Incorporate Family Members in the Care of ICU Patients

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:

• Including family members in decision making
• Relieving family members' anxiety and stress
• Providing cultural support to families
• Patient visitation and access to family pets in the ICU
• The presence of family members at resuscitation
• The impact of the ICU environment on families
• The role of family members in providing palliative care.

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:

• Transfer from the ICU to the floor
• Dealing with several physicians
• Failure to be notified promptly of changes in the patient's status
• Disruption of normal interactions with the patient.

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:

• Develop personal self-awareness
• Get to know the patient's and family's cultural beliefs
• Understand the dynamics of cultural differences
• Communicate effectively with patients and families.

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.