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

Introduction

The intensive care unit (ICU) family conference is a key event in the course of a critical illness. ICU family conferences often define the goals of care for the patient, facilitate shared decision making between the ICU team and surrogate decision makers, and shape the experience of the family involved in a patient's care.^1,2 Higher quality of communication during the ICU family conference is associated with higher satisfaction and reduced psychological distress among family members.^3–6 Conducting family conferences is also an important skill set in settings other than the ICU, and the ICU rotation can serve as a key opportunity to train residents in this skill set. Recent approaches to teaching the ICU family conference include the use of simulation or structured feedback from faculty.^7,8

Many residency-training programs already use a learning approach for procedures, such as central line placement, which provides learners with specific structured components and gradually increasing responsibility. Evidence supports the use of simulation and competency-based modules in teaching invasive procedures. ⁹ These procedure modules often include initial didactic training, observation of others performing the procedure, supervised practice with feedback, determination of competency to perform the procedure, and then teaching the procedure to others. ⁹ Such a framework might be an advance over the current default of unstructured training for ICU family conferences common in residency programs. We developed and piloted an approach to family conference training for internal medicine residents during a four-week-long medical ICU rotation. The purpose of this pilot study was to determine the acceptability and feasibility of using a procedure-training model for skill acquisition to conduct family conferences.

Methods

This pilot study was conducted over a three-month period from August to October 2014 with support from the medical ICU faculty at a single teaching hospital. Over three months, there were 27 eligible internal medicine residents; 12 third year residents and 15 interns. This program evaluation was determined to be exempt from IRB approval because it was conducted in established educational settings, involving normal educational practices, and because survey results were anonymous.

This family conference training module incorporated five components in a multifaceted learning sequence (Table 1). First, we used a brief instructional video created by VitalTalk^® that provided an overview of seven important components of a family conference (Fig. 1). ¹⁰ The video was provided to participants as a web link with the intention that residents would watch the video immediately before the family conference. Second, residents were asked to conduct two faculty- or fellow-observed family conferences. Fellows were asked to complete a family conference observed by a faculty member before observing a family conference by a resident. Third, faculty were asked to use a standardized teaching and evaluation form adapted from a previously published form ⁷ for both formative feedback and evaluation and to submit the completed form in a locked box in the ICU. Fourth, residents were asked to record the family conference in a procedure log through an online tracking website. Finally, residents were asked to document the family conference in the electronic medical record using a template developed for this project. The video, evaluation form, and documentation template were designed to cover the same basic components and are each available online (see VitalTalk website for video ¹⁰ and Supplementary Data [Supplementary Data are available online at www.liebertpub.com/jpm] for evaluation form and documentation template).

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FIG. 1.

Seven components to conducting a successful family conference from VitalTalk^® video. ¹⁰

We distributed a brief anonymous survey (10 closed-ended questions) to the 27 residents within a week of finishing their ICU rotation to assess the acceptability of the family conference training module. The survey was completed online. We sent three e-mail reminders to nonresponders.

We performed descriptive analyses with the goal of assessing the feasibility and acceptability of this approach. We determined feasibility by evaluating the proportion of residents who received the training and submitted the observation form and the proportion of residents who were supervised for the targeted two family conferences. We aimed to determine acceptability through anonymous surveys completed by residents.

Results

A total of 27 residents rotated through the ICU during the three-month pilot. The residents included 15 interns and 12 third-year residents; 70% were women and they had an average age of 31 years (SD 2.7). Of the 27 residents, 11 completed one observed conference and submitted the feedback form (41%) and 4 completed two or three observed family conferences and submitted forms (15%) with two residents completing three observed conferences. The two most common reasons reported on the survey for not completing the targeted two conferences included having other patients requiring critical care at the time of a scheduled family conference and conferences occurring at night when the attending or fellow was not available. One respondent noted that a conference was observed, but no feedback form was completed. There were 19 observation and feedback forms completed for 11 residents (7 interns, 4 senior residents). Only nine family conferences were logged on the procedure tracking website.

There was a 44% response rate for the survey (12/27). Of the respondents, 92% rated the project favorably, defined as good, very good, or excellent (Fig. 2). The same 92% stated they would recommend the family conference training module to other residents.

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FIG. 2.

Resident ratings of the acceptability of the five-component training module.

Discussion

Effectively conducting family conferences is an important skill set for the provision of high-quality care, and ICU rotations represent an important opportunity to teach and evaluate this skill. ¹ We describe an innovative model for teaching ICU family conferences to residents rotating through the ICU, which is based on a common approach for teaching ICU procedures. Our module used a five-part learning sequence that included a standardized evaluation form developed and evaluated by others for teaching and evaluating family conferences. ⁷ In this pilot study, approximately half of the eligible residents completed one to three observed family conferences in a single month rotation, but only 15% completed the target of two observed family conferences. For those who responded to the survey, this was generally viewed as a good to excellent approach to teaching ICU family conferences.

There were a number of barriers to successful completion of observed family conferences. First, in the ICU environment, the immediate needs of critically ill patients can interfere with organized teaching plans. Second, introducing a new routine or program into a busy critical care environment creates logistical challenges. Successful and sustainable implementation of this program will require strong support from the residency program and critical care faculty. Anecdotally, the two residents who completed three supervised conferences were supervised by critical care faculty who also attend on the palliative care service, suggesting faculty buy-in may be a key factor. Some potential solutions to these challenges might include training third-year residents to supervise first-year residents for family conferences occurring at night and using more than a single month to ensure adequate opportunities for supervised and evaluated conferences. In addition, this training module would need to become a routine part of the culture of the ICU educational program, much as central line procedure training has in most academic medical centers.

This report has important limitations, including the small number of eligible residents and the low response rate to our survey. Importantly, we have no way to determine how nonresponders would have rated the intervention. In addition, this study was done after a randomized trial of a communication skill-building training intervention that included conducting family conferences, which may have increased general skill level at this institution, thus limiting generalizability of this report.^11,12 However, the goal of this project was to describe a novel approach to teaching family conferences and assess the feasibility of this approach. The limited number of supervised family conferences is due to a combination of limitations, including a limited number of opportunities for supervised family conferences for all trainees as well as missed opportunities that occurred because of avoidable and unavoidable competing demands in the ICU. Our report highlights the importance of developing systems to ensure that avoidable competing demands are minimized and to ensure that this type of teaching opportunity becomes routine. Another limitation is that this project was conducted at a single center and may not generalize to other centers. Importantly, centers with 24-hour attending coverage may have less difficulty with supervised family conferences during the night. Finally, we do not have data on whether residents watched the training video.

In conclusion, we developed and assessed the acceptability and feasibility of an innovative method to teach the conduct of ICU family conferences during a critical care rotation. We found this five-component training module was rated as acceptable by most of the residents who responded to the evaluation survey, but that significant barriers to successful implementation must be addressed before this will be a feasible teaching method. Improved development, implementation, and evaluation of communication training approaches are essential if we are going to effectively train the next generation of physicians to provide high-quality communication during family conferences. Teaching family conferences as a key ICU procedure holds promise for implementing this training, but individual programs will need to identify ways to overcome barriers to successful implementation.