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

Development of a Simulation-Based Mastery Learning Curriculum for Late Goals of Care Discussions

INTRODUCTION

Fellows in critical care medicine (CCM) routinely help patients and families navigate complex decisions near the end of life. These "late goals of care" (LGOC) discussions require rigorous skills training and impact patient care. Innovation is needed to ensure that fellow training in leading these discussions is centered on reproducible competency-based standards. The aims of this study were to (1) describe the development of a simulation-based mastery learning (SBML) curriculum for LGOC discussions and (2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners.

INNOVATION

We developed an SBML curriculum for CCM fellows structured around REMAP, a mnemonic outlining foundational components of effective communication around serious illness. A multidisciplinary expert panel iteratively created an LGOC discussion assessment tool. Pilot testing was completed to refine the checklist, set the MPS, and assess skill acquisition.

OUTCOMES

The LGOC discussion assessment tool included an 18-item checklist and 6 scaled items. The tool produced reliable data (k ≥ 0.7 and ICC of ≥ 0.7). Using the Mastery Angoff method, the panel set the MPS at 87%. Ten CCM fellows participated in the pilot study. Performance on the checklist significantly improved from a median score of 52% (IQR 44%-72%) at pretest to 96% (IQR 82%-97%) at post-test (P = 0.005). The number of learners who met the MPS similarly improved from 10% during pre-testing to 70% during post-testing (P = 0.02).

COMMENT

We describe the development of a LGOC SBML curriculum for CCM fellows which includes a robust communication skills assessment and the delineation of a defensible MPS.

Communication Skill Training Levels among Critical Care Doctors in India

Medical training programs outline the necessity of communication skills but there is likely a dearth of teaching at the bedside in part due to prioritization of other skills over communication or due to lack of opportunity. In India, the majority of critical care units are open in nature, and communication lead is likely to be taken by the primary specialty rather than the critical care doctors themselves. In the majority of the cases, the root cause analysis shows a lack of clear communication as a barrier. The sicker the patient, the higher the chance for anxiety and miscommunication among healthcare professionals as well as the family. The current project aims to find the training levels in Indian critical care settings and draw conclusions to see if there are avenues to improve the process. This study was based on a web-based questionnaire that was sent out to 1,000 critical care doctors across India. Educational experience and learning of communication techniques/concepts were assessed using a modified educational experience and attitudes questionnaire. Baseline demographic data were obtained and results were tabulated across 193 complete responses, which consistently showed a disparity in perceived levels of competence across different mandatory aspects of communication. Further, we find that though communication is a trainable skill, the mode of training has been largely reactive and has remained so for the last 20 years hinting at poor training in communication. Our survey suggests an urgent need for improvement of the training processes to reduce the burden of ethical, clinical, and legal dilemmas in critical care.

How to cite this article

Gopaldas JA, Narayanaswamy N, Chandregowda NP. Communication Skill Training Levels among Critical Care Doctors in India. Indian J Crit Care Med 2023;27(8):567-571.

Asking "Meaning Questions" in Evidence-Based Reviews and the Utility of Qualitative Findings in Practice

Evidence-based practice (EBP) systematic reviews are mostly conducted using etiology, diagnosis, therapy, prevention, and prognosis question format. "Meaning" or qualitative questions are very rarely used. The purpose of this article is to discuss qualitative findings' contribution to EBP through asking "meaning questions" in conducting systematic reviews and the utilization of the results to practice. Two EBP systematic review exemplars using meaning questions including the relevance and utilization of qualitative findings in health care decision-making, practice, and policy are presented. There is a need to instill an evidence-based mindset into systematic reviews that balance scientific knowledge gained through empirical research and evidence from qualitative studies. This is turn will increase awareness among clinicians and decision makers on the different ways in which qualitative evidence can be used and applied in practice.

The impact of organ donation specialists on consent rate in challenging organ donation conversations

Background: Consent rates for organ donation conversations (ODCs) vary. We hypothesised that a simple grading system could identify challenging ODCs. We further hypothesised that challenging ODCs would have higher consent rates when conducted by ODC specialists. Objectives: We aimed to study the utility of a grading system for ODCs and test the hypothesis that any training effect would be associated with improved consent rates in ODCs graded as most challenging. Methods: We stratified 2017 Australian DonateLife Audit aggregate consent and donation discussion data into four ODC grades based on Australian Organ Donor Register (AODR) status and person first raising the topic of organ donation. Grade I: "yes" present on AODR and family-raised organ donation; Grade II: "yes" present on AODR, and clinician-raised organ donation; Grade III: no registration on AODR but family-raised organ donation; and Grade IV: no registration on AODR, and clinician-raised organ donation. Results: Grade I ODCs were uncommon 7.7% (109/1420), with a consent rate of 95.4% (104/109). Grade IV ODCs were frequent (60.4%, 857/1420), with a consent rate of 41.4% (355/857). However, in Grade IV ODCs, organ donation specialist consent rate was 53.5% (189/353), significantly greater than for other trained staff at 33.1% (88/266) (P < 0.005; odds ratio [OR], 2.33; 95% CI, 1.68-3.24) or untrained requestors at 32.8% (78/238; P < 0.005; OR, 2.36; 95% CI. 1.68-3.33). Conclusion: The likelihood of consent can be predicted using readily available variables. This allows prospective identification of Grade IV ODCs, which carry low but potentially modifiable likelihood of consent. Involving donation specialists was associated with more consents for organ donation when applied retrospectively to Australian audit data.

Implementation of a Standardized Patient/Family Communication Bundle

During critical illness, active discussions about a person's preferences are linked with better patient outcomes. Our intensive care unit implemented an evidence-based standardized communication bundle that included education to providers on effective family communication, focused patient/family discussions to identify Durable Power of Attorney/surrogate decision maker and obtaining advanced directive documents, and documenting conversations in the electronic medical record and appropriately updating the patient's code status. The aim of the bundle was to increase compliance with conducting and documenting family discussions, clearly identifying and documenting surrogate decisions makers, and to improve patient/family satisfaction and caregiver satisfaction.

Family group decision-making interventions in adult healthcare and welfare: a systematic literature review of its key elements and effectiveness

BACKGROUND

Family group decision-making (FGDM) is a structured decision-making process, aiming to shift the balance of power from professional towards the person in need and their family. It differentiates from other family-centred meetings by the presence of three key elements: (1) plan with actions/goals, (2) family driven, (3) three phases of meetings gradually increasing empowerment. FGDM studies are increasing in different settings in adult healthcare/welfare, although effectiveness is unknown at this date.

OBJECTIVES

(1) to systematically review the presence of the three FGDM key elements in family-centred interventions in adult care and welfare, (2) to evaluate the effectiveness of FGDM interventions.

DESIGN

Systematic review.

DATA SOURCES AND ELIGIBILITY CRITERIA

A total of 14 relevant electronic databases and 1 academic search machine were searched until February 2018. First, family-centred studies were selected with controlled trial designs in adult healthcare/welfare. Second, interventions were categorised as FGDM if all three key elements were present.

DATA EXTRACTION AND SYNTHESIS

Studies were examined concerning their (1) characteristics (2) quality/level of evidence (3) presence of FGDM key elements and (4) results.

RESULTS

Six articles from three studies on family-centred interventions were selected from a total of 1680 articles. All were of low quality. One study (two articles) met all criteria for an FGDM intervention, describing the efficacy of family group conferences among social welfare recipients on mental health outcomes. Although the intervention group showed significantly better outcomes after 16-23 weeks; no differences were seen at the 1-year follow-up.

CONCLUSIONS

Controlled studies of both family-centred interventions and FGDM are still low in quantity and quality. No conclusions on FGDM effectiveness can be drawn. Further high-quality intervention studies are required to evaluate the impact of FGDM on adults in need, including their families; as well as evaluation research detecting possible barriers and facilitators influencing FGDM implementation.

PROSPERO REGISTRATION NUMBER

CRD42017077585.

Content-Area Framework for Conducting Family Meetings for Acutely Ill Psychiatric Patients

Family meetings are a critically important component of managing acutely psychiatrically ill patients, and learning how to conduct such a meeting is critically important in the training of psychiatrists. Because we found no published comprehensive tools that dealt with the biopsychosocial content areas to be covered in family meetings in acute psychiatric settings, we developed and present such a comprehensive tool that is based in part on a review of existing tools utilized by other disciplines. This article describes the specific steps involved in premeeting planning, the formal topic areas that might be canvassed during the meeting, and postmeeting documentation and debriefing. The general content areas for discussion during the meeting include the setting of goals and expectations, relevant history-gathering, assessment of the family's understanding of the issues at stake, formal psychoeducation, and review of specific treatment strategies and clinical progress. The meeting may also include a discussion of resources available to the patient and family members and a review of issues related to the safety of the patient and others, management of early warning signs, and sensitive topics such as trauma, abuse, or violence that may play a role in the presentation or treatment of the patient to best translate established goals into a longer term plan of care. Implementation of this comprehensive and necessarily structured model should enhance the patient's and family's understanding of the issues at stake and should improve satisfaction, promote trust and an effective working alliance, and enhance the quality of the biopsychosocial care plan.

A Procedural Approach to Teaching Residents To Conduct Intensive Care Unit Family Conferences

RATIONALE

Family conferences are an essential component of high-quality ICU care and an important skill for physicians. For residents, intensive care unit (ICU) rotations represent an opportunity to learn to conduct family conferences, and residents are already familiar with an approach for learning ICU procedures with steps of increasing responsibility organized as a module.

OBJECTIVES

To determine the acceptability and feasibility of a procedure-training module for teaching family conferences.

METHODS

We conducted a feasibility pilot study of a family conference training module with residents during a one-month ICU rotation over a three-month period. The module had five components: (1) two-minute instructional video; (2) faculty observation of two family conferences; (3) standardized observation and formative evaluation; (4) online resident procedure log; and (5) family conference note template to document the conference in the medical record. We evaluated acceptability with an anonymous survey.

RESULTS

Twenty-seven residents rotated through the ICU during the pilot with 11 completing only one observed conference (41%) and 4 completing two or three observed conferences (15%). The most common reasons for not having conducted observed and evaluated conferences included competing work demands and conferences occurring at night. The survey response rate was 44% (12/27). Of respondents, 92% gave the module a rating of good, very good, or excellent and 92% stated they would recommend the module to others.

CONCLUSIONS

This five-component module for teaching family conferences was rated as acceptable by most respondents, but significant barriers to successful implementation must be addressed before this is likely to be an effective teaching method.