A 5-point strategy for improved connection with relatives of critically ill patients with COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has spread throughout the world, leading hospitals to expand their critical-care capacity.¹ Logistics in times of surging demand are challenging. Health-care providers are overwhelmed by the relentless workload and tend to focus on the patients, as they have little time for family-centred care.

In many places, a nearly complete lockdown combined with stringent social distancing measures have been put in place in an attempt to curb the spread of the COVID-19 pandemic. Hospital visits are prohibited to ensure that relatives do not contaminate other family members, patients, or health-care professionals. However, the burden on intensive care unit (ICU) relatives of patients with COVID-19 is particularly heavy.² The lockdown imposed by many governments can result in confusion, stress, frustration, anger, communication gaps, and post-traumatic stress-related symptoms.³ People are more exposed than usual to the media, whose messages often cause additional distress. Moreover, studies have shown that family members of survivors of acute respiratory distress syndrome have higher rates of post-ICU burden than the patients themselves.4, 5 Masks and other protective equipment hamper the ability of health-care professionals to express empathy and provide fine-tuned communication. As a result, patients could be in a suboptimal position to make decisions, and families might feel frustrated. Finally, post-traumatic stress disorder is significantly more common in bereaved relatives when the patients were seen with shortness of breath before death.⁶

We suggest a 5-point strategy to foster a positive connection between patients, relatives, and health-care professionals during the COVID-19 pandemic (panel ). Studies are needed to identify the specific communication needs of relatives of critically ill patients with COVID-19. Moreover, whether these family members suffer a greater post-ICU burden than relatives of other ICU patients with acute respiratory failure (for instance, due to community-acquired pneumonia or influenza) deserves further exploration. This 5-S strategy to maintain the connection with families and patients with COVID-19 aims primarily to improve communication with highly vulnerable relatives. Post-traumatic stress disorder has been shown to be associated with suboptimal communication, particularly in relatives of patients who died in the ICU.⁸ In this setting, the quality of interactions between family and health-care professionals is a major determinant of complicated grief.⁶

Panel. A 5-point (5S) strategy to maintain the connection with relatives of critically ill patients with COVID-19.

• 1Stimulate family visits by restricting them to the closest relative who is asymptomatic and able to apply optimal personal protective measures.
• 2Standardised written information for the relatives. This letter is sent to the relatives but also discussed during the first remote call between the health-care professionals and the family.
• 3Schedule routine telephone calls with the relatives to maintain continuity of communication. The calls could be made by a medical student, a non-ICU physician, another health-care professional, or a volunteer. In addition to these calls, family members are invited to call the physician and bedside nurse once a day to receive basic information. More detailed information is to be provided during a face-to-face meeting when the relative visits the patient. For conscious patients, smartphones and digital tablets can allow video calls or virtual ICU visits.
• 4Stay in touch by encouraging the family to find ways to improve the link with the relative (web-based remote family conferences, diaries, drawings, text messages, and media groups).
• 5Switch to a different approach in end-of-life situations to avoid depriving family members of the opportunity to say goodbye to a relative. For example, family conferences should be organised, remotely if needed, to meet family needs and prepare for the bereavement.⁷ The relative should be allowed to stay in the room as much as possible. However, safety of the relative is a primary concern, and the health-care professionals must provide the relative with training in the use of personal protective equipment.