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C OMMUNICATION IN
CRITICAL CARE: FAMILY
ROUNDS IN THE INTENSIVE
CARE UNIT
By Natalie L. Jacobowski, BA, Timothy D. Girard, MD, MSCI, John A. Mulder,
MD, and E. Wesley Ely, MD, MPH
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Although much attention has been given to the often is lacking.3,20 Failure to comprehend a diagno-
family conference separate from rounds,5,8-11 commu- sis, prognosis, or treatment occurs in 35% to 50%
nication may also be enhanced through routine of family members.21,22 Improved comprehension is
incorporation of families into daily interdisciplinary thought to be a base from which overall satisfaction
ICU rounds. Studies in pediatric12-14 and trauma15,16 can arise,1 making this deficit in understanding a
patients have suggested a beneficial significant impediment to optimal care. Thus, a
effect of including patients’ families “family rounds” approach, with nurses inviting and
Studies have in interdisciplinary rounds, and bringing the family into daily rounds, might facili-
suggested a exploration of the related practice of tate the earliest possible and most regular form of
bedside rounds shows the practice communication for all patients, not just those for
beneficial effect to be positively received by patients whom problems arise, such as the need for end-of-
of including as well.17,18 Studies of families’ experi- life discussions. On the other hand, such an
ences with end-of-life care in the approach of hearing the actual medical discussions
patients’ families ICU indicate a need for better com- on rounds could increase family members’ fear,
in interdisciplinary munication, as communication
deficits may contribute to family
confusion, and doubts about care.
We conducted this pilot investigation to explore
rounds. anxiety and depression,1,3,5,6 increased the effect of consistent, early communication through
risk of contradictory information the addition of a family component to interdiscipli-
from multiple physicians,19 and potential family nary rounds in the medical ICU, a setting in which
mistrust of physicians.5 Families desire more fre- this type of communication intervention has rarely
quent communication with nurses and physicians,6 been reported. This intervention will be referred to
and access to and comprehension of information as “family rounds” to focus on this 1 aspect of inter-
disciplinary rounds. While constructing this study,
we noted the importance of including both families
About the Authors
Natalie L Jacobowski is a medical student at the Vander- of patients who survive their ICU stay and families
bilt University School of Medicine, Nashville, Tennessee. of patients who die during or shortly after an ICU
John A. Mulder is an assistant professor in the Department stay in the study. The needs of surviving patients
of Family Medicine at the Michigan State University
College of Human Medicine and the medical director and their families for communication can be neg-
for palliative care services for Spectrum Health in Grand lected because of the focus on communication in
Rapids, Michigan. Timothy D. Girard is an assistant pro- the end-of-life setting.23 We hypothesized that
fessor and E. Wesley Ely is a professor in the Division of
Allergy, Pulmonary, and Critical Care Medicine and the implementation of family rounds would enhance
Center for Health Services Research in the Department communication and facilitate end-of-life planning
of Medicine at Vanderbilt University School of Medicine. (when appropriate) between families and the med-
Dr Girard is also a staff physician and Dr Ely is the asso-
ciate director for research in the Geriatric Research, ical team, leading to improved family satisfaction,
Education, and Clinical Center at the Department of Vet- especially with aspects of communication.
erans Affairs Medical Center, Tennessee Valley Healthcare
System, in Nashville.
Materials and Methods
Corresponding author: Natalie L. Jacobowski, BA, Vander- Study Design
bilt School of Medicine, 6th floor Medical Center East #6109,
Vanderbilt University Medical Center, Nashville, TN We conducted a before-after study during which
37232-8300 (e-mail: natalie.jacobowski@vanderbilt.edu). family satisfaction in the ICU was assessed before and
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Discussion
In this pilot before-after study, a family rounds family satisfaction but did result in significant
component during interdisciplinary rounds in the improvements in some aspects of family satisfaction
medical ICU did not affect the global measure of related to communication. Specifically, families of
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Patient
Age, median [interquartile range], y 57 [46-66] 55 [37-66] .45 62 [51-68] 56 [49-71] .94
Female, % 49 42 .31 56 50 .73
Race, % .61 .97
White 79 85 82 82
Black 12 10 18 18
Other 9 5 0 0
Admission diagnosis, % .11 .36
Cardiovascular 11 8 17 9
Respiratory 21 33 50 27
Neurological 11 16 6 9
Sepsis 14 10 0 18
Gastroenterological 12 18 6 9
Other 31 15 21 28
Days in intensive care unit, median 3 [2-5] 4 [3-8] .001 4 [2-6] 4 [3-9] .46
[interquartile range]
Full code status, % 97 93 .33 65 76 .23
Respondent
Age, y, % .41 .23
≥80 0 1 0 4
60-79 30 21 47 18
40-59 53 57 35 55
20-39 16 20 18 23
<20 1 1
Female, % 69 80 .10 61 77 .27
Race, % .56 .97
White 79 87 82 82
Black 13 10 18 18
Other 8 3
Relationship to patient, % .66 .33
Spouse/partner 49 49 72 50
Child 28 23 11 36
Parent 11 17 6 5
Other 12 11 11 9
discharged patients reported an increased frequency the scheduled opportunity to receive information
of communication. Additionally, although family and answers to questions. Past studies also have
rounds had been conceived as an efficient use of revealed a link between family satisfaction and psy-
time for both families and the medical team, the chological health.1,3,5,6 Hospitalization of a loved one
results indicated that more families perceived the in the ICU is a very stressful event for family mem-
time for decision making as inadequate after imple- bers, with nearly 3 out of every 4 family members
mentation of family rounds. struggling with anxiety and 1 in 3 showing signs of
Other researchers have evaluated patients’ per- depression.6,28 A proactive approach to bereavement
spectives of similar interventions such as bedside and implementation of a proactive communication
case presentations that brought the patient and fam- strategy leads to decreases in the frequency of post-
ily into the midst of rounds. Most patients preferred traumatic stress disorder, anxiety, and depressive
such bedside presentations.17,18 Studies of family symptoms.5 In our family rounds pilot study, this com-
inclusion in ICU rounds are limited,15,16 but the results munication began at admission, congruent with the
available indicate that patients’ families appreciated reported increased satisfaction with communication
426 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2010, Volume 19, No. 5 www.ajcconline.org
a “% excellent” indicates the proportion of respondents who gave the survey item the highest rating, that is, expressed the highest level of satisfaction.
when prognostic information is provided within a format and a frequently updated picture of their
shorter time interval.29 By addressing some of these loved one’s condition.13,15 These rounds also helped
key components of family satisfaction, family rounds prepare families for more in-depth discussions that
could minimize psychological distress in the stress- were sometimes necessary later in the day to meet
ful ICU environment (especially if family members their reported need for more time in decision mak-
who feel rushed by such an approach are encour- ing than might be possible during rounds. However,
aged to have family conferences later in the day to the effect of family rounds on knowledge and com-
allow more time for decision making). Simultane- prehension was not studied in this investigation
ously, subsequent studies of family inclusion should beyond families’ summary statements about access
consider the potential for families to feel intimidated to and satisfaction with information. As comprehen-
or overwhelmed in the setting of daily rounds and sion is a central aspect of good communication, it
should explore family comfort in that setting and warrants more extensive attention in future studies.
any potential effects on families’ levels of stress and Studies of families of patients with end-of-life
anxiety. This important balance must be explored experiences have documented a need for informa-
in future research. tion early and often,7,22 and inadequacies of infor-
This pilot study highlights that family satisfac- mation and communication may impede removal
tion with communication may hinge on receipt of of life support, leading to a prolonged dying process
adequate knowledge to improve family members’ and longer stays for patients.32 Interdisciplinary inclu-
comprehension and aid in surrogate decision mak- sion of the ICU medical care team during family
ing.1,5,20,21,25,28,30,31 Inadequate comprehension is reported rounds may reduce communication obstacles by
in 30% to 50% of patients’ families,21,22,28 a statistic fostering more cohesive care with better integration
that we felt necessitated that the structure of family of palliative care,33 yet the pace of these rounds and
rounds include having the physician provide the the inclusion of medical terminology amid the dis-
families with a 1- or 2-minute summary in lay lan- cussions between doctors and nurses could also
guage. Family rounds initiated brief, structured, and increase communication problems.
consistent communication within the first 24 hours Our study included only English-speaking
of admission, providing families a realistic, real-time patients. This necessitates further study of the
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