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New Guidelines Provide First Evidence-Based Standards
Crit Care Med
Family members play a crucial role in the care of critically ill patients and should be a part of the multidisciplinary intensive care unit (ICU) team, recommend new practice guidelines (. 2007;35:605-622).
These guidelines are the first to define evidence-based standards for the incorporation of families into the decision making and care for ICU patients and were developed, in part, in response to an increasing recognition of the psychosocial needs of critically ill patients and a growing emphasis on patient-centered care.
"Including and embracing the family as an integral part of the multiprofessional ICU team is essential for timely restoration of health or optimization of the dying process for critically ill patients," said Charles Durbin, Jr, MD, president of the Society of Critical Care Medicine (SCCM).
The guidelines reflect a departure from physician- and disease-centered healthcare delivery and toward the patient-centered structure the Institute of Medicine recommended in 2001. Developed by a multidisciplinary task force convened from the SCCM and American College of Critical Care Medicine, the guidelines are based on an extensive review of recent literature on family-centered care.
Key recommendations (Table) include specific evidence-based recommendations for:
Shared medical decision making has replaced the paternalistic and patient-autonomy models. It involves the creation of a partnership between the ICU team and the patients and their loved ones.
Stress is common in family members and may affect their ability to make end-of-life decisions. Common sources of family member stress are:
Disparities in access to healthcare among members of racial and ethnic minority groups have been attributed to patients' spiritual and cultural beliefs and a lack of trust in the healthcare system. The guidelines highlight physicians' need to:
All members of the interdisciplinary team need to recognize the impact of spirituality on ICU patients and their families to overcome barriers to meaningful discussions about resuscitation status, hospice care, and other sensitive topics.
Palliative care in the ICU is an important component of family support and can prevent the perception of inadequate pain relief and other problems. Palliative care must coexist with aggressive clinical care and should begin when the illness is first diagnosed.
Table. Incorporate families in the support of ICU patients
Category
Recommendation
Decision making
Fully disclose the patient's current status and prognosis to designated surrogates; clearly explain all reasonable management options
Family coping
Encourage families to provide as much care as the patient's condition allows
Staff stress related
  to family interactions
Inform multiprofessional team of treatment goals to ensure consistency of messages to the family
Spiritual and
  religious support
Assess the spiritual needs of the patient; incorporate those that affect health/healing into the plan of care
Family visitation
Allow open visitation in the adult ICU, to be determined on a case-by-case basis
Family presence
  on rounds
When possible, allow adult family members/surrogates to participate in rounds
Family presence
  at resuscitation
Have a structured process in place that allows family members to be present during cardiopulmonary resuscitation, staff debriefing
Palliative care
Assess the family's understanding of and ability to cope with the illness and its consequences
Crit Care Med
Adapted from 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. . 2007;35:605-622.