The therapeutic effect of intensive care is measured by mortality, survival, quality of life and satisfaction of patients and their families [1, 2, 3, 4, 5, 6, 7, 8]. These parameters enable to assess the direct outcome of management (i.e. survival) and its effects on post-therapy quality of life of patients with various pathologies. Moreover, based on them the intensive therapy costs versus effects can be estimated. Today, the satisfaction of patients is assessed in a much broader context than the post-therapy quality of life. During the last decade, numerous studies were focused on the issues of satisfaction of patients and their families [3, 4, 5, 8, 9, 10, 11]. The findings of analyses show the benefits resulting from good relationships between the ITU personnel and patients` families and stress the importance of communication between them. The benefits involve three spheres.

The first sphere regards additional information not only about the pre-disease quality of life but also preferences of patients, which in many cases allow choosing the therapy option based on their wishes. This last element is particularly important in cases of unconscious patients, who cannot express their expectations, i.e. ITU patients. In Poland, the recent discussions of ethicists and physicians concerning official approval of a living will have not brought about any positive results. Therefore, all other options of getting to know the preferences and wishes of patients unable to express them should be considered. In this sphere intensive communication with the patients` families may enable the physician to carry out the management according to the patient’s will and thus support the decision regarding the range of therapy administered [5, 12].

The second sphere is of a particular educational value for the patient’s family. The knowledge of medical management methods enables them to participate in the therapy, accept or limit it. The family may easier realize the condition of their relative, better understand the situation and perceive the usefulness and effects of the therapy. As a result, unreal expectations of the families, so commonly observed, can be prevented [10, 13, 14].

The third sphere is to result in benefits for both families and ITU personnel. The worldwide studies have demonstrated that “intensive communication” with families of ITU patients limits the stress, fear and anxiety of families affecting their emotional attitudes, prevents conflicts and limits their claims [15, 16, 17, 18, 19, 20]. It has been stressed that suitable and intensive communication with the medical personnel prepares the families of patients requiring just the palliative management for participation in or taking over the end-of-life care in a home setting [12].

The family satisfaction results from the feeling of personnel involvement in their experiences. This feeling is the source of relationship enhancing the confidence in physicians and nurses participating in the therapeutic process. Another element building confidence is good communication and relationships between physicians and ITU staff versus patients` families, which are considered the relevant bond based on respect for their mutual value, i.e. good of a patient. It is not easy to achieve this in the light of common lack of confidence in the health care system and their workers, which results from the media hype regarding failures or abuses in this field. This loss of confidence requires arduous efforts at all levels of activity to reverse the unfavourable phenomena. This particularly concerns the units providing care of critically ill patients, e.g. ambulance services, emergency departments and ITUs. The imperfect communication between the patients` families and ITU personnel may be improved by defining the rules of management aimed at family support, which should improve mutual relations and enhance the image of intensive therapy and anaesthesiology strengthening its position in the social perception.

BASIC RULES OF GOOD COMMUNICATION

Interpersonal communication is the sphere requiring not only education but also experience in this field. Good relationships between health care professionals and patients` families should be built by both parties. The knowledge of principles to form proper relations with patients or their families is an essential element of staff education. However, this element has not been included in the medical curriculum or additional trainings.

The key rules of communication between the patient’s family and a physician include:

• limitation of paternalism,

• provision of reliable information,

• confidence based on mutual understanding and respect,

• elimination of impulsive behaviour.

The additional elements to mould proper communication should include the use of proper language and provision of information adjusted to the intellectual level of an interlocutor, the application of appropriate proportions between the statements of a physician and of families and taking into consideration the cultural and religious factors. Moreover, the knowledge of needs and habits of patients, obtainable by the personnel from their families, is essential. Myerscough and Ford [21] list the features of good communication based on care ethics, which include:

• comfort – the capacity to address difficult issues,

• acceptance – understanding and respect for family feelings,

• reactive behaviour-active listening, sensibility,

• empathy – positive reactions to the feelings of other individuals. 

The first two features require the control of negative emotional reactions of the physician resulting from various reasons, e.g. inability to communicate, impatience, lack of time, etc. The further two features regard the physician’s reactions to family emotions. It is emphasized that the physician should professionally control family reactions to the problem faced by keeping the controlled distance. The typical mistakes made during discussions with families include incompressible terms, laconic conversations in haste and poor conditions, without privacy, ignoring questions and requests for explanations. The less common mistakes result from inability to show understanding, uncontrolled emotions, inconsistency of information provided by different physicians. The studies on relationships between the ITU personnel and patients` families discuss in detail the elements of proper information provision [10, 11, 12, 13, 22]. The authors stress the danger resulting from too optimistic prognosis. It is recommended to limit the information during the first days of stay to data about the current condition of the patient and to ignore the information regarding possible prognosis. 

REASONS FOR IMPROPER COMMUNICATION WITH FAMILIES OF ITU PATIENTS

The main reasons are related to the lack of ability to communicate, patronizing manner of physicians, and lack of confidence of families in health care professionals. The factors impeding good communication include time pressure felt by physicians and avoidance of conversations about unfavourable outcomes. The family-related factors, which hinder communication, are reactions manifested in anxiety and anger or even aggression. The experience shows that information provided by physicians is perceived in a limited way, which is associated with difficulties in understanding the information and psychological determinants concerning acceptance of those messages which the families want to hear; the other data, particularly unfavourable ones conveyed in emergency situation are partially or even completely eliminated. This is defined as limited acceptance of information. The studies assessing family satisfaction and perception of the information provided revealed that only 50% of families interpreted correctly the inf
ormation about diagnosis, prognosis and treatment; 29% interpreted wrongly all data; the information about prognosis was misinterpreted by 29%  and treatment-related data were not understood by 15% of families [23].

The lack of proper communication with the patients` families may also be affected by the physician himself /herself or their current situation, including internal anxiety resulting from the burden of poor treatment results, fear of family reactions as well as anxiety related to personal matters, which cannot be completely ignored.

RESULTS OF IMPROPER COMMUNICATION WITH PATIENTS` FAMILIES

Improper communication of the ITU personnel with patients` families induces conflicts. The families suffer from deeper fears and stress, painfully experienced lack of satisfaction, demands for futile therapy or even control of the quality of care and therapy. The confidence in the personnel vanishes and is replaced by claims; conflicts are stressful for the personnel due to the complaints concerning malpractice and  threats of legal actions, which in many cases are groundless. The prestige of profession decreases.

According to some studies [5, 13, 15, 17, 24], an important element eliminating conflicts is regular meetings with patients` families and actions according to the defined rules adjusted to the specificity of the unit, which particularly regards the system of visits and participation of families in the care of patients.

The national system of health care is increasingly criticised and the confidence in the medical personnel is commonly lacking; the issue of direct relationship of the physician and patients or their families requires at least to draw attention to this relevant element of professional activity. The increasing number of compensation claims filed into courts and offices of professional responsibility results from the lack of proper communication between  physicians and patients or their families. However, this is not the only reason, which should direct our attention to improvement of communication, thus the relationship between the medical personnel and those needing help. In intensive therapy with numerous dramatic events to be faced, the patient’s family also requires help and support. For several years, these issues have gained attention and have been analysed in worldwide studies. They should also be addressed to in Poland as this may contribute to better understanding and gaining our own experience in moulding good interpersonal relations, particularly in the units with critically ill patients.

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REFERENCES

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8.    Myhren H, Ekcberg O, Langen I, Stokland O: Emotional strain, communication, and satisfaction of family members in the intensive care unit compared with expections of the medical staff: experiences from Norwegian university hospital. Intensive Care Med 2004; 34: 1791-1798.

9.    Heyland DK, Rocker GM, Dodek PM, Kutsogiannis DJ, Konopad E, Cook DJ, Peters S, Tranmer JE, O’Callaghan CJ: Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med 2002; 30: 1413-1418.

10.    Dodek PM, Heyland DK, Rocker GM, Cook DJ: Translating family satisfaction data into quality improvement. Crit Care Med 2004; 32: 1922-1927.

11.    Rothen HU, Stricker KH, Heyland DK: Family satisfaction with critical care: measurements and messages. Curr Opin Crit Care 2010; 16: 623-631.

12.    Truog RD, Campbell ML, Faan RN, Curtis JR, Curtis EH, Luce JM, Rubenfeld GD, Hylton Rushton C, Kaufman DC: Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008; 36: 953-963.

13.    White DB, Engelberg RA, Wenrich MD, Lo B, Curtis JR: Prognostication during physician – family discussions about limiting life suport in intensive care units. Crit Care Med 2007; 35: 442-448.

14.    Curtis JR, Engelberg RA: Measuring succes of interventions to improve the quality of end-of-life care in the intensive care unit. Crit Care Med 2006; 34: 341-347.

15.    Lilly CM, De Meo DL, Sonna LA, Haley KL, Massaro AF, Wallace RF, Cody S: An intensive communication intervention for the critically ill. Am J Med 2000; 109: 469-475.

16.    Alvarez GF, Kirby AS: The perspective of families of the critically ill patient: their needs. Curr Opin Crit Care 2006; 12: 614-618.

17.    Davidson JE, Powers K, Hedayat KM, Tieszen M, Kon AA, Shepard E, Spuhler V, Todres ID, Levy M, Barr J, Ghandi R, Hirsch G, Armstrong D: 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. Crit Care Med 2007; 35: 605-622.

18.    Levy MM, Mc Bride DL: End of life care in the intensive care unit. State of the art in 2006. Crit Care Med 2006; 34: 306-308.

19.    Stapleton RD, Engelberg RA, Wenrich MD, Goss CH, Curtis JR: Clinician statements and family satisfaction with family conferences in the intensive care unit. Crit Care Med 2006; 34: 1679-1685.

20.    Lilly CM, Sonna LA, Haley KJ, Massoro AF: Intensive communication: four-year follow-up from clinical practice study. Crit Care Med 2003; 31: 394-399.

21.    Myerscough PR, Ford M: Jak rozmawiać z pacjentem. Gdańskie Wydawnictwo Psychologiczne, Gdańsk 2001: 69-87.

22.    Heyland DK, Rocker GM, O’Callaghan CJ, Dodek PM, Cook DJ: Dying in the ICU: perspectives of family members. Chest 2003; 124: 392-397.

23.    Rego Lins Fumis R, Nishimoto IN, Deheinzelin D: Measuring satisfaction in family members of critically ill cancer patients in Brazil. Intensive Care Med 2006; 32: 124-128.

24.    Fussier T, Azoulay E: Conflicts and communication gaps in the intensive care unit. Curr Opin Crit Care 2010, 16, 664-665.

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address:

*Janina Suchorzewska
Zakład Etyki, Gdański Uniwersytet Medyczny
ul. Tuwima 15,80-210 Gdańsk
tel.: 58 349 14 86
e-mail: zakladetyki@gum.edu.pl

received: 01.02.2011
accepted: 05.04.2011