Expanding the framework of non-technical skills in resuscitation: why family communication matters

Dear Editor,

We read with great interest the recent systematic review by Zhang et al. evaluating the effectiveness of non-technical skills (NTS) training in emergency departments [1]. The authors comprehensively summarized the impact of NTS—such as leadership, teamwork, situational awareness, decision-making, and inter-team communication—on resuscitation performance, while robustly demonstrating the contribution of simulation-based training. In this regard, the review provides a valuable and up-to-date framework for NTS education in emergency medicine.

However, a crucial point caught our attention. In the reviewed training programs, communication is addressed almost exclusively within the context of the resuscitation team. While closed-loop communication, task allocation, leader-team interaction, and information transfer are discussed in detail, communication with patient relatives during ongoing resuscitation is not specifically addressed.

In our view, this omission invites a critical discussion. Communication during cardiopulmonary arrest does not occur solely among healthcare professionals. Family members waiting outside the resuscitation room in profound uncertainty and anxiety are an inseparable part of this process. Therefore, we believe that communication with patient relatives should be recognized as a core NTS component of high-quality resuscitation, aligning with international guidelines that advocate for structured family-centered care during cardiac arrest [2].

Although the literature on breaking bad news and death notification is extensive, family communication during cardiopulmonary arrest is mostly evaluated through the lens of the final interview where death is pronounced. However, death notification is not an isolated event. The crisis for the family begins the exact moment the patient enters the resuscitation room. Consequently, death notification should be viewed as the final link in a continuous communication process sustained throughout the resuscitation.

Gathering the medical history during the initial family contact and delivering the final prognosis are natural components of daily practice. Conversely, the period between these two milestones is rarely managed within a structured communication framework and relies heavily on the individual experience of the physician. Yet, scheduled family updates during this interim period serve a purpose beyond mere information sharing. These updates represent an active communication intervention that reduces uncertainty, manages expectations, makes the ongoing medical efforts visible, and sustains the trust between the physician and the family. Through this approach, death notification may become the natural continuation of a carefully managed communication process rather than an abrupt and unexpected event.

This communication approach should not impose a rigid number of interviews or standardized phrases. The frequency and content must adapt to the patient’s clinical status, the nature of the event, the expected prognosis, and the psychological characteristics of the family. The communication needs of families facing unexpected traumatic events or sudden cardiac arrest in a young individual differ fundamentally from those dealing with an elderly patient with severe comorbidities. Effective family communication is not a standardized formula; it is a structured yet contextually adaptable professional skill.

We argue that this perspective has significant implications not only for patient relatives but also for medical education. Many early-career physicians experience intense anxiety—not just about breaking the news of death, but about how to navigate the communication process leading up to it [3]. This anxiety is often exacerbated by the fear of encountering anger, blame, or aggressive behavior following a death notification. We believe a substantial portion of this anxiety stems from a perceived inability to manage the communication sequence preceding the final announcement. Teaching communication as a planned, structured, yet flexible process initiated at the very start of resuscitation could improve the family experience while boosting the confidence of novice physicians facing these challenging clinical scenarios.

From an educational perspective, this gap has also become evident throughout years of undergraduate emergency medicine teaching. Consequently, in our training modules for intern physicians, we conceptualize family communication during resuscitation across three distinct phases: initial contact, scheduled interim updates, and the final outcome interview. This approach is not presented as an absolute algorithm, a validated educational model, or a guideline recommendation. Rather, the goal is to equip young physicians with a systematic yet adaptable mental framework to manage communication from the beginning to the end of resuscitation. Evidence from clinical simulations highlights that integrating family interactions into resuscitation training substantially improves communication quality and clinician confidence [4]. We believe the impact of such a phase-based approach on communication skills, communication anxiety, and family experience warrants evaluation in future prospective studies.

In conclusion, the review by Zhang et al. powerfully underscores the significance of NTS in resuscitation. Nevertheless, we believe that expanding the NTS framework in the future—moving beyond inter-team dynamics to encompass communication with patient relatives—will contribute significantly to both medical education programs and patient- and family-centered resuscitation practices.

Author contributions

YK: conceived the idea, reviewed the literature, drafted the manuscript, and approved the final version.

Funding

No funding was received for this work.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics, consent to participate, and consent to publish

Not applicable.

Competing interests

The authors declare no competing interests.