is also the Medical Director of the Coronary Intensive Care Unit (CICU), and Associate Director, Research and Innovation in Interventional Cardiology and Coronary Intensive Care at the University Health Network (UHN).