The prevalence of goals of care discussions in the ICU setting can only match the lack of preparation healthcare providers have regarding this topic. While it is always challenging, considering a few aspects of human psychology can help make complex discussions more straightforward.
Families of ICU patients frequently feel a loss of control. Start the conversation by reassuring them that the patient’s wishes are of the utmost importance and that the care team will abide by them. Speaking of control, humbly admitting that you might not be controlling everything either may decrease the number of unreasonable demands and give you a way out of the situation you cannot fix.
People tend to accept their own ideas better than someone else’s. Most families may receive unfavorable scenarios better when they make conclusions themselves rather than taking those from the care team. Ask the family to voice their understanding of the patient’s condition and ongoing treatment in their own words.
Many are uncomfortable making life-and-death decisions for someone else. It makes families much more engaged if one takes that burden off their shoulders by explaining that surrogates convey the patient’s preferences rather than make decisions for the patient.
Laypeople have difficulty making expert decisions that require significant training and experience. Asking families to choose from a list of therapeutic options they may not understand leaves them guessing, patients hurt, and the care team frustrated. Instead, families should be asked about patients’ values and preferences. The care team should then offer a treatment plan consistent with the patient’s life choices. Questions like “Do you want them to be a full code?” are rarely helpful.
When asked about accepting a particular procedure, most assume that the intervention may be beneficial (otherwise, why ask). The care team should only offer potentially helpful interventions and explain why some options are futile and not provided.”Do you want everything done?” is not a meaningful question.
Finally, treat your patients’ families like your own, and you will rarely have any problems, even with the most challenging discussions.