Communication After Isolation: The Challenge of Re-Engaging Family Members in Neurocritical Care
Published on: April 24, 2023
Communication is a cornerstone of patient care. We are taught that patient-centered care requires trust, which can only be fostered if both patient and provider are understood. A patient might decline a therapy supported by robust clinical data if the practitioner fails to consider the patient’s cultural, spiritual, and personal beliefs. In critical care, this patient insight often comes from family members – people who can speak to a patient’s values before they were hospitalized. We know that family involvement in the intensive care unit improves patient outcomes. Neurocritical care patients experience unique communication challenges, and providers have a heightened responsibility to engage family members. If communication with family members was no longer feasible, how could the healthcare system train responsible practitioners?
I began my pharmacy residency in July of 2020. Like many others entering healthcare careers and post-graduate training, I had never known patient care in the pre-pandemic world. Patient interactions felt impersonal through layers of personal protective equipment. Presence of family members became a hypothetical consideration, as visiting hours grew increasingly restrictive. New practitioners could dedicate more time than ever to the assessment and application of treatment guidelines, primary literature, and clinical data. Yet the importance of communication was still woven throughout these teachings. The ABCDE bundle had been recently amended to include family engagement (F) after active family participation was linked to benefits like decreased ICU length of stay and improved patient and practitioner satisfaction.1 I felt that I understood the important role that family members play in the delivery of optimal critical care medicine.
Two years later, I began my career in an intensive care unit at a large, urban medical center with high volumes of patients with traumatic brain injury. Many of these patients struggle with communication deficits during their recovery. As families returned to the bedside, I recognized an immediate impact. They shared chronic pain and mental health diagnoses that resolved impervious agitation. They identified hobbies and interests that re-engaged patients in physical and occupational therapy. They brought photos and stories that highlighted the patient’s impact on the world outside of the hospital, providing a refreshing connection to purpose.
One day, a patient’s mother stopped me after rounds. I had recommended that we start propranolol, a non-selective beta-blocker that has been associated with a mortality benefit in patients with traumatic brain injury.2 She had a family member who had been started on this medication for a cardiac condition, but knew that her young son, who was perfectly healthy prior to his accident, had no cardiac problems. In that moment, I realized that through months of interacting with only healthcare professionals I had forgotten to explain interventions in a way that made sense to families at the bedside. My practice shifted to include daily debriefs with family members. I spent time explaining the indication for various medications and their desired outcome, particularly in mechanically ventilated patients where family members served as the primary patient advocate. At first, I struggled to explain complex clinical concepts in a way that was clear and concise. I had never been challenged to describe the pharmacotherapy underlying conditions like elevated intracranial pressure or paroxysmal sympathetic hyperactivity to someone without any medical knowledge. Questions and comments from family members taught me how to elucidate these topics over time. As a result, family members were empowered to ask more insightful questions and participate in patient care rounds.
As I look back on this time, I’m reminded of a quote that struck me as a pharmacy student. Sir William Osler once said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” The same could be said for a generation of providers who completed their training without direct patient and family interaction. Unfortunately, my experience is not unique. While the concept of empowering family members is not novel, its application will be unfamiliar to many new practitioners. Current healthcare mentors and educators are tasked with addressing the communication deficit that is the unintended consequence of a global pandemic. Effective education must challenge learners to translate their medical knowledge in a way that empowers patients and family members. Without direct experiences in patient and family communication, learners will always be stuck on the shore.
1. Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF Bundle in Critical Care. Crit Care Clin. 2017;33(2):225-243.
2. Ley EJ, Leonard SD, Barmparas G, Dhillon NK, Inaba K, Salim A, et al. Beta Blockers in Critically Ill Patients with Traumatic Brain Injury: Results from a Multi-Center, Prospective, Observational American Association for the Surgery of Trauma Study. J Trauma Acute Care Surg. 2017;84(2):234-244.