When conducting care conferences with families in the pediatric ICU, communicating important news and pausing to allow family participants time to express emotions and provide feedback appears to give valuable information that can enhance decision making.
Care conferences with families of critically ill children in the pediatric ICU are often conducted to review a patient’s condition, discuss their prognosis, and make important medical decisions, and these meetings often take place when medical conditions worsen or when there is a need for medical decisions about care planning. “We know these decisions are often challenging for families because they are highly emotional,” explains Tessie W. October, MD, MPH. “Care conferences often involve high-stakes decisions, such as whether to withhold life-sustaining therapies or use invasive treatments.”
A Qualitative Analysis
Recent research in adult ICU patients suggests that physicians do not frequently show empathy and often miss opportunities to connect with families, but it is unknown if the same is true for those practicing in pediatric ICUs. To address this gap, Dr. October and colleagues had a study published in JAMA that evaluated empathetic statements from physicians during family care conferences in the pediatric ICU. “Our goal was to determine how physicians responded to emotions during these high-stakes meetings and if responses by physicians impacts how conversations progress,” Dr. October says.
In a single-center qualitative study, Dr. October and colleagues gathered audio-recorded care conferences from 30 physicians who interacted with 179 family members of 68 children in the pediatric ICU. Empathetic statements were classified using the NURSE pneumonic, which stands for naming, understanding, respecting, supporting, and exploring. Statements were coded as unburied or buried, with buried defined as statements followed by a pause to allow families time to respond and buried defined as empathetic statements encased in medical talk or terminated with a closed-ended statement.
After assessing 68 care conferences, researchers found that physicians recognized families’ emotional cues 74% of the time. About 61.5% of empathetic statements were unburied, whereas the remaining 38.5% were buried. Investigators noted that buried statements were most commonly followed by medical talk. Buried statements also did not result in any family expressions of mourning, such as crying or asking for time to collect themselves, whereas unburied empathetic statements resulted in some expressions of mourning.
“When physicians buried empathetic statements or filled this time with more medical talk, it frequently halted progression of the conversation or stopped it altogether,” says Dr. October. “Conversely, when physicians responded to emotions and then paused to allow space for families to respond, there was an 18-fold increased likelihood that families would share information about their hopes, fears, and motivations.”
The study also revealed that opportunities were missed to address emotion 26% of the time, and at least one missed opportunity occurred in 78% of conferences. Physicians attended to all family emotions in only 7% of all audio-recorded care conferences in the study. Several categories of missed opportunities were identified (Table). “Recognizing when families are expressing emotion is the first step to building empathetic relationships,” Dr. October says. “There’s certainly room for improvement.”
According to Dr. October, physicians need to slow down, allow space for silence, and give families chances to respond. “These simple gestures can reward us with new information that can be extremely helpful in shared decision-making,” she says. Efforts should be made strive to limit medical talk, use open-ended questions to explore emotions, and reduce outside interruptions. “Doctors need to be in the moment, stay aware, and be alert to recognize when families are making emotional statements,” says Dr. October. “When responding to these emotions, we need to leave space for families to respond and then learn from what is said to avoid missing opportunities to deepen these discussions.”
October TW, Dizon ZB, Arnold RM, Rosenberg AR. Characteristics of physician empathetic statements during pediatric intensive care conferences with family members: a qualitative study. JAMA Network Open.2018;1:e180351. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2687051.
October TW, Watson AC, Hinds PS. Characteristics of family conferences at the bedside versus the conference room in pediatric critical care. Pediatr Crit Care Med. 2013;14:e135-e142.
Ogle J, Bushnell JA, Caputi P. Empathy is related to clinical competence in medical care. Med Educ. 2013;47:824-831.
Bylund CL, Makoul G. Empathic communication and gender in the physician-patient encounter. Patient Educ Couns. 2002;48:207-216.