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Innovative solutions: family conference progress note

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 Innovative Solutions
solutions

Innovative Solutions
Family Conference Progress Note
Mary Whitmer, RN, FNP; Brian Hughes, MDiv, BCC
Susan Hurst, MSN, RN, CCRN, CNRN; Tye Young, DO

The grief and anxiety of complex medical illness, with a high likelihood of death,
strains communication between medical staff and patients’ families in the intensive
care unit (ICU). For decades, the emphasis has been on curative intent and a pater-
nalistic approach to decision making, which has been fostered by physicians, when
patients are unable to communicate for themselves. However, the past 15 to 25
years have seen a paradigm shift in both what families expect from physicians and
what physicians see as the goal of medical (especially ICU) care with respect to the
patient and family wishes. This article will address this topic. Keyword: Families.
[DIMENS CRIT CARE NURS 2005:24(2): 00-00]

Families want to be more involved with decision making
at the end of life, and many intensivists believe that family
interests should be incorporated into the decision-making
process.1 As a result, physicians have begun to partner
with paraprofessionals in approaching patients with criti-
cal illness and their families. Despite the intent to involve
families, many investigators have shown that physicians
are ineffectively communicating.2
Families want to be more involved with
decision making at the end of life
Some barriers to communication have been identified:
physicians are unsettled by their inability to specifically
pinpoint when death will occur, lack of healthcare profes-
sionals’ preparedness to deal with the emotional responses
of families, use of medical jargon, time delays in commu-
nication, and a lack of a central physician communicator.3
Improvements in residency training and incorporation of
[AQ1] the EPEC initiative will enhance physician communica-
tion in the future. Many of our intensive care unit (ICU)
patients are aging and may already have compromised
quality of life, thus, an approach is needed that delicately
balances curative and life-prolonging interventions with
attention to palliative care.4
Increased research interest in end-of-life care has
shown the “error of our way.” The SUPPORT trial
showed substandard success in pain control.5 Other
studies have shown that not only the medical care sys-
tem fails patients with palliative care needs but also that
we have underestimated the role that families play in the
delivery of care. For example, one study has shown that
family members can accurately predict the presence or
absence of pain in ICU patients 75% of the time.2 And,
despite the fact that communication is lacking,
when present, families often heed the suggestions of
physicians.6 With several studies now showing deficient
physician-family communication, ways of improving
this communication, and its implications for care
(reduced length of stay, lessened total cost of hospital-
ization, more appropriate use of ICU beds, and
improved patient/family satisfaction), it is incumbent on
the healthcare system to respond.4,7 And, the healthcare
system is beginning to respond. The Society of Critical
Care Medicine has adopted recommendations for end-
of-life care that include elements of palliative care,
bereavement, hospice and preparation for the patient,

March/April 2005 1
 Innovative Solutions
family, and caregivers.8 It is with this impetus that the
interdisciplinary subcommittee of the Pain and Palliative
Care Committee at Banner Good Samaritan Medical
Center (BGSMC) approached the issue of communica-
tion with families of patients in the ICUs of a healthcare
facility based in Phoenix, Ariz.
Interdisciplinary communication in a high-acuity,
urban ICU is an ideal—but rarely a reality. Like many
large hospitals, BGSMC seeks to provide the best possi-
ble medical care for its patients and families, primarily
through a subspecialty system. As such, a patient with a
closed-head injury admitted to the neuro ICU may have
not only a neurosurgeon following him or her but also
a nephrologist, a trauma surgeon, a hospitalist, and an
intensivist. Families, however, are rarely, if ever, edu-
cated about this system. Most do not understand that
the “kidney doctor” (as a limited specialty) may not be
able to describe the “big picture” for their loved one.
Interdisciplinary communication in a
high-acuity, urban ICU is an ideal—but
rarely a reality.
As a result, miscommunications can become the
norm. Families may well assume that when the nephrol-
ogist says the kidney is doing better, the patient is con-
sequently getting better, even if that same patient may
have a grim prognosis. It is often the bedside nurse,
social worker, or chaplain who may first discern that
the family may not have a realistic or sufficient grasp of
the patient’s diagnosis and subsequent prognosis. The
resultant miscommunications sometimes create a
longer-than-necessary length of stay, more aggressive
treatment than the patient would have wanted, a poorly
timed conversation regarding code status or withdrawal
of treatment, and almost invariably a heightened ten-
sion and anxiety level of the family.
The Pain and Palliative Care Committee at BGSMC
appointed a nurse educator, a hospitalist, a palliative care
nurse, and a chaplain to research process improvement
to address these issues of interdisciplinary communica-
tion. After researching more than a dozen articles, they
developed a progress note format to be utilized by an
interdisciplinary team when a patient has an estimated
ICU length of stay greater than 72 hours.
Process for the Use of the Note
The process of utilizing the form is displayed in Figure 1
(process flowchart). The form (Figure 2) is placed at the
beginning of the physician progress note area and is cur-
rently still in the pilot phase of implementation. The
2 Dimensions of Critical Care Nursing Vol. 24 / No. 2
nonphysician subcommittee members audit the bedside
charts of patients (Figure 3) in the care of the participat-
ing hospitalist group. Each patient who has either been
in the ICU for greater than 72 hours or who has an
admitting diagnosis where more than 72 hours of ICU
stay is anticipated then triggers a formal conference.
It is the auditor who then initiates the process. He
or she communicates to the Health Unit Secretary
(HUS) the need to establish contact with the attending
physician. The physician then shares 2 or 3 possible
times when he or she might be available to meet with
family and interdisciplinary staff—preferably setting
aside a minimum of 30 minutes. The auditor then dis-
cusses the meeting, its purpose, and the possible times
with the family (preferably in person). It is necessary
that the Medical Power of Attorney (MPOA) is present
at the meeting, and ideal if that person designates only
2 or 3 more people from the patient’s family to attend
(though intentional sensitivity to the often complex cul-
tural, familial, and idiosyncratic communication needs
of the patient’s family is paramount in determining the
optimal persons to attend). The family chooses which
time would work best. The HUS then contacts the
patient’s physician, social worker, clinical case manager,
chaplain, bedside nurse, and palliative care nurse prac-
titioner and communicates the assigned meeting time,
place, and participants. During the meeting, it is the
physician who fills out the form.
An alternative scenario may be an opportunity for
a spontaneous meeting where the MPOA is at the bed-
side and the attending physician is present. In this case, [AQ2]
the same process would occur, with the HUS communi-
cating the pending spontaneous family-physician con-
ference to the same staff listed earlier. Any of the inter-
disciplinary team members who can attend, do. At the
very least, the team is made aware that a formal confer-
ence is to take place. The meeting occurs with the physi-
cian, the bedside nurse, and the MPOA of the patient.
The physician then fills out the form.
The form itself focuses on 6 basic steps. The first is
a brief, “big-picture” communication of the patient’s
current diagnosis, what is known, not known, and still
pending. Of particular import in this section is that the
diagnosis be succinct and understandable to the family
members. The second step is a lay-communicated prog-
nosis, what the patient’s family and loved ones can
expect to happen. The third step is a discussion of code
status (if applicable), as well as a potential inquiry made
as to whether the patient is a registered organ donor.
The fourth step, which according to the literature has
the most significant impact on patient/family satisfac-
tion as well as outcomes, is an invitation for the family
to ask questions of clarification, share with the medical
 Innovative solutions

Figure 1. The Process Chart.

March/April 2005 3
 Innovative solutions
Figure 2. Family Communications Chart Audit.
team the patient’s known wishes regarding treatment,
and other pertinent information. In this section, the
physician asks the family to articulate what they under-
stand to be happening medically, as miscommunications
can be clarified in the moment. The fifth step is a com-
munication of what the family can expect in the near
future: a next step. This may be in terms of giving a spe-
cific time frame to see if a therapy might work, or if the
patient may rally. The key is to make the time frame and
parameters of patient response very specific, with a date
and time set to meet again, and to determine if the treat-
ment plan meets the goal of care. The final step is then
to make specific consults to other members of the inter-
disciplinary team that might be integral in assisting the
family and/or the patient.
Development of the Progress Note
Best practice for healthcare providers mandates actions be
evidence-based. An interdisciplinary subcommittee was
formed from the Pain and Palliative Care Committee. Bed-
side RNs and the subcommittee reviewed and summarized
the current literature that deals with family conferences for
ICU patients and their families. The summary and a
lengthy bibliography were presented to the ICU Process
Improvement Task Force (PITF), which is also an interdis-
ciplinary group that meets biweekly. Suggestions were
4 Dimensions of Critical Care Nursing Vol. 24 / No. 2
made to change the form. Some physician resistance cen-
tered on their belief that family conferences were already
happening and were quite effective. Bedside nurses, how-
ever, continued to believe that families were either not
receiving medical information and progress updates in lay
terms or were receiving no information. Nurses were frus-
trated and felt some of their patients were declining while
families lacked understanding of the “big picture.”
The subcommittee then developed an audit tool and
audited ICU charts for evidence of family conferences
(Figure 3). Charts were audited for 3 weeks. Results
demonstrated that while intensivists and attendings felt
that family conferences were conducted, the majority of
written progress notes audited demonstrated that docu-
mentation was lacking or was very brief. For example,
“Met with family to discuss medical status.” In addition
to auditing the charts of all ICU patients, bedside nurses
were also queried as to whether or not a family confer-
ence had been held. Nurses frequently reported physi-
cian conversations with families that ranged from 5 to
15 minutes. The conversations were informal and infor-
mation was passed in only one direction—from physi-
cian to family members. The literature review clearly
indicated increased family satisfaction and understand-
ing. The ICU PITF meetings were placed on hold and so
the subcommittee decided to take another approach.
 Innovative solutions

Figure 3. ICU Family Conference Process.

March/April 2005 5
 Innovative solutions
At BGSMC, a large hospitalist group also has an
active role in the management of ICU patients. The sub-
committee approached the group to assist with this pro-
ject. At that time, one of the hospitalist physicians
joined the subcommittee and became the physician
champion within his group for this process. After read-
ing the relevant literature, the physician worked with
the subcommittee to develop the progress note. This
process to design the note took several meetings and
was presented to the Pain and Palliative Care Commit-
tee for review before finalizing the draft. The form was
designed to be user-friendly and to cover the informa-
tion that the literature review as well as the committee
members felt was relevant. The check-off box design
was chosen to meet physician and staff needs to con-
serve time. Lines are provided to elaborate, if needed.
When completed, the form helps facilitate communica-
tion between covering physicians and the interdiscipli-
nary team. The form also allows the team to begin to
collect data about the length of stay (LOS) and satisfac-
tion related to ICU family conferences. During recent
audits for use of the form, it has been noted that other
physicians not in the pilot hospitalist group are also
using the form to conduct family meetings, as the
progress note form is placed in each new ICU chart
regardless of attending physician.
CHALLENGES AND FUTURE DIRECTIONS
The family conference progress note at BGSMC was a
multidisciplinary effort between nursing, physicians,
and chaplaincy to meet the diverse psychosocial and
emotional needs of patients and families in the ICU. The
initial efforts involved a review of the literature, an
assessment of the current practices related to family
communication, and the development of a form to pio-
neer a practice culture of family inclusion.
The start of the process required frequent reminders
to staff (nursing and secretaries) that a call was needed
or that the form needed to be completed. The practice
change was met with some anxiety about schedules,
irritation to busy physicians, or an inability of the key
players to respond to a consult for conference. These
needs required education and time-sensitive repetition
The family conference progress note
was a multidisciplinary effort between
nursing, physicians, and chaplaincy to
meet the diverse psychosocial and
emotional needs of patients and families
in the ICU.
6 Dimensions of Critical Care Nursing Vol. 24 / No. 2
Innovative Solutions
to ensure the call was made, the consult was ensured,
and the progress note was completed by the physician.
The evolving family conference process includes
(1) the input from other disciplines to include social
work, case management, and nursing management,
(2) the development of a reasonable and time-limited
tracking method, and (3) the incorporation of an over-
sight group to ensure quality and standards for the
process. The evidence-based data suggest that the form
and process are integral to patient and family satisfac-
tion. Our future plans include data collection and track-
ing related to LOS and ventilator days, and how these 2
areas are affected by an increase in multidisciplinary
communication with the family.
Editor’s note: Nurses are encouraged to write about
any policies, treatments, guidelines, and/or protocols
they have successfully implemented for their units and
wish to share with other nurses. For more information,
please contact the editor at vmiracle@aol.com.
References
1. McDohagh JR et al. Family satisfaction with family conferences
about end of life care in the intensive care unit: increased pro-
portion of family speech is associated with increased satisfaction.
Crit Care Med. 2004;32(7). [AQ3]
2. White DB et al. Palliative care in the intensive care unit: barriers,
advances, and unmet needs. Crit Care Clin. 2004;20(3). [AQ4]
3. Prendergrst T, Puntillo K. Withdrawal of life support: intensive
caring at the end of life. JAMA. 2002;288(21).
4. Ahrens T et al. Improving family communications at the end of [AQ5]
life: implications for length of stay in the intensive care unit and
resource use. Am J Crit Care. 2003;12(4).
5. Desbies N et al. Pain and satisfaction with pain control in seri- [AQ6]
ously ill hospitalized adults: findings from the SUPPORT
research investigators. Crit Care Med. 1996;24(12).
6. Prendergrast T, Luce, J. Increasing incidence of withholding and [AQ7]
withdrawal of life support from the critically ill. Am J Respir
Crit Care Med. 1997;155.
7. Lilly C et al. An intensive communication intervention for the [AQ8]
critically ill. Am J Med. 2000;109(6).
8. Truog R et al. Recommendations for end of life care in the inten- [AQ9]
sive care unit: the Ethics Committee of the Society of Critical
Care Medicine. Crit Care Med. 2001;29(12).
ABOUT THE AUTHORS
Mary Whitmer, RN, FNP, is Palliative Care Nurse at Banner Good
Samaritan Medical Center, Phoeniz, Arizona.
Brian Hughes, BCC, Mdiv, is Staff Chaplain at Banner Good
Samaritan Medical Center, Phoeniz, Arizona.
Susan Marie Hurst, MSN, RN, CCRN, CNRN, is Critical Care
Clinical Nurse Specialist in Transplant, Medical-Surgical, Neuro and
Trauma Intensive Care at Banner Good Samaritan Medical Center,
Phoeniz, Arizona.
Tye B. Young, DO, is Associate Medical Director and Hospitalist,
American Physicians Inc, Phoenix, Arizona.
Address correspondence and reprint requests to: Susan Marie Hurst,
MSN, RN, CCRN, CNRN, Transplant, Medical-Surgical, Neuro and Trauma
Intensive Care, Banner Good Samaritan Medical Center, 10410 N Cave
Creek Rd, 2035, Phoenix, AZ 85020 (Sue.hurst@bannerhealth.com).
 Innovative solutions

AUTHOR QUERIES

TITLE: Innovative Solutions

AUTHOR: Mary Whitmer, RN, FNP; Brian Hughes, MDiv, BCC
Susan Hurst, MSN, RN, CCRN, CNRN; Tye Young, DO

AQ1: Spell out “EPEC.”

AQ2: Check whether the insertion of the word “physician” is correct. Else, provide an appropriate word.
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page range.
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page range.
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page range.
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page range.

7 Dimensions of Critical Care Nursing Vol. 24 / No. 2 March/April 2005 7

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