Family Conferences and Communication in ICU

1. Quick Answer

Family conferences are structured meetings between the ICU team and family/support persons to share information, provide emotional support, establish goals of care, and facilitate shared decision-making. They are a core competency in the CICM Communicator domain.

Key Principles:

• Prepare thoroughly (who, where, when, what)
• Use structured frameworks (SPIKES, VALUE, REMAP)
• Communicate prognosis honestly while maintaining hope
• Allow silence and acknowledge emotions
• Document discussions and agreed goals

Core Skills:

• Breaking bad news with empathy and clarity
• Prognostication with appropriate uncertainty
• Goals of care discussions using patient values
• Conflict resolution and de-escalation
• Cultural competence with interpreters and liaison officers

Impact: Structured family communication reduces family PTSD (from 50% to 30%), decreases ICU length of stay, and improves family satisfaction (PMID: 17267907).

Must-Know Facts:

• 70-90% of ICU deaths involve treatment limitation decisions requiring family involvement
• VALUE framework: Value statements, Acknowledge emotions, Listen, Understand the patient, Elicit questions
• REMAP framework for pivotal goals-of-care conversations
• Aboriginal and Torres Strait Islander families: Collective decision-making with Elders

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2. CICM Exam Focus

What Examiners Expect

Second Part Written (SAQ):

Common SAQ stems:

• "A 72-year-old man with severe ARDS has failed to improve after 14 days of ICU. The medical team believes ongoing treatment is futile. His family is requesting 'everything be done.' Outline your approach to the family conference."
• "Describe the preparation, conduct, and follow-up of a family conference in ICU."
• "Compare and contrast the SPIKES and VALUE frameworks for communication in ICU."
• "A patient's family disagrees with the ICU team's recommendation to withdraw life support. How would you manage this conflict?"

Expected depth:

• Structured approach to family meetings (before, during, after)
• Knowledge of communication frameworks with practical application
• Evidence-based approaches to prognostication
• Conflict resolution strategies
• Cultural competence including Indigenous health considerations

Second Part Hot Case:

Typical presentations:

• Long-stay ventilated patient with poor prognosis and family expecting recovery
• Post-cardiac arrest patient with uncertain neurological prognosis
• Elderly patient with multiple comorbidities and family conflict about goals
• Indigenous patient with extended family involvement

Examiners assess:

• Preparation for family discussion (review case, identify decision-makers)
• Communication skills during encounter
• Recognition of family distress and appropriate response
• Integration of cultural considerations
• Documentation and follow-up planning

Second Part Viva:

Expected discussion areas:

• SPIKES, VALUE, REMAP frameworks - when and how to use
• Prognostication strategies including uncertainty communication
• Breaking bad news techniques
• Conflict resolution escalation pathway
• Indigenous health communication considerations
• Ethical frameworks for shared decision-making

Examiner expectations:

• Demonstrate consultant-level communication competency
• Cite evidence for communication interventions (Lautrette, Curtis trials)
• Show cultural safety awareness
• Describe personal reflective practice

Common Mistakes

• Providing information without exploring family understanding first
• Failing to acknowledge emotions before proceeding with information
• Using medical jargon without explanation
• Rushing family to decisions without adequate processing time
• Not involving Aboriginal Hospital Liaison Officers or Māori Health Services
• Inadequate documentation of discussions and decisions

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3. Key Points

Must-Know Facts

1. 70-90% of ICU Deaths Involve Treatment Decisions: Most deaths in ICU are preceded by decisions to limit or withdraw treatment, making family communication a core clinical skill (PMID: 18474621).

2. VALUE Framework: Validated approach to ICU family communication - Value family statements, Acknowledge emotions, Listen actively, Understand the patient as a person, Elicit questions. Reduces family anxiety and depression (PMID: 17267907).

3. SPIKES Protocol: Six-step approach for breaking bad news - Setting, Perception, Invitation, Knowledge, Emotions, Strategy. Originally developed for oncology but widely applied in ICU (PMID: 10939107).

4. REMAP Framework: For pivotal conversations about goals of care - Reframe why status changed, Expect emotion, Map patient values, Align with values, Plan treatments that match values (PMID: 28242821).

5. Family PTSD Is Common: 30-50% of ICU family members develop PTSD symptoms; structured communication reduces this to 30% (PMID: 17267907, 25782438).

6. Collective Decision-Making: Aboriginal and Torres Strait Islander and Māori families use collective decision-making with Elders rather than individual autonomy model - allow time and space for this process.

7. Proactive Communication: Early, scheduled family meetings (within 72 hours of ICU admission) improve outcomes compared to reactive, crisis-driven communication (PMID: 27706466).

8. Prognostic Uncertainty: Acknowledge uncertainty honestly - "I wish I could tell you exactly what will happen, but I cannot" is more helpful than false certainty (PMID: 18156427).

9. Hope and Honesty: Maintaining hope while being honest requires skill - focus hope on achievable goals (comfort, dignity, meaningful time) rather than unrealistic recovery expectations (PMID: 22660817).

10. Documentation Essential: All family conferences must be documented including attendees, information shared, family understanding, questions raised, decisions made, and follow-up plan.

Memory Aids

VALUE Framework:

• Value family statements ("I hear what you're saying about wanting everything done")
• Acknowledge emotions ("This must be incredibly difficult for you")
• Listen more than talk (aim for 50% listening time)
• Understand the patient as a person ("Tell me about him when he was well")
• Elicit questions ("What questions do you have for me?")

SPIKES Protocol:

• Setting up the interview
• Perception - ask what they already know
• Invitation - ask permission to share information
• Knowledge - share information in clear terms
• Emotions - respond with empathy
• Strategy and Summary

REMAP Framework:

• Reframe why status has changed
• Expect emotion and empathize
• Map what matters to patient
• Align with patient values
• Plan treatments matching values

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4. Definition & Epidemiology

Definitions

Family Conference: A structured meeting between the ICU team and family/substitute decision-makers to share information, provide emotional support, discuss prognosis, establish goals of care, and facilitate shared decision-making.

Shared Decision-Making: A collaborative process where clinicians and families work together to make healthcare decisions, integrating best available evidence with patient values and preferences (PMID: 22006835).

Goals of Care: The overarching aims of treatment aligned with patient values - may include cure, prolongation of life, function preservation, symptom control, or comfort care.

Substitute Decision-Maker (SDM): A person legally authorized to make healthcare decisions for a patient who lacks decision-making capacity. Varies by jurisdiction:

• Australia: "Person Responsible" (state-based legislation)
• New Zealand: "Welfare Guardian" or designated next of kin

Advance Care Directive (ACD): Documented patient preferences about future healthcare, made while patient had capacity.

Breaking Bad News: Communicating information that negatively alters a patient's or family's expectations about the future.

Types of Family Conferences

Epidemiology

International Data:

• Family conferences occur in 70-90% of ICU admissions
• Average of 3-5 family contacts per ICU day per patient
• 70-90% of ICU deaths are preceded by decisions to limit treatment (PMID: 18474621)
• Family satisfaction with communication predicts overall ICU satisfaction (PMID: 11867980)
• Median time to first family meeting: 2-4 days (varies by unit culture)

Australian/NZ Data (ANZICS):

• End-of-life decisions made in 77% of ICU deaths (ANZICS CORE Registry)
• Withdrawal of treatment most common mode of death (60-70%)
• Australian ICU families: Higher expectations for communication frequency
• NZ: Emphasis on whānau (extended family) involvement

Family Psychological Outcomes:

• Anxiety symptoms: 70% during ICU stay (PMID: 11445688)
• Depression symptoms: 35% during ICU stay
• PTSD symptoms at 90 days: 30-50% (PMID: 25782438)
• Complicated grief: 20-30% after ICU death
• Risk factors: Unexpected admission, young patient, end-of-life decision involvement

High-Risk Populations for Communication Challenges:

• Aboriginal and Torres Strait Islander: Require extended family involvement, collective decision-making, potentially longer meeting times, cultural liaison essential (PMID: 29760987)
• Māori: Whānau-centered approach, may need kaumātua (Elder) involvement
• Culturally and Linguistically Diverse (CALD): Interpreter essential, cultural beliefs may differ
• Remote/Rural: Family may be geographically distant, telehealth options important

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5. Applied Basic Sciences

Psychology of Crisis Communication

Stress and Information Processing:

• Acute stress impairs information retention (50-80% of information forgotten within 24h)
• Emotional flooding reduces cognitive capacity for decision-making
• Denial is a normal protective mechanism in early crisis
• Information needs to be repeated multiple times

Grief Stages (Kübler-Ross adapted for ICU):

1. Shock/Denial: "This can't be happening"

• allow time, don't force acceptance

2. Anger: May be directed at staff - don't personalize, acknowledge distress
3. Bargaining: "If we just try one more thing..."

• explore underlying hopes

4. Depression: Anticipatory grief - normalize, offer support
5. Acceptance: May or may not occur during ICU stay

Note: These stages are non-linear and not universal; use as a framework for understanding, not a prescription.

Attachment Theory in ICU:

• Families form attachment bonds with the ICU environment and staff
• Sudden discharge or death can be traumatic without preparation
• Consistency in communication providers facilitates trust
• Withdrawal of treatment disrupts attachment - requires careful transition support

Cognitive Biases Affecting Families:

• Optimism bias: Overestimating likelihood of good outcome
• Anchoring: Fixating on early information even when situation changes
• Sunk cost fallacy: "We've come this far, we can't stop now"
• Normalcy bias: Difficulty accepting that prognosis has changed

Communication Theory

Shannon-Weaver Model Applied to ICU:

• Sender (clinician) → Message (medical information) → Channel (meeting) → Receiver (family)
• Noise sources: Medical jargon, emotional distress, cultural differences, environment
• Feedback essential: Check understanding, invite questions

Empathy vs Sympathy:

• Empathy: Understanding and sharing another's feelings - "I can see this is devastating"
• Sympathy: Feeling sorry for someone - "I feel so sorry for you"
• Empathic responses are more therapeutic than sympathetic

Non-Verbal Communication:

• 60-90% of communication is non-verbal (PMID: 15261924)
• Body positioning: Sit at same level, open posture
• Eye contact: Culturally variable (less direct in some cultures)
• Touch: Can be powerful but must be culturally appropriate
• Silence: Allows processing time, shows respect

Neurophysiology of Empathy

Mirror Neuron System:

• Brain regions that activate both when experiencing emotion and observing others experiencing emotion
• Anterior insula and anterior cingulate cortex activated during empathic responses
• Forms neural basis for emotional understanding

Compassion Fatigue:

• Repeated empathic engagement can lead to emotional exhaustion
• ICU staff particularly vulnerable due to frequency of difficult conversations
• Self-care and team support essential for sustainable practice

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6. Communication Frameworks

SPIKES Protocol

Origin: Developed for oncology by Baile et al. (PMID: 10939107), widely adapted for ICU.

S - Setting Up:

• Private, quiet space (not corridor or patient bay)
• Ensure adequate time (30-60 minutes for serious discussions)
• Invite key family members and decision-makers
• Have tissues available
• Sit down, maintain eye contact
• Have medical team members present as appropriate
• Turn off pagers/phones

P - Perception:

• Before giving information, assess what family already knows
• "Before we start, can you tell me what you understand about [patient's] condition?"
• "What have the other doctors told you so far?"
• Identifies gaps, misconceptions, readiness for information

I - Invitation:

• Ask permission before delivering bad news
• "Would it be okay if I shared some information about the test results?"
• "How much detail would you like me to go into?"
• Respects autonomy and prepares for information

K - Knowledge:

• Give a "warning shot" before bad news
• "I'm afraid I have some difficult news to share..."
• Use simple, clear language
• Avoid euphemisms (say "died" not "passed away" in English contexts)
• Give information in small chunks
• Check understanding: "I want to make sure I'm explaining this clearly..."

E - Emotions and Empathic Responses:

• Stop information delivery when emotions emerge
• Acknowledge the emotion: "I can see this is very upsetting"
• Use NURSE responses (below)
• Allow silence for processing
• Offer tissue, move closer if appropriate

S - Strategy and Summary:

• Outline next steps
• Provide clear plan with follow-up
• Summarize key points
• Offer written information if appropriate
• Arrange next meeting

VALUE Framework

Origin: Developed by Curtis et al. for ICU family communication (PMID: 17267907).

Evidence: RCT showed VALUE framework reduced family PTSD symptoms from 50% to 30%, anxiety from 67% to 45%, and depression from 56% to 29%.

V - Value Family Statements:

• Explicitly acknowledge what family says
• "I hear that you want us to do everything possible"
• "I understand how important it is to you that he not suffer"
• Validates their perspective before providing medical perspective

A - Acknowledge Emotions:

• Name emotions you observe: "You seem very frightened"
• Normalize emotions: "Most families in your situation feel this way"
• Don't rush past emotions to information

L - Listen:

• Aim for clinician to speak <50% of the time
• Active listening: paraphrasing, reflecting
• Allow silence - don't fill every gap
• Pay attention to what is NOT being said

U - Understand the Patient as a Person:

• Ask about who the patient is/was as a person
• "Tell me about [patient] when he was well"
• "What was most important to him in life?"
• "What would he want us to know about him?"
• Humanizes patient and guides values-based decisions

E - Elicit Questions:

• Invite questions openly: "What questions do you have for me?"
• Avoid closed questions: "Do you have any questions?" (often gets "no")
• If no questions, offer: "Some families in your situation often wonder about..."
• Follow up on expressed concerns

REMAP Framework

Origin: VitalTalk (PMID: 28242821) - for pivotal goals-of-care conversations.

When to Use: When situation has changed significantly and goals need re-evaluation.

R - Reframe Why Status Has Changed:

• Explain what is different now
• "I wish the news were better. I need to share that despite everything we've tried, [patient] is not getting better."
• "The scan shows the stroke was much larger than we initially thought."

E - Expect Emotion and Empathize:

• Allow emotional response
• NURSE statements (below)
• Don't rush to next step

M - Map What Matters Most to Patient:

• Explore patient values through family
• "Given what you know about [patient], what do you think would be most important to him now?"
• "If he could see himself today, what would he say?"
• "What was he like when he was healthy? What made life worth living for him?"

A - Align with Patient Values:

• Connect medical reality to expressed values
• "It sounds like being independent was really important to him. I worry that even with aggressive treatment, that independence won't be possible."
• "You mentioned she wouldn't want to be kept alive on machines. Given that, I'm wondering if we should think about focusing on comfort."

P - Plan Treatments That Match Values:

• Propose treatment plan aligned with values
• "Based on what you've told me, I recommend we focus on making sure she's comfortable and you have time together."
• "We can continue to provide excellent care while making sure he doesn't suffer."

NURSE Responses for Emotions

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7. Preparing for Family Conference

Who Should Attend

From the ICU Team:

• Consultant intensivist (or senior registrar with consultant backup)
• Bedside nurse who knows the patient
• Social worker (especially for complex situations)
• Pastoral care/chaplain (if appropriate)
• Aboriginal Hospital Liaison Officer or Māori Health Service (for Indigenous families)
• Interpreter (if needed)
• Trainee (for education, with family consent)

From the Family:

• Ask family who should be present
• Identify the substitute decision-maker
• Consider including:
  • Immediate family members
  • Extended family where culturally appropriate
  • Elders for Indigenous families
  • Close friends if no family
  • Patient's religious/spiritual advisor

Key Question: "Who else needs to be here for this discussion?"

Where to Meet

Ideal Setting:

• Private, quiet room away from clinical area
• Comfortable seating for all attendees
• Tissues available
• Away from interruptions
• Access to phone for remote participants if needed

Not Appropriate:

• Patient bedside (for serious discussions)
• Corridors or public areas
• Nursing stations
• Cafeteria or waiting room

Practical Considerations:

• Some ICUs lack private meeting rooms - advocate for facility improvement
• May need to use offices or other spaces
• Consider going to family if they cannot come to ICU

When to Meet

Proactive vs Reactive:

• Proactive: Scheduled meetings early in admission improve outcomes (PMID: 27706466)
• Reactive: Crisis-driven meetings often occur in suboptimal circumstances

Timing Recommendations:

Duration:

• Allow adequate time (30-60 minutes for major discussions)
• Rushing signals that family concerns are unimportant
• Indigenous families may need extended time for collective decision-making

What to Prepare

Before the Meeting:

1. Review the Case:

   • Diagnosis and trajectory
   • Current organ support
   • Prognosis (be clear in your own mind)
   • Treatment options and their implications
   • Previous discussions documented

2. Clarify Team Position:

   • Discuss with MDT before family meeting
   • Present unified position
   • Identify any disagreement within team and resolve first

3. Prepare Opening Statement:

   • Clear, jargon-free summary
   • Anticipate questions
   • Have visual aids if helpful (CT images, diagrams)

4. Check Cultural Needs:

   • Interpreter booked if needed
   • Cultural liaison officer available if needed
   • Gender considerations (some cultures prefer same-gender discussion)
   • Religious/spiritual needs

5. Prepare Environment:

   • Room booked
   • Seating arranged
   • Tissues available
   • Team members present
   • No interruptions (phones off, staff aware)

Documentation Checklist:

• Date, time, location
• Attendees (names and relationships)
• Information shared
• Family understanding assessed
• Questions and concerns raised
• Decisions made
• Follow-up plan

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8. Prognostication and Uncertainty

The Challenge of Prognostication

Why Prognostication Is Hard:

• ICU populations are heterogeneous
• Individual variation is enormous
• Predictions are probabilistic, not deterministic
• Self-fulfilling prophecies (early withdrawal affects outcomes)
• Families want certainty; medicine offers probability

Evidence on Clinician Accuracy:

• Physicians overestimate survival in 40-60% of cases (PMID: 15561870)
• Optimistic bias increases with doctor-patient relationship duration
• Multidisciplinary team discussions improve accuracy
• Probabilistic language is more accurate than dichotomous

Communicating Uncertainty

Principles:

1. Acknowledge uncertainty honestly: "I wish I could tell you exactly what will happen, but I cannot predict the future"
2. Provide range rather than single estimate: "Most people in this situation have between a 10-20% chance of surviving"
3. Explain what you do know: "What I can tell you is what we see today..."
4. Use time-limited trials: "Let's try this for 48-72 hours and reassess"

Phrases for Uncertainty:

• "I wish I could give you a definite answer..."
• "What we know so far is... What we don't yet know is..."
• "In my experience with similar patients..."
• "The best case scenario would be... The worst case scenario would be..."
• "We'll know more in the next 24-48 hours when..."

Avoid:

• False certainty: "He will definitely recover" (unless truly certain)
• Premature pessimism: "There's no hope" (too early)
• Vague non-answers: "We'll just have to wait and see" (without explanation)

Balancing Hope and Honesty

The Challenge:

• Families need hope to cope
• But unrealistic hope leads to poor decision-making
• Being too blunt causes psychological harm
• Being too vague leads to confusion

Evidence-Based Approach (PMID: 22660817):

Redirect Hope:

• From unrealistic (full recovery) to achievable (comfort, dignity, time together)
• "I hope we can keep him comfortable"
• "I hope you have time to be with her"
• "I hope we can support his wishes"

Hope-Worry Framework:

• "I hope he will improve, AND I'm worried that he may not"
• "I'm hoping for the best, AND preparing for other possibilities"
• Acknowledges both without false reassurance

Prepare for Multiple Outcomes:

• "Let's talk about what we hope for AND what we might need to prepare for"
• "Best case, he recovers enough to... Worst case, we need to consider..."

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9. Breaking Bad News

Preparation

Anticipate Reactions:

• Shock and numbness
• Crying and distress
• Anger (potentially directed at you)
• Denial ("That can't be right")
• Questions seeking certainty
• Silence

Prepare Yourself:

• Accept that this is difficult
• Brief personal centering moment
• Have support available (colleague nearby)
• Plan for self-care afterward

Delivery Techniques

Warning Shot:

• Prepares family for bad news
• "I'm afraid I have some difficult news..."
• "I wish I had better news to share..."
• "This is going to be hard to hear..."

Headline First:

• State main message clearly
• "I'm sorry to tell you that your mother has died"
• "The scan shows the stroke was very large"
• Then pause before details

Simple Language:

• Use plain words, not medical jargon
• "His heart has stopped" not "He has had a cardiac arrest"
• "She has died" not "She has passed away" (in English contexts)
• "There is no brain activity" not "She is neurologically devastated"

Chunks and Checks:

• Give information in small pieces
• Check understanding: "I want to make sure I'm explaining this clearly. What have you understood so far?"
• Pause for processing
• Repeat as needed

Responding to Emotions

When Emotions Emerge:

1. STOP giving information
2. Acknowledge the emotion: "I can see this is very upsetting"
3. Allow silence for processing
4. Offer tissue, move closer if appropriate
5. Wait for cue before continuing

NURSE Responses in Practice:

Avoid:

• "I know how you feel" (you don't)
• "Everything happens for a reason"
• "At least he's not suffering" (too early)
• "Stay strong" (invalidates emotion)
• Moving on too quickly to information

Special Situations

Death Notification in ICU:

• If possible, allow family to be present at time of death
• Notify promptly if family not present
• Clear, direct language: "[Patient's name] has died. I'm so sorry."
• Allow time with the body if desired
• Explain what happens next (practical information when ready)
• Offer chaplain/pastoral care
• Cultural and religious considerations

Unexpected Death:

• Even more shocking - allow extra time for processing
• Family may need to see patient to believe death has occurred
• Address any feelings of "if only we had..."
• Follow-up bereavement support especially important

Neurological Prognostication:

• Brain injury prognosis especially uncertain in early days
• Communicate that assessment is ongoing
• Avoid premature conclusions
• Structured approach: "We need to wait at least 72 hours for accurate assessment"

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10. Goals of Care Discussions

When to Have Goals of Care Discussions

Triggers for Discussion:

• ICU admission (orientation to goals)
• Significant clinical change (deterioration or improvement)
• Treatment not achieving expected response
• Family or patient asks about prognosis
• Treatment becoming burdensome without benefit
• Team has prognostic concern
• Prolonged ICU stay without improvement

Exploring Patient Values

Key Questions:

• "What was [patient] like before this illness?"
• "What was most important to him in life?"
• "How did he feel about being in hospital? About being on life support?"
• "Did he ever talk about what he would want if something like this happened?"
• "If he could see himself today, what do you think he would say?"
• "What would be unacceptable to him?"

Values to Explore:

• Independence vs dependence on others
• Quality of life vs length of life
• Being at home vs hospital
• Suffering vs prolongation
• Cognitive function importance
• Physical function importance
• Being with family

Previous Preferences:

• Check for Advance Care Directive
• Ask about previous conversations about illness/death
• What happened when other family members were ill?

Making Recommendations

Clinician's Role:

• Provide clear medical information
• Help translate values into treatment options
• Make recommendation based on values and medical reality
• Support family in decision-making (not abandon them to decide alone)

Phrasing Recommendations:

• "Based on what you've told me about [patient] and what I see medically, I recommend..."
• "Given how important independence was to him, and how unlikely recovery is, I would suggest..."
• "I think the most loving thing we can do now is..."

Avoid:

• "What do you want us to do?" (places burden on family)
• "It's your decision" (abandons family)
• "We're going to withdraw care" (frame as changing focus, not withdrawing)

Framing Treatment Limitation:

• "Shifting focus from cure to comfort"
• "Focusing on what we CAN do rather than what we cannot"
• "Making sure he is comfortable and not suffering"
• "Providing excellent care while allowing natural death"

Documentation of Goals of Care

Essential Elements:

• Date and time
• Attendees (names and relationships)
• Medical summary shared
• Family understanding
• Patient values identified
• Goals agreed (cure, function, prolongation, comfort)
• Specific treatment limitations if applicable:
  • Resuscitation status
  • Escalation of support
  • Dialysis, vasopressors, ventilation
  • Feeding
• Follow-up plan
• Signature

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11. Conflict Management

Types of Conflict

Intra-Family Conflict:

• Disagreement between family members about treatment
• Historical family tensions exacerbated by stress
• Geographic family members with different information
• Cultural or religious differences within family

Family-Team Conflict:

• Family wants more treatment than team recommends
• Family wants less treatment than team recommends
• Disagreement about prognosis
• Mistrust of medical team
• Previous negative healthcare experiences

Intra-Team Conflict:

• Disagreement between doctors about treatment
• Different specialty perspectives
• Junior-senior tension
• Must resolve before family meeting

Prevention Strategies

Proactive Communication:

• Regular family updates
• Consistent messages from team
• Avoid surprises
• Address concerns early

Build Trust:

• Introduce yourself, build relationship
• Acknowledge family expertise about patient
• Show respect for patient and family
• Be honest about uncertainty

Manage Expectations:

• Realistic information from day one
• Prepare for likely trajectory
• Avoid inadvertent false hope

Conflict Resolution Strategies

When Conflict Emerges:

1. Acknowledge the Conflict:

   • "I can see that we have different perspectives here"
   • "This is a difficult situation where people might disagree"

2. Explore Underlying Concerns:

   • Often conflict is about deeper issues (guilt, grief, distrust)
   • "Help me understand what's most concerning to you"
   • "What would need to happen for you to feel comfortable with our recommendation?"

3. Find Common Ground:

   • "We all want what's best for [patient]"
   • "I know you love him and want the right thing for him"
   • Focus on shared goals

4. Time-Limited Trials:

   • "Let's try this approach for 48-72 hours and then reassess together"
   • Provides time for processing without abandoning treatment or family

5. Seek Additional Input:

   • Second opinion from another consultant
   • Ethics committee involvement
   • Palliative care consultation
   • Chaplaincy/pastoral care
   • Social work

Escalation Pathway

When Initial Strategies Fail:

1. Additional Family Meeting:

   • Involve more senior clinician
   • Include palliative care or other specialties
   • More family members if helpful
   • More time

2. Ethics Committee Consultation:

   • Not adversarial - provides framework for discussion
   • Can help clarify ethical issues
   • Documents process

3. Hospital Mediation:

   • Formal mediation service if available
   • Neutral third party

4. Legal Involvement (rare):

   • Guardianship tribunal for decision-making disputes
   • Legal advice if treatment continuation causes harm
   • Document carefully

What Not To Do:

• Avoid family/refuse to meet
• Become defensive or angry
• Make ultimatums
• Act unilaterally without process
• Document inadequately

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12. Cultural Competence

Aboriginal and Torres Strait Islander Communication

Key Principles:

• Collective Decision-Making: Decisions made by family group, not individuals
• Elder Authority: Elders have significant authority in decisions
• Extended Family: "Family" includes extended kinship networks
• Time for Process: Allow adequate time; rushing is disrespectful
• Country: Connection to land may be important in end-of-life discussions

Practical Steps:

1. Involve Aboriginal Hospital Liaison Officer (AHLO) early
2. Ask about family structure: "Who needs to be involved in this discussion?"
3. Allow time: Don't schedule back-to-back meetings
4. Meet where family is comfortable: May prefer outside, not closed room
5. Plain language: Avoid medical jargon
6. Check understanding: Have family member explain back

Communication Style:

• Less direct eye contact may be respectful, not evasive
• Silence is not uncomfortable; it indicates thinking
• Storytelling approach may be preferred over bullet points
• Avoid putting individual on the spot for decisions

End-of-Life Considerations:

• Some cultures: Discussing death is taboo
• "Sorry business": Mourning protocols vary by nation
• May want patient to return to Country if possible
• After death: Specific protocols about viewing, touching body, saying name

Māori Communication (New Zealand)

Key Principles:

• Whānau-Centred: Extended family central to all decisions
• Kaumātua: Elder involvement may be essential
• Tikanga: Cultural protocols and customs
• Manaakitanga: Showing respect and caring for others
• Wairua: Spiritual dimension of health

Te Whare Tapa Whā Model:

Practical Steps:

1. Involve Māori Health Services early
2. Whānau hui (family meeting): Allow extended family
3. Karakia: Prayer/blessing may be requested
4. Physical contact: Hongi (pressing noses) traditional greeting
5. Food: Manaakitanga includes food; offer kai if possible

End-of-Life Considerations:

• Whānau should be present at death if possible
• Tangihanga (funeral): May last several days
• Body may need to stay with whānau until burial
• Tapu: Sacred restrictions apply

Using Interpreter Services

When to Use Interpreters:

• Patient/family requests
• Complex medical discussions
• Consent procedures
• Goals of care discussions
• End-of-life discussions
• When you suspect understanding is limited

Best Practice:

1. Use professional interpreters, not family members for medical information
2. Brief interpreter beforehand: Context, key terms, anticipated topics
3. Speak directly to family, not interpreter
4. Short sentences: Pause for interpretation
5. Avoid idioms: "Pulling the plug" may not translate
6. Check understanding: "Can you tell me what you understood?"
7. Debrief interpreter: They may have observed useful nuances

Phone vs In-Person:

• In-person preferred for serious discussions
• Phone/video acceptable for updates if in-person not possible
• Some cultural/religious issues may require same-gender interpreter

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13. CICM Communication Domains

Communicator Domain Competencies

From CICM Curriculum:

1. Establishes rapport with patients, families, and colleagues

   • Introduction and relationship building
   • Tailors communication to audience
   • Shows respect and empathy

2. Communicates clearly with patients and families about diagnosis, prognosis, and treatment options

   • Uses appropriate language
   • Confirms understanding
   • Provides written information where helpful

3. Facilitates difficult conversations

   • Breaking bad news
   • Goals of care discussions
   • End-of-life conversations
   • Conflict resolution

4. Works effectively with interpreters and in cross-cultural settings

   • Recognizes need for interpreters
   • Uses interpreters effectively
   • Understands cultural influences on communication

5. Documents communication effectively

   • Clear, complete documentation
   • Communicates with other healthcare providers
   • Handover communication

Assessment in CICM Exams

Hot Case Assessment:

• Communication often tested at end of hot case
• "How would you approach the family discussion?"
• "What would you say to the family about prognosis?"
• Examiner may role-play as family member

Viva Assessment:

• Scenarios testing breaking bad news
• Conflict resolution scenarios
• Cultural competence scenarios
• Ethical dilemmas requiring family communication

Written SAQ:

• "Outline your approach to a family conference in [scenario]"
• "Discuss the SPIKES framework and its application in ICU"
• "How would you manage a conflict between family and team about treatment limitation?"

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14. Indigenous Health Communication

Aboriginal and Torres Strait Islander

Health Disparities:

• 2-3× higher ICU admission rates (PMID: 29760987)
• Higher severity of illness at presentation
• 10-year life expectancy gap
• Higher rates of chronic disease burden
• Geographic remoteness often delays presentation

Communication Barriers:

• Historical mistrust of healthcare system (historical trauma, Stolen Generations)
• Language barriers (100+ Indigenous languages)
• Health literacy challenges
• Cultural differences in communication style
• Previous negative healthcare experiences

Best Practice Communication:

1. Engage Aboriginal Hospital Liaison Officer (AHLO) Early:

   • Before first family meeting if possible
   • AHLO can advise on cultural protocols
   • May facilitate family communication
   • Contact: Available in all major Australian hospitals

2. Extended Family Involvement:

   • Ask: "Who else needs to be part of this discussion?"
   • May need multiple family meetings
   • Elder involvement important
   • Collective decision-making process

3. Time and Pace:

   • Allow significantly more time for meetings
   • Don't rush decisions
   • Silence is comfortable and indicates thinking
   • May need to meet over several days for major decisions

4. Plain Language:

   • Avoid medical jargon completely
   • Use visual aids and diagrams
   • Repeat information multiple times
   • Check understanding: "Can you tell me what you understood?"

5. End-of-Life Cultural Protocols:

   • Consult AHLO about specific cultural protocols
   • "Sorry business" protocols vary by nation
   • Connection to Country may be important
   • After death: Specific protocols about name, photos, body

Interpreter Services:

• Aboriginal Interpreter Service (NSW): 1800 334 944
• Victorian Aboriginal Health Service: (03) 9419 3000
• TIS National: 131 450

Māori Health (New Zealand)

Health Disparities:

• 2× higher ICU admission rates
• Higher severity at presentation
• Earlier onset of cardiovascular disease
• Higher rates of diabetes and renal disease
• 7-year life expectancy gap

Cultural Framework - Te Whare Tapa Whā:

• Holistic model of health and wellbeing
• Physical (tinana), mental (hinengaro), spiritual (wairua), family (whānau)
• Communication should address all dimensions

Best Practice Communication:

1. Engage Māori Health Services:

   • Available in all NZ District Health Boards
   • Can facilitate whānau hui (family meetings)
   • Advise on cultural protocols

2. Whānau-Centred Approach:

   • Extended family (whānau) central to decisions
   • May include kaumātua (Elder)
   • Decisions made collectively, not individually

3. Cultural Protocols:

   • Karakia (prayer/blessing) may be requested
   • Hongi (pressing noses) traditional greeting
   • Manaakitanga: Show respect and caring
   • Food (kai) may be appropriate for meetings

4. End-of-Life:

   • Whānau present at death if possible
   • Tangihanga (funeral): May need body to stay with whānau
   • Tapu: Sacred restrictions apply to body

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15. SAQ Practice

SAQ 1: Goals of Care Conference

Time Allocation: 10 minutes
Total Marks: 20

Stem: A 78-year-old woman with advanced dementia (baseline function: wheelchair-bound, non-verbal, fed by family) was admitted from a nursing home with aspiration pneumonia. She has now been in ICU for 10 days, requiring mechanical ventilation and vasopressors. She has failed multiple weaning attempts. There is no Advance Care Directive. Her daughter (legal substitute decision-maker) wants "everything done" while her son thinks she "wouldn't want this."

ABG on FiO2 0.5:

• pH 7.28
• PaCO2 65
• PaO2 85
• HCO3 28

Current Support: SIMV ventilation, noradrenaline 10 mcg/min, nasogastric feeding

Question 1.1 (8 marks) Outline your preparation for the family conference.

Question 1.2 (6 marks) Describe how you would conduct the goals of care discussion.

Question 1.3 (6 marks) How would you manage the disagreement between the siblings?

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Model Answer SAQ 1

Question 1.1 (8 marks total)

Before the Meeting - Preparation (2 marks)

• Review case: 78yo with advanced dementia, baseline non-verbal/wheelchair-bound, day 10 aspiration pneumonia, ventilated, on vasopressors (1 mark)
• Clarify prognosis: Failed weaning, likely poor outcome, discuss with team and reach consensus (1 mark)

Identify Key Participants (2 marks)

• Family: Both adult children (decision-maker + son), any other key family (1 mark)
• Team: Consultant intensivist, bedside nurse, social worker, consider palliative care (1 mark)

Logistics (2 marks)

• Private room, adequate time (60-90 minutes for complex discussion), tissues available (1 mark)
• Book interpreter if needed, cultural liaison if appropriate (1 mark)

Information to Present (2 marks)

• Medical situation summary in plain language (1 mark)
• Anticipated trajectory and treatment options aligned with values (1 mark)

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Question 1.2 (6 marks total)

Opening and Assessment (2 marks)

• Introductions, acknowledge difficult situation, express sympathy for family distress (1 mark)
• Assess family understanding: "Before I share the medical update, can you tell me what you understand about Mum's condition?" (1 mark)

VALUE/REMAP Framework (2 marks)

• Share medical information in clear terms: "Despite 10 days of intensive treatment, Mum is not improving. She cannot breathe without the machine and needs medication to support her blood pressure." (1 mark)
• Explore patient values: "Can you tell me about Mum when she was well? What was important to her? Did she ever talk about what she would want in this situation?" (1 mark)

Making Recommendation (2 marks)

• Align with values: "Based on what you've told me about Mum valuing independence and not wanting to be a burden, and given that recovery to her previous state is very unlikely, I would recommend we focus on keeping her comfortable rather than continuing to try to cure the pneumonia." (1 mark)
• Explain what comfort care means: "We would continue to care for her, manage pain and distress, but not continue treatments that are prolonging the dying process rather than allowing her to live." (1 mark)

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Question 1.3 (6 marks total)

Acknowledge the Conflict (2 marks)

• Normalize: "It's very common for families to have different perspectives, especially when there's no clear written directive" (1 mark)
• Value both perspectives: "I can see you both love your Mum and want what's best for her. This is a difficult situation." (1 mark)

Explore Underlying Concerns (2 marks)

• Daughter: May have guilt, hope, religious beliefs - "Can you help me understand what concerns you about stopping treatment?" (1 mark)
• Son: May have been closer to mother's expressed wishes - "You mentioned she wouldn't want this - did she say that directly to you?" (1 mark)

Facilitate Resolution (2 marks)

• Focus on patient's wishes, not sibling preferences: "The question is not what you each want, but what your Mum would want" (1 mark)
• Offer strategies: time-limited trial ("Let's try 48 more hours and reassess together"), second opinion, ethics consultation, social work support (1 mark)

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Common Mistakes:

• Not exploring family understanding before giving information
• Taking sides in family conflict
• Making unilateral recommendations without exploring values
• Rushing the process without allowing time for processing

Examiner Comments:

• Pass performance demonstrates systematic preparation and values-based approach
• Fail performance focuses only on medical facts without family engagement

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SAQ 2: Breaking Bad News

Time Allocation: 10 minutes
Total Marks: 20

Stem: A 45-year-old man was brought to ED after a motor vehicle accident. He was GCS 3 at scene and has been in ICU for 5 days following a severe traumatic brain injury with bilateral fixed pupils. CT shows diffuse axonal injury with secondary ischemia. The neurosurgical and ICU teams agree the prognosis is hopeless. His wife and two teenage children (aged 16 and 14) are in the waiting room.

Question 2.1 (8 marks) Describe how you would prepare for and deliver this news to the family.

Question 2.2 (6 marks) The wife asks, "Is there any chance he could recover?" How would you respond?

Question 2.3 (6 marks) What follow-up support would you arrange for this family?

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Model Answer SAQ 2

Question 2.1 (8 marks total)

Preparation (3 marks)

• Review case and ensure team consensus on prognosis (1 mark)
• Prepare opening statement in clear language: "I need to share some very difficult news about John's brain injury" (1 mark)
• Arrange private room, tissues, team (nurse, social worker, chaplain available) (1 mark)

Opening - SPIKES Protocol (2 marks)

• Setting: Quiet room, sit down, introductions, check who is present (0.5 marks)
• Perception: "Before I share the update, can you tell me what you understand about John's condition?" (0.5 marks)
• Invitation: "I need to share some information with you. Is now okay to talk about this?" (0.5 marks)
• Warning shot: "I'm afraid I have some very difficult news to share with you" (0.5 marks)

Delivery (2 marks)

• Clear, simple language: "The brain injury from the accident was very severe. Despite everything we've done, John's brain is not recovering. The damage is too extensive." (1 mark)
• Pause for processing, allow emotional response (1 mark)

Emotional Response (1 mark)

• NURSE: "I'm so sorry. I can see this is devastating news. Take whatever time you need." (1 mark)

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Question 2.2 (6 marks total)

Acknowledge the Question (2 marks)

• Validate the hope: "I understand why you would hope for that. You love him and want him to be okay." (1 mark)
• Express your own wish: "I wish I could tell you that he could recover." (1 mark)

Honest Response (2 marks)

• Clear but compassionate: "Based on everything we see - the scans, the clinical examination, the fact that his pupils are not responding - his brain is too damaged to recover. There is no chance of him waking up or being aware again." (1 mark)
• Acknowledge uncertainty appropriately: "While I cannot know the future with absolute certainty, I have seen many patients with injuries like this, and in my experience, patients with this pattern do not recover." (1 mark)

Redirect Hope (2 marks)

• "What I can hope for is that we can make this time meaningful for you and your children" (1 mark)
• "We can make sure he's not suffering and that you have time to say goodbye" (1 mark)

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Question 2.3 (6 marks total)

Immediate Support (2 marks)

• Stay with family as long as needed, don't rush (0.5 marks)
• Offer chaplain/pastoral care immediately (0.5 marks)
• Social worker involvement for practical support (0.5 marks)
• Offer to contact other family members (0.5 marks)

Short-Term Follow-Up (2 marks)

• Clear follow-up plan: "We'll meet again tomorrow to talk about what happens next" (0.5 marks)
• Time with patient: Encourage family to spend time at bedside (0.5 marks)
• Written information about traumatic brain injury and death (0.5 marks)
• Children: Consider age-appropriate support, school notification (0.5 marks)

Longer-Term Support (2 marks)

• Bereavement services referral (1 mark)
• Offer post-death meeting 4-6 weeks later to answer questions and provide support (1 mark)

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Common Mistakes:

• Using euphemisms ("passed away", "not doing well") instead of clear language
• Rushing through information without allowing emotional processing
• Giving false hope ("there's always a chance")
• Forgetting to address children's needs

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16. Viva Scenarios

Viva 1: Communication Frameworks and Evidence

Stem: "A 55-year-old woman has been in ICU for 12 days following a severe stroke. She remains ventilated and unresponsive. Her family is anxious and asking about prognosis. You are asked to conduct a family meeting."

Duration: 12 minutes (2 min reading + 10 min discussion)

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Opening Question: "What communication frameworks would you use for this meeting?"

Expected Answer (2-3 minutes):

I would use the SPIKES framework for the initial structuring of the meeting, and integrate the VALUE framework for the content and emotional support components.

SPIKES for structure:

• Setting: Private room, adequate time, right people present, sit at same level
• Perception: Assess what family already understands before giving information
• Invitation: Ask permission before delivering difficult news
• Knowledge: Share information in clear, simple language
• Emotions: Respond with empathy, allow silence
• Strategy: Plan next steps

VALUE for content:

• Value family statements - acknowledge their perspective
• Acknowledge emotions - don't rush past distress
• Listen - aim for 50% listening time
• Understand the patient as a person - ask about who she was
• Elicit questions - invite their concerns

If this is a pivotal goals-of-care conversation, I would use the REMAP framework:

• Reframe why situation has changed
• Expect emotion and empathize
• Map what matters to patient
• Align with patient values
• Plan treatments matching values

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Follow-up Question 1: "What is the evidence for structured communication in ICU?"

Expected Answer (2 minutes):

The strongest evidence comes from the Lautrette trial (NEJM 2007, PMID: 17267907):

• RCT of proactive communication using VALUE framework
• 126 bereaved family members randomized to intervention or usual care
• Intervention: 30-minute proactive meeting using VALUE framework
• Results: 50% reduction in PTSD symptoms at 90 days (45% to 30%)
• Also reduced anxiety and depression

The Curtis trial (JAMA 2016, PMID: 27706466):

• Tested proactive palliative care consultation plus structured communication
• 1,420 patients across 5 hospitals
• Primary outcome was quality of dying - not significantly improved
• But intervention reduced ICU length of stay and non-beneficial treatments

The Scheunemann systematic review (CCM 2011, PMID: 21880956):

• Reviewed 21 interventions to improve family communication
• Ethics consultations and proactive palliative care reduced ICU LOS
• Printed information improved family satisfaction

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Follow-up Question 2: "How would you communicate prognosis in this case where there is uncertainty?"

Expected Answer (2 minutes):

Communicating prognostic uncertainty is essential for honest, trust-building communication.

Key Principles:

1. Acknowledge uncertainty honestly:

   • "I wish I could tell you exactly what will happen, but I cannot predict the future with certainty"
   • "What I can tell you is what we see today..."

2. Provide range, not single number:

   • "Most patients with strokes of this severity have a 10-20% chance of meaningful recovery"
   • Avoid false precision

3. Explain what we DO know:

   • "What I can tell you is that the stroke was very large and affected areas that control consciousness"
   • "The fact that she hasn't woken up after 12 days is concerning"

4. Time-limited trial:

   • "Let's continue for another week and reassess. If we don't see improvement, that tells us..."

5. Hope-Worry framework:

   • "I hope she will improve, AND I'm worried that she may not"

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Follow-up Question 3: "How would your approach differ for an Aboriginal family from a remote community?"

Expected Answer (2-3 minutes):

Significant adaptations required for cultural safety:

Before the Meeting:

• Engage Aboriginal Hospital Liaison Officer (AHLO) early
• Ask AHLO about specific cultural protocols for this family/community
• Allow more time - don't rush
• Identify who needs to be present - likely extended family, possibly Elders

During the Meeting:

• Collective decision-making: Don't focus on one "decision-maker"
• Elders: May have significant authority; include and respect
• Communication style:
  • Less direct eye contact may be respectful, not evasive
  • Allow silence - comfortable and indicates thinking
  • Plain language, no jargon
  • May prefer storytelling approach rather than bullet points
• Don't rush decisions: "Take whatever time you need. We can meet again tomorrow."

Cultural Considerations:

• Connection to Country may be important - "Would she want to go home?"
• Some communities: Discussing death may be taboo
• After death: "Sorry business" protocols vary by nation

End-of-Life:

• Consult AHLO about specific protocols
• Family may want body returned to Country
• Specific protocols about viewing body, saying name

This approach aligns with CICM commitment to Indigenous health advocacy and reducing the 10-year life expectancy gap through culturally safe care.

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Viva 2: Conflict Resolution

Stem: "An 85-year-old man has been in ICU for 3 weeks with multi-organ failure following emergency surgery. The team believes further treatment is futile and recommends withdrawal. His family of 6 adult children are divided - 3 want to continue, 3 agree with the team. The family is threatening to go to the media and their lawyer."

Duration: 12 minutes (2 min reading + 10 min discussion)

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Opening Question: "How would you approach this conflict?"

Expected Answer (2-3 minutes):

This is a complex conflict requiring systematic approach:

Immediate Steps:

1. Acknowledge the conflict explicitly:

   • "I can see this is an incredibly difficult situation and there are different perspectives"
   • Avoid taking sides

2. Ensure adequate previous communication:

   • Review documentation of previous meetings
   • Has all medical information been shared clearly?
   • Have all family members received consistent information?

3. Explore underlying concerns:

   • Meet with each "camp" separately first if needed
   • "Help me understand what's most concerning to you about stopping treatment"
   • Often the issue is deeper: guilt, grief, distrust, religious beliefs

Family Meeting Approach:

1. Find common ground:

   • "You all love your father and want what's best for him"
   • "We share that goal"

2. Refocus on patient:

   • "The question is not what you each want, but what your father would want"
   • "Did he ever talk about this? What were his values?"

3. Time-limited trial:

   • "Let's continue for 48-72 hours and reassess together"
   • Gives time for processing without abandoning patient

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Follow-up Question 1: "The family is still threatening legal action. What do you do?"

Expected Answer (2 minutes):

Don't become defensive or adversarial. Legal threats often reflect fear and frustration.

Response to Threat:

• "I understand you're very distressed. We want to work with you, not against you."
• "Let me assure you that we won't do anything without discussing it with you first."
• "If you would like legal advice, that's your right. We're happy to continue working with you."

Escalation Pathway:

1. Hospital Ethics Committee:

   • Not adversarial - provides ethical framework
   • Documents process carefully
   • May help family understand medical perspective

2. Independent Second Opinion:

   • Another intensivist or relevant specialist
   • Often reassures family

3. Hospital Mediation:

   • Formal mediation service
   • Neutral third party

4. Legal/Risk Management:

   • Inform hospital risk management
   • Document all discussions meticulously
   • In Australia: Guardianship Tribunal may be needed for rare cases

What NOT to do:

• Act unilaterally without process
• Refuse to meet with family
• Become defensive or argumentative
• Poor documentation

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Follow-up Question 2: "The family asks to speak with 'someone more senior.' How do you respond?"

Expected Answer (2 minutes):

Don't take this personally. It's understandable that families in distress seek higher authority.

Response:

• "Of course. I understand you want to explore every avenue. I can arrange for you to speak with Dr [Senior Consultant/Department Head]."
• "In the meantime, is there anything I can clarify about what I've shared?"

Practical Steps:

• Inform senior colleague of situation before meeting
• Ensure senior gives consistent message (team has agreed position)
• Document request and escalation

If Registrar/Junior:

• "The consultant, Dr [Name], is responsible for your father's care. I'll ask them to come and speak with you directly."
• Never continue contentious discussions alone as a junior

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Follow-up Question 3: "What documentation is required throughout this process?"

Expected Answer (2 minutes):

Documentation is critical - both for patient care and medicolegal protection.

Every Meeting Must Document:

1. Participants:

   • Date, time, location
   • Names of all attendees (staff and family)
   • Relationship to patient

2. Information Shared:

   • Medical summary provided
   • Prognosis discussed
   • Treatment options explained

3. Family Response:

   • Understanding assessed
   • Questions and concerns raised
   • Emotional state noted

4. Decisions:

   • Any decisions made
   • Treatment limitations if applicable
   • If no decision, document why and plan for follow-up

5. Follow-Up:

   • Plan for next meeting
   • Actions required

For Conflict Situations:

• Document exact nature of conflict
• Document family statements (quotations if possible)
• Document all offers made (second opinion, ethics, etc.)
• Document family response to each offer
• Senior clinician review and co-sign

Legal Note: Clear, contemporaneous documentation is the best protection if case is reviewed later.