Professional Role · Topic 13 of 26
Therapeutic Relationship & Serious-Illness Communication
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Therapeutic Relationship & Serious-Illness Communication
Ask what the patient understands, give a short headline, stop, and answer emotion before facts. Offer families presence at resuscitation.
SPIKES: six steps for serious news
Find out what the patient understands before giving the news
Before serious news
Ask first, and honor the answer rather than assuming
Ask-Tell-Ask
Tell a short headline, then stop talking
When emotion appears
Respond to emotion before giving more facts
More empathic statements by clinicians were associated with higher family satisfaction, yet one-third of audiotaped ICU conferences contained no empathic statement at all.
NURSE: five empathy statements
Articulate empathy out loud
Words that hurt · words that help
Avoid
Say instead
Giving prognosis
State prognosis as a range and acknowledge uncertainty
Team pre-meeting before a family meeting
So the family hears one consistent message
VALUE: the ICU family-meeting framework
Give the family more talk time
That conference also used longer meetings and more family talk time. The 2017 SCCM family-centered care guideline makes 23 recommendations on communication, family presence and family support; all are weak, reflecting a young evidence base. ASCO's 2017 consensus guideline applies core communication skills to prognosis, goals of care, treatment choice, end-of-life care and family involvement, and supports clinician training in communication skills.
Family presence during resuscitation
Offer relatives the option to be present
At 1 year after that trial, complicated grief was more common among assessed relatives in the control group than in the group offered presence (36% vs 21%).
Grief and bereavement
Grief is a natural response to loss
A handwritten condolence letter to ICU relatives failed to relieve grief symptoms and may have worsened depression and PTSD-related symptoms in a randomized trial, so do not assume a letter alone is enough.
Normal grief or prolonged grief disorder?
| Normal grief | Prolonged grief disorder | |
|---|---|---|
| Course | Symptoms decrease over time | Intense symptoms persist |
| Timing | No time criterion | ≥ 12 months after the loss in adults |
| Symptom burden | May resurge at points | ≥ 3 symptoms nearly daily for the past month |
| Function | Not disabling the way prolonged grief is | Distress or impaired daily function |
| Next step | Support; treatment not usually needed | Refer for CBT-based treatment |
The therapeutic relationship
Keeping the boundary is the clinician's responsibility
Resolution is also called termination. The working phase is sometimes split into identification and exploitation.
Ask before you tell, then stop talking: emotion comes first and facts come after.
Sources · Baile et al. SPIKES: a six-step protocol for delivering bad news. The Oncologist 2000 · VitalTalk: Responding to emotion with NURSE statements · Ohio State CME: Medical communication and conflict management (Ask-Tell-Ask, headline, silence) · Jabre et al. Family presence during cardiopulmonary resuscitation. NEJM 2013 · AACN: Research supports policy shift toward family presence · AACN: Practice alert supports family presence policies (2024 update) · Lautrette et al. A communication strategy and brochure for relatives of patients dying in the ICU. NEJM 2007 · McDonagh et al. Family satisfaction with family conferences about end-of-life care in the ICU. Crit Care Med 2004 · Selph et al. Empathy and life support decisions in intensive care units. J Gen Intern Med 2008 · Back, Arnold, Tulsky et al. A talking map for family meetings in the intensive care unit. J Clin Outcomes Manag 2017 · American Psychiatric Association: Prolonged grief disorder · 42 CFR 418.64: Hospice core services, bereavement counseling · Kentish-Barnes et al. Effect of a condolence letter on grief symptoms. Intensive Care Med 2017 · Davidson et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU (SCCM). Crit Care Med 2017 · Vermont Ethics Network palliative series: Communication skills (prognosis ranges) · Jabre et al. Offering the opportunity for family to be present during CPR: 1-year assessment. Intensive Care Med 2014 · NCSBN: A nurse's guide to professional boundaries · Gilligan et al. Patient-clinician communication: ASCO consensus guideline. J Clin Oncol 2017 · Applying Peplau's interpersonal relations theory to older adults' health literacy: a theory analysis (phases of the nurse-patient relationship) · GVSU Reference Notes for Palliative Care Consultation: SPIKES, NURSE, VALUE · Oncology Nursing Society: Break bad news to patients with this step-by-step guide (SPIKES) · Clinician.com: SPIKES steps for breaking bad news · University of Washington: Harborview program improves end-of-life communication (VALUE, 2007) · Follow your institution's protocols.