Syed Sohaib Nasim, MD, Research Fellow, Department of Anesthesiology, Cleveland Clinic Florida, Weston.

Syed Sohaib Nasim, MD, Research Fellow, Department of Anesthesiology, Cleveland Clinic Florida, Weston.

Steven Minear, MD, Associate Staff, Department of Anesthesiology, Cleveland Clinic Florida, Weston.

Steven Minear, MD, Associate Staff, Department of Anesthesiology, Cleveland Clinic Florida, Weston.

The COVID-19 pandemic has had a devastating impact on health care, and it has brought forth new challenges to the current system (J Hosp Med 2020;15:437-9). The communication process with patients and their families in the perioperative setting, especially during critical moments and critical illness, has changed significantly over the past few months, moving wherever possible to virtual platforms. Online or telephone appointments have become an expected aspect of care (J Hosp Med 2020;15:437-9).

During extended critical illness, this virtual setting is unsatisfactory for both patient and doctor. Building rapport with patients and their family members is crucial because it helps clinicians connect, and it improves patient care (J Hosp Med 2020;15:437-9). As patients continue through their perioperative course, especially patients in the ICU, these complicated treatment plans and their clinical implications cannot be easily translated to an episodic, virtual conversation (J Hosp Med 2020;15:437-39). Prior to stricter visiting policies, family would come frequently to visit, creating opportunities to interact with the care team. These frequent, casual, patient-family-doctor moments cements care team rapport: the feeling of being “on the same team” and present for families (J Hosp Med August 2020).

With multiple trips to the OR, rapid changes in clinical status, and the potential for eventual decline, palliative options and end-of-life conversations are made even more challenging due to necessarily strict hospital visiting policies in place (J Hosp Med August 2020). At times, the first instance physicians and family physically meet is for an end-of-life discussion. The unsung bystanders of the COVID pandemic are the families and care team of critically ill patients, who are missing that team dynamic, strengthened by many informal points of contact outside of the official “update.”

The Centers for Disease Control and Prevention (CDC) has recommended that states limit visitation, allowing them in situations such as altered mental status or end-of-life settings (J Hosp Med August 2020). Hospitals by necessity are pressured to introduce strict policies, and consequently family members often could not visit patients even in non-COVID situations. This was done to limit COVID transmission while allowing clinicians the ability to provide compassionate care. However, it has raised challenges for communicating patient progress with family members (J Hosp Med August 2020).

There are feelings of isolation, and clinicians cannot communicate easily with different family members at the same time. This makes care discussion very challenging because family members are unable to witness patient progress, either to recovery or decline (J Hosp Med 2020;15:437-9; J Hosp Med August 2020). Moreover, there are challenges with discharge planning and education because family members are not present at critical moments, which can negatively affect care coordination. This is especially true for the ICU, where patients recovering from their illnesses may be expected to understand instructions about wound care, nutritional requirements, or learn about antibiotic infusions at home (J Hosp Med 2020;15:437-9). These activities require caregiver support and may also increase the risk of readmission if it is unsupervised.

One of the strategies proposed to improve communication between caregivers and family members is to hold virtual meetings with an identified contact. Ideally, this person is designated as the durable power of attorney regarding the patient's health care (J Hosp Med 2020;15:437-9). This person will in turn be responsible for contacting the rest of the family and to share information about the patient's progress. Family dynamics are often more subtle than this, and cross-cultural problems arise (J Hosp Med 2020;15:437-9; Patient Educ Couns 2020;103:1067-9). Furthermore, accurate information is dependent on this family member's ability to fully understand the patient's progress and to transmit the information effectively to other family members. Since the physicians are unable to spend time communicating with other members not present at bedside, this complex information can be overwhelming (J Hosp Med 2020;15:437-9). Concerns are therefor raised about effective communication of the patient's current status, and it can create further challenges in establishing rapport. Some care teams may decide to call the family during morning rounds so the family member can participate. This can be effective for rapport and team-building when this interval events occurs. The process is unfortunately dependent on the ability of the family member to be available at rounds time, which is very difficult to assess (J Hosp Med 2020;15:437-9; Patient Educ Couns 2020;103:1067-9). The many moments between official rounds – the handshake, the informal update, the excitement of progress, are all missed. They are filtered out in the efficiency and decorum of morning rounds.

The current pandemic has caused significant challenges for communicating with family regarding patient's critical illness, their current status, future care plans, and goals of care. The main goal of ICU and perioperative care still remains healing and compassionate care. But newer strategies are needed for effective communication and building rapport with family members.