The intensive care unit family conference. Teaching a critical intensive care unit procedure.

The intensive care unit (ICU) is a setting in which clinicians care for many of the sickest, most critically ill patients in our healthcare system. Unfortunately, many of our patients die in the ICU. Indeed, approximately 20% of Americans die in, or shortly after, a stay in the ICU, making the ICU a common location for end-of-life care (1). The majority of deaths that occur in ICUs in the United States are preceded by a decision to withhold or withdraw life-sustaining therapy (2), which means ICU clinicians are often making difficult decisions with patients or, more commonly, as patients often cannot participate, with the patients’ family members. Many of these decisions are made in the setting of an ICU family conference, and studies have used the ICU family conference as an important quality metric for patients at significant risk for death or prolonged ICU stay (3). Importantly, even if patients ultimately survive the ICU, their family members often have intense communication needs and are also at risk for consequences of stress and poor communication, including anxiety, depression, and posttraumatic stress disorder (4). In fact, family members of patients who survive the ICU rate ICU clinician communication more poorly than family members of patients who die in the ICU, attesting to the importance of communication for family members of all ICU patients (5). The consequences of poor communication with family members in the ICU are significant. A randomized trial showed that a relatively simple intervention designed to improve communication during family conferences and provide a bereavement packet to family members was associated with dramatic reductions in symptoms of anxiety, depression, and post-traumatic stress disorder (6). Other studies have shown that improved communication with family members is associated with reductions in nonbeneficial treatment seen so commonly in our ICUs (7–9). In this context, we argue that the ICU family conference is a critical “ICU procedure” that needs to be effectively taught to all fellows training to be intensivists. The ICU is also an opportunity to teach this procedure to residents and others who need to learn this skill set for care across the healthcare continuum, including the acute care and outpatient settings. Although this skill set can also be taught in these other areas of medicine, there are few places where these conferences occur more frequently or have been studied so thoroughly. The ICU is our opportunity to teach and model effective and supportive family conferences to the next generation of physicians, as well as nurses, social workers, spiritual care providers, and other healthcare professionals. In this month’s issue of AnnalsATS, there appear two important reports of programs designed to teach critical care fellows to conduct effective and supportive ICU family conferences (10, 11). Both reports describe the development and implementation of a formal program for teaching this important skill set, although they apply somewhat different approaches. The program developed by McCallister and colleagues (pp. 520–525) uses a formal family conference checklist as a teaching guide to provide formative feedback to fellows about their performance during actual family conferences in the ICU (11). Hope and coworkers (pp. 505–511) tested a targeted simulation training program, along with a list of directly observable family conference tasks, that was implemented in teaching sessions over the course of a month-long curriculum (10). Both of these programs were implemented successfully and were rated highly by critical care fellows. Both of these programs also showed improved communication ratings, as assessed by a third-party rater: either a faculty member teaching the course, who could not be blinded to whether fellows had received the training (10), or independent clinical psychologists who were blinded to preversus posttraining (11). The use of an independent rater blinded to training status greatly enhances our confidence in these assessments but can be difficult to accomplish. Although both studies demonstrate improvements in a fellow’s overall performance, as well as many individual aspects of the family conference, these studies also highlight significant remaining gaps in the attainment of key educational goals. A preintervention survey included in the McCallister study showed that only 40% of fellows reported ever being explicitly taught in residency how to respond to emotion (11). This lack of training and modeling in emotional content during early parts of medical education is widespread. This is evident in the report by Hope and colleagues, which showed poor performance in attending to emotion, accomplished in only about 20% of encounters both pre and postintervention, despite this being part of the curriculum