Communicating in the ICU

Connie Ge, MS4

During my first observation of a goals-of-care family meeting as a first-year medical student, the conversation was so raw and honest that I still remember seeking refuge in the ICU supply closet afterward to collect my thoughts. I had never talked about the value of life or the understanding of death so openly, nor had I any personal experience with difficult health outcomes in family or friends. Rather, I was just there as part of a research project centered on examining clinician-family communication, and therefore found myself sitting on the sidelines of dozens of these meetings over the next few years.

As part of our project, we wanted to explore the different ways clinicians lead family meetings. In my role, I was able to see how a variety of clinicians communicated and I gained insight into the answers that families responded best to and found helpful in decision-making for their loved ones. With this exposure to goals-of-care meetings, I started to define for myself what approaches were “good” or “bad.”

“Good” meant that the clinician genuinely listened to family members’ questions and answered them directly. They responded with empathy. They explained the relevant clinical picture and left space for questions. They partnered with family members and treated them like decision-making equals by recognizing the family member’s expertise on and knowledge of the patient. In contrast, during “bad” encounters, clinicians steamrolled through the conversation or sometimes made insensitive comments. Other times, clinicians appeared uncomfortable and dodged difficult questions. I picked up on moments where the words spoken were not thoughtful and could have been improved. I promised myself that I would work to be a better communicator, to inspire confidence in my patients and their family members, and to support them through these tough decisions.

Our formal analysis of the clinician and family conversations largely supported the anecdotal evidence I was starting to compile and internalize. During my clinical rotations, I drew on my research experiences to examine similar complicated conversations in other settings, hoping to learn how to lead these meetings myself. As my clinical year progressed, I took a more active role in conversing with patients and their families. I started to make some small strides: a patient thanking me for answering their questions; an attending complimenting my ability to relay information and explain medical concepts. I attributed this progress to my early exposure to goals-of-care meetings and I began to see how my actions could directly help patients and their families.

Then, I met Anna (named changed for privacy). Anna was a young woman who was admitted for difficulty breathing. She was worried she had an infection or, worse, a heart attack like the one her father had recently suffered.

I found out the following day that she had metastatic ovarian cancer.

From the primary team, we knew that Anna’s workup would include a tissue biopsy and further imaging to stage her disease. I checked in with Anna later that morning. I asked if she understood the next steps and what questions she may have had.

“I’m okay, thank you,” she said immediately. She paused, “Well… They told me this morning I have a mass in my stomach. I guess that this means it’s cancer and it’s spread to other places already.”

I nodded as she continued. I tried to recall the specifics of her scan and the report, thinking that she may have wanted to know more details.

“What I’m wondering is — and I know you might not have this answer — but what does that mean?” I stopped nodding. I knew I should have anticipated this question, but somehow, I didn’t. Anna didn’t seem to notice that I’d frozen. “Does it mean that it’s really bad?” She looked at me. “Am I going to die?”

I can’t remember the specifics of what I said, other than telling her, “I don’t know” and “We’ll have more answers soon” before retreating from her room. I do, however, recall very vividly how ashamed I felt in that moment. I had seen so many serious illness conversations just like this one and knew the literature well in terms of what clinician responses are most helpful to patients. However, now confronted with these questions directly, I was unable to access that knowledge and instead failed to help a patient who was searching for answers in the face of terrible uncertainty.

I have thought back to this interaction many times since. One conclusion I’ve drawn is that, in pushing myself to prove that I could be a great clinician communicator, I was building on an unstable foundation. In my early days of listening to family meetings, I had started identifying what made for empathetic communication, but I did not have enough practice leading this conversation myself. I’ve since realized that true knowledge comes from experience, and this experience takes time to develop.

During my research, I’ve seen that even seasoned clinicians have moments when they may falter. For now, I am trying to approach these interactions with greater humility and empathy, knowing that the expert in what families or patients are looking for are the families and patients themselves. There is so much to be learned from them, and I know I have a lifetime to shape that experience.

Connie Ge, BA, is a 4th year medical student at the UMass Chan Medical School. Email: connie.ge@umassmed.edu