139CHAPTER 16 Patient and Family Centered Care in the Pediatric Intensive Care Unit Medicine, endorse offering families the option to remain in close proximity to their loved ones during cardiopulmona[.]
CHAPTER 16 Patient- and Family-Centered Care in the Pediatric Intensive Care Unit Medicine, endorse offering families the option to remain in close proximity to their loved ones during cardiopulmonary resuscitation and invasive procedures.24,25 Allowing family presence has direct benefits for parents and caregivers, including improved satisfaction, better understanding, reduced anxiety, better coping, more emotional stability, and improved adjustment to a child’s death.25–27 Despite these potential benefits, the practice remains controversial Clinicians raise concerns that parental presence may increase the risk for litigation and may impact technical performance, clinical decision-making, and the ability to teach.25,26 In a large single-center study, using formal practice guidelines and interprofessional education to prepare clinicians for parental presence, “few clinicians reported that parent presence affected their technical performance (4%), therapeutic decision-making (5%), or ability to teach (9%).”26 Moreover, recent data suggest that family presence during intubations does not affect the rate of first attempt success, adverse events, or self-reported team stress level, suggesting that family presence during invasive procedures can be safely implemented.28 By developing protocols, institutional policies, education, and dedicated staff resources to allow parental choice and provide support for parental presence during invasive procedures and cardiopulmonary resuscitation, these concerns can be minimized.25 Transition Points and Follow-up Care, including Bereavement Once adjusted to the ICU, many families ultimately appreciate the high level of physician supervision and nursing presence, making transitions to the acute care floor potentially difficult Supporting families through these transitions during the course of an illness is necessary.29 For families who spend an especially long period of time in the ICU, providing families with realistic expectations and allowing families to visit the acute care floor prior to transfer can be beneficial In addition to providing additional support for transitions between different geographic locations in the hospital, developing a framework to help families transition through different approaches to care, from curative to life-prolonging to comfort care, is important.19 Furthermore, using a systematic approach to follow-up with families following the death of child, with condolence letters and formal follow-up meetings, is also necessary to reduce the perception of abandonment and support the bereavement process.17,30–32 Sharing Information Using Collaborative Communication High-quality communication with families is essential in the ICU, where medical information is complex and detailed, highstakes decisions are required, and multiple teams of healthcare providers are involved.33 While there is a spectrum of preferred decision-making roles of families, ranging from an independent and autonomous approach to delegating decisions to clinicians, most families need to be well informed.5 Optimizing communication with families reinforces the development of a partnership with families, acknowledging the important role of parents and caregivers and their unique knowledge of their child The AAP recommends “sharing complete, honest, and unbiased information with patients and their families on an ongoing basis so that they may effectively participate in care and decision making.”1 Over the past decades, there has been extensive research in optimizing communication between healthcare providers, particularly in the ICU and surrounding end-of-life care 139 decision-making.32,34,35 In the ICU, information is shared using three different verbal models, including individual updates at the bedside, family-centered rounds, and formal care conferences Written information may also be provided Often a combination of all of these approaches is necessary to optimize communication with patients and families Depending on the educational, social, and cultural backgrounds of patients and families, in addition to different provider styles, a variety of approaches to communication may be used Elements of High-Quality Communication Sharing medical information is complex and requires a high level of skill among healthcare providers Parents and providers identify a number of barriers to communication in the PICU, including communication breakdown related to care coordination and provider hand-offs, families feeling undervalued or unheard as the experts on their children, and the inadequacy of family-centered morning rounds.36 While using a variety of means to communicate with patients and families is necessary (as detailed earlier), parents cite specific elements of communication as very important.35,37 High-quality elements of communication include “comprehensive and complete information; clarity of information with the use of clear language; ease of access to caregivers and their explanations through the course of care; pacing of information, soliciting of parents’ emotional responses and addressing their questions; consistency of information; honesty, lack of false hope, empathy as demonstrated by verbal and nonverbal, and affective communication; summary statements and next steps.”23 Other important components of high-quality communication include using open-ended questions, soliciting goals, and increasing time families spend speaking.38 Recent research has found that these elements of high-quality patient- and family-centered communication are associated with higher parent satisfaction when incorporated into family conferences in the PICU.39 A useful tool to help clinicians practice high-quality communication is the VALUE mnemonic, in which family statements are valued, family emotions are acknowledged, the family is listened to, the patient is understood as a person, and family questions are elicited.40 This mnemonic emphasizes the importance of using collaborative communication, or a form of communication in which interpersonal communication and the relationship between the parties are “inexorably entwined.”20 Collaborative communication can accomplish at least five important tasks in PFCC, including (1) establishing a set of goals that guides collaborative efforts; (2) exhibiting mutual respect and compassion for each other; (3) developing sufficient understanding of differing perspectives; (4) ensuring maximum clarity and correctness of what is communicated; and (5) managing intrapersonal and interpersonal processes that affect how information is sent, received, and processed.20 When used consistently in family conferences, evidence suggests that the VALUE mnemonic is associated with lower family symptoms of anxiety, PTSD, and depression.41 Particularly in the setting of the ICU, optimizing these elements of high-quality communication may be difficult owing to the number of healthcare team providers involved and the short time frame in which news must be delivered Therefore, adequate training for all healthcare providers who interact with families is essential In addition, when patients spend prolonged periods of time within the ICU or have multiple subspecialty services involved, the identification of a continuity provider whose role is to maintain consistency in the healthcare plan while ensuring adequate communication with the family may be beneficial 140 S E C T I O N I I I Pediatric Critical Care: Psychosocial and Societal However, current evidence is inadequate to demonstrate clear benefit of or harm from increasing staffing consistency.42 Furthermore, using a team approach with respectful and excellent communication among team members, including physicians and nurses, ensures that clear, consistent, and comprehensive information is shared in an empathetic manner Collaboration within the healthcare team results in improved overall outcomes in critical care, including increased patient survival, decreased length of stay, and decreased readmission rates, in addition to improved patient and family satisfaction, decreased symptoms of anxiety and depression among family members, and reduced ICU nurse and physician burnout.40 Family-Centered Rounds Rounds in the ICU serve several purposes, including (1) to provide a setting for decision-making related to the management of the child’s care; (2) to ensure adequate communication among healthcare team members; and (3) to allow for teaching of medical students, residents, and other trainees.43 Incorporating the patient and family into these rounds fosters a partnership with the family and aligns with a patient- and family-centered approach While larger and more extensive studies are necessary to fully determine the benefits and potential barriers to this approach, many professional organizations endorse it According to several pediatric studies, this approach improves family satisfaction, improves communication between all stakeholders, increases family trust in the medical team, and potentially improves the quality of medical care provided, leading to shorter lengths of stay.44–46 Several potential barriers and healthcare provider concerns regarding this approach include (1) prolongation of rounds, (2) breach of confidentiality of protected health information, (3) reduced opportunities for teaching, and (4) concern for undermining trust of the healthcare team when different opinions are shared or teaching is done.43,45,47 Current evidence suggests that family presence on rounds does increase per patient rounding times.48 However, family-centered rounds exhibit other benefits Family-centered rounds have demonstrated improved efficiency and communication because family concerns are addressed with clarity, preventing communication gaps and confusion In addition, family presence usually lends itself to additional teaching opportunities.45,47 Finally, when surveyed, the majority of parents are not concerned about privacy issues Therefore this concern can easily be discussed with parents on an individual basis.40,42,44 To remain effective and efficient, using a family-centered approach to rounding requires thoughtful planning and following specific guidelines to streamline the process Highlighting the purpose of rounds to all stakeholders and identifying explicit roles prior to rounds can help prevent misunderstandings.43 Structured Transdisciplinary Care Conferences In critical care, in which illnesses are life threatening and changes occur rapidly, sharing information with frequent updates at the bedside is crucial Furthermore, in circumstances in which medical decision-making is highly complex, multiple subspecialties and disciplines are involved, or the severity of illness may lead to the demise of the patient, proactive and timely structured transdisciplinary care conferences may also be beneficial.40 Although there is variability in the approach and style of these conferences, the palliative care and adult critical care literature provides a general framework for the facilitation of these conferences and highlights several tools.20,40,41,49,50 In adult critical care, specific aspects of these conferences are associated with increased quality of care, decreased family psychological symptoms, improved family ratings of communication, and improved outcomes These aspects include timeliness (occur within 72 hours of ICU admission), private location for the conference, consistent communication by all members of the healthcare team, increased proportion of time spent listening to families speak, the use of empathetic statements, assurance that the loved one will not suffer, and providing explicit support for decisions made by the family.40,41 Current pediatric research suggests that pediatric intensivists fail to incorporate certain aspects that make transdisciplinary conferences effective for furthering PFCC Often pediatric intensivists dominate conversations in family conferences, focus mostly on the medical aspects of care, and use complex speech, possibly preventing valuable family engagement in these conferences.39 While additional research is needed to detail the benefits and potential negative aspects of this format for communication in the pediatric patient population, using elements of high-quality communication should be considered as potentially useful to optimize communication with families Providing Transdisciplinary Support for the Family Unit Fundamental to PFCC is “providing and ensuring formal and informal support for the child and family for each phase of the child’s life.”1 Owing to the complex nature of pediatric critical illness and the high level of emotional distress triggered by hospitalization, a transdisciplinary team approach is necessary to provide full support for the patient and family, including siblings, who are at high risk for feeling abandoned and neglected Acknowledging that patients and families enter the ICU with varying degrees of internal coping mechanisms in addition to external support systems is critical to optimizing support Teams from a multitude of disciplines, all with different expertise, should be incorporated into the healthcare team, when appropriate, to help demonstrate the value in providing a holistic approach to care Nurses at the bedside play a crucial role in recognizing family coping strategies, identifying unmet family needs, and bridging gaps in communication.7 Consultation with subspecialists in palliative care and ethics should be considered early in the course of hospitalization to improve communication, prevent conflict, identify important goals through eliciting patient values and preferences, and ultimately optimize shared medical decisionmaking.5 Physical therapy, occupational therapy, and rehabilitation medicine should be incorporated into the patient’s care using a systematic approach to assist with functional recovery and potentially improve long-term quality of life Specialists in music therapy, art therapy, pet therapy, psychology, child life, and educational services can improve the quality of life in the ICU and reduce ICU-related morbidities, such as anxiety, depression, delirium, psychosis, and PTSD.4,7 Social workers can provide assistance to reduce both emotional distress and stressors that arise from practical aspects of having a child hospitalized, such as food, transportation, and employment, while chaplains can address the spiritual needs of the patient and family.5,13,51 With the multitudes of providers involved, excellent communication is necessary to avoid additional stressors to families that inconsistent messaging can cause In addition to incorporating healthcare providers from multiple disciplines, peer-to-peer support can also be highly beneficial.1 Families may choose to serve on patient advocacy committees, CHAPTER 16 Patient- and Family-Centered Care in the Pediatric Intensive Care Unit share their experiences with other families through family support groups, and volunteer to serve as consultants to other families who are affected by similar disease processes or experiences Allowing families who are in a crisis mode to contact and access other families who have shared similar experiences may broaden coping mechanisms and may help guide families through their journey, particularly when they are faced with making very difficult decisions Collaborating and Building Partnerships with Patients and Families Developing a partnership with families is essential to fulfilling the fundamental principles of PFCC A partnership requires an “interpersonal relationship between two or more people who work together to achieve a mutually defined purpose” which, in the PICU, is “providing the best possible care for the child from a holistic perspective.”52 The holistic approach requires inclusion of the family, as the center of strength for the child When partnering with parents and caregivers, who know the child best and provide invaluable information regarding who the child is as a person, healthcare providers treat the child more effectively and address the child’s needs more appropriately.45 This partnership allows parents and healthcare providers to contribute their own expertise to achieve a common goal, leading to a relationship in which the power differential between healthcare providers and families equalizes.10 While building a partnership with patients and families at the bedside is essential, optimizing PFCC also requires collaboration “at all levels of healthcare: in the delivery of care to the individual child; in professional education, policy making, program development, implementation, and evaluation; and in healthcare facility design.”1 Encouraging families to participate in all dimensions of healthcare through serving on family advisory councils, quality improvement projects, and developing research protocols is critical.1 Furthermore, building this partnership requires a transdisciplinary approach and is “grounded in collaboration among patients, families, physicians, nurses, and other professionals in clinical care.”1 In order to optimize these relationships, clarity and transparency regarding the roles, boundaries, and expertise of each stakeholder is critical.53 Empowering Patients and Families to Facilitate Shared Medical Decision-Making PFCC is optimized through “recognizing and building on the strengths of individual children and families and empowering them to discover their own strengths, build confidence, and participate in making choices and decisions about their healthcare.”1 Empowering the patient and family to participate in shared decision-making is fundamental, for “the perspectives and information provided by families, children, and young adults are essential components of high-quality clinical decision-making.”1 In the setting of the ICU, complex and high-stakes decisions are made in a short time frame In many circumstances, there is a high degree of uncertainty in outcomes, making these decisions even more difficult The majority of these clinical decisions are based on the medical expertise, empirical evidence, experience of the healthcare providers and consultants, and—most importantly—values and perspectives of the patient and family By definition, shared decision-making occurs when both the physician and patient (if possible) and family “share their opinions 141 and jointly reach a decision.”40 Dimensions of shared decisionmaking include (1) providing medical information and eliciting patient values, preferences, and goals; (2) exploring family’s preferred role in decision-making; and (3) deliberation and decisionmaking.40,54 Collaborative communication, as discussed earlier in this chapter, is required to adequately fulfill the first dimension In regard to dimension two, multiple studies demonstrate that families have varying decision-making preferences, particularly regarding limitation of life support or other aggressive interventions.5,40 Therefore prior to making assumptions, exploring the family’s preferential role in decision-making is important Furthermore, shared decision-making should not be interpreted as allowing the family to decide without support from the providers or giving families increased responsibility or autonomy,12 as “there is a fine balance between supporting and guiding a family while allowing the family appropriate space to make their own decisions.”23 Most families not want to feel alone when making difficult decisions Recommendations and guidance from providers may help alleviate potential burdens associated with making difficult decisions Finally, shared decision-making does not mean that families should exclusively drive medical care or be empowered to make decisions that are not medically sound The key aspect of shared decision-making is that the process is collaborative and incorporates the opinions and expertise of all stakeholders Finding the right balance among stakeholders to achieve goal-oriented patient care through established frameworks for shared decision-making is necessary to provide optimal PFCC.54 There are multiple benefits associated with shared decisionmaking When patients and families become active participants in their healthcare, there is improved understanding and more motivation to follow through with care In addition, for parents and caregivers who lose their sense of control with the hospitalization of a critically ill child, participating in decisions can provide a great source of strength As one mother explains, “I was able to still be her mom.”55 By “encouraging them to continue actively in their parental role by promoting shared decision making and helping the family to retain their responsibilities throughout hospitalization” parents and caregivers retain their identities, which fosters the integrity of the parent-child relationship, maintains cultural and family traditions, and demonstrates respect for and value of the child as a person.52,55 Although further studies are necessary to elucidate the important driving factors for parental decision-making, parents overall want to be “good parents.”56 Understanding what parents value as important factors in “being a good parent” potentially may improve the quality of PFCC.56 Patient- and Family-Centered Care Improves Outcomes for all Stakeholders Over the past decades, PFCC has improved outcomes in the provision of high-quality patient care According to the AAP, “patient and family-centered care can improve patient and family outcomes, improve the patient’s and family’s experience, increase patient and family satisfaction, build on child and family strengths, increase professional satisfaction, decrease healthcare costs, and lead to more effective use of healthcare resources.”1 According to numerous studies, patients and families directly benefit from the incorporation of the fundamental principles into practice Patients and families have reduced anxiety, better cooperation, improved satisfaction, reduced emotional distress, better 142 S E C T I O N I I I Pediatric Critical Care: Psychosocial and Societal adjustment to hospitalization, and faster recovery from illness and surgery.1,8 Because the needs of families are addressed more explicitly, families also have improved functioning, increased confidence in providing ongoing care to their child, are more willing to seek help from healthcare providers, develop a greater degree of trust, and demonstrate improved competence in problem-solving and making complicated healthcare decisions.1,8 When families receive clear and consistent communication and actively participate in the care of their child, they experience a greater sense of control, resulting in preservation of the parent-child relationship, with reduced anxiety, posttraumatic stress, and complicated grief.8 Implementing PFCC in PICUs has special implications in the setting of pediatric death The majority of inpatient pediatric deaths occur in the PICU Current end-of-life practices in the ICU are suboptimal Families describe disempowerment, loss of control, and alienation from their dying child in the ICU as a result of both their child’s illness and the cultural and physical environment in the PICU.57 Moreover, bereaved parents are at risk for adverse mental and physical health after their child’s death.58 Compassionate and empathetic PFCC in PICUs may help improve end-of-life care and mitigate bereavement outcomes by helping parents preserve their parental role, engaging families more, maintaining the pediatric patient’s personhood, and fostering meaning making.57 Healthcare providers, institutions, and the healthcare systems also directly benefit from PFCC When healthcare providers gain important insights into the needs and values of patients and their families, they establish trusting relationships and improve the quality, efficiency, and safety of the care they provide As a result, providers have improved work satisfaction, which leads to improved job performance, reduced burnout, and decreased staff turnover.1 With the provision of higher-quality care, healthcare institutions and systems benefit with reduced healthcare costs, improved patient and family satisfaction, reduced risk for litigation, and potentially gain a more competitive position in the marketplace.1 Overcoming Barriers and Challenges to Patient- and Family-Centered Care in the Intensive Care Unit While significant progress has been made in incorporating PFCC into the ICU, there remains a gap between current and proposed practice Ongoing research reveals that families continue to express that their needs are not always met.2,8,15,17,22 While the reason for this gap in practice is likely multifactorial, there are several barriers that are extremely challenging to overcome (Box 16.1) First, there is a fundamental difference in perceiving the ICU as a “bedroom” versus an “office.”21 For families, the ICU needs to serve as a bedroom, where a sick child can experience warmth, comfort, and a healing environment On the other hand, critical care providers need an office equipped with computers, monitors, alarms, and advanced technology This dichotomy fundamentally inhibits the creation of a bedroom and reinforces the role of “the visitor” and “the patient,” rather than fostering a collaborative partnership.21 Second, the emotional intensity of life-altering and life-threatening circumstances is unavoidable The impact of this emotional intensity on patients and families and the complexity of the medical care provided creates an implicit power differential between healthcare providers, patients, and families, further reducing the ability to develop a partnership Finally, the necessity • BOX 16.1 Potential Barriers to Patient- and Family- Centered Care in the Intensive Care Unit • Dichotomy in patient, family, and provider needs of the ICU as a “bedroom” versus an “office” • Emotional intensity of life-altering and life-threatening circumstances • High-stakes nature and complexity of medical decision-making, requiring explicit value-based decisions • Implicit and explicit power differential between healthcare providers, patients, and families • Lack of or minimal formal training in high-quality communication skills for healthcare providers • Enhancement of cultural and language barriers in the fast-paced, emotionally intense, and complex setting • Healthcare provider misperception of increased risk for litigation, distraction, and the inability to teach trainees with greater family involvement • Increased complexity of patient population, leading to medical- and technology-savvy families who have different needs and potentially require different models of care of making high-stakes decisions wrought with uncertainty exposes fundamental differences in belief and value systems that are potentially challenging to overcome Even under ideal circumstances with the most advanced communication systems and extensive training in cultural humility, these differences can create intense barriers and conflict rooted in different perceptions of what is in the best interest of the patient These conflicts further prohibit the development of partnership Overcoming these fundamental barriers requires acknowledgment, transparency, and further research to identify both the explicit and implicit practices and values within the ICU (Box 16.2).21 Using a model of PFCC, this research requires employing a collaborative approach in which all stakeholders have an equal voice in order to develop creative solutions In addition to these fundamental barriers, there is an increasing complexity to the patient population that requires the PICU Accommodating the needs of medically complex children’s parents who are medically and technology savvy may require different models of care.59 PICUs need to be able to fully accommodate for the “skills and expertise” of families of chronically ill and medically complex patients: “there is a clear need for research that identifies what constitutes success to these families, along with the challenges faced by staff who care for them…[in order to] change practice and foster a culture of supportive care inside the PICU.”59 • BOX 16.2 Overcoming Barriers to Patient- and Family-Centered Care in the Intensive Care Unit • Provide formal training in cultural humility; develop a robust interpreter service and hire cultural navigators • Provide formal training in collaborative communication and goal-oriented, shared medical decision-making • Include patient and family input for intensive care unit (ICU) policies, procedures, planning, and delivery of healthcare • Acknowledge and maintain transparency regarding implicit and explicit values and practices in the ICU • Support and engage in patient- and family-centered care research to identify and overcome additional barriers • Develop adequate support systems for healthcare providers who suffer from compassion fatigue and vicarious trauma CHAPTER 16 Patient- and Family-Centered Care in the Pediatric Intensive Care Unit PFCC is not equivalent to family-driven care, in which families exclusively direct the medical care, dominating the relationship The establishment of professional boundaries and specific roles is critical in the development of mutually respectful and collaborative partnerships Despite the knowledge that high-quality communication is an essential component of providing comprehensive PFCC, physicians’ communication skills remain suboptimal Adult and pediatric communication literature has consistently demonstrated that family satisfaction with PFCC is associated with a higher proportion of family speech, empathetic statements, and specific statements of support, as outlined in previous sections of this chapter.39 Yet when participating in care conferences, physicians use complex language, speak for the majority of the time, and miss one-third of families’ emotional cues.38,60 Further research is needed to understand how physicians’ communication skills can be improved and whether training programs can be implemented to improve PFCC.42 Finally, the development of compassion fatigue and secondary traumatization experienced by healthcare providers who are witnesses to extreme suffering of children and families in this complex environment can lead to disengagement from patients and families.61 High clinical workloads and demanding extraneous professional obligations can lead to provider burnout and loss of the ability to maintain an empathetic approach to patients and families Therefore the needs of healthcare providers should also be explicitly recognized and addressed by institutions and healthcare systems in order to improve the quality of PFCC delivered Summary The pediatric critical care unit is a complex environment that creates a high level of stress for patients and families Incorporating PFCC into practice improves patient and family satisfaction, reduces stress and anxiety, fosters the parent-child relationship, and ultimately increases the quality, efficacy, efficiency, and safety of care delivered Developing a partnership with patients and families built on mutual respect, using collaborative communication, providing extensive support for the family unit, and encouraging patient and family participation in all aspects of care, including shared medical decision-making, are fundamental principles essential to the practice of PFCC Overcoming real and 143 perceived barriers to incorporating PFCC into practice requires a collaborative and transparent approach involving all stakeholders to identify creative solutions while providing adequate support to healthcare providers, who are at risk for compassion fatigue, secondary traumatization, and burnout Key References Committee on Hospital Care, Institute for Patient- and Family-Centered Care Patient- and family-centered care and the pediatrician’s role Pediatrics 2012;129(2):394-404 Davidson JE, Aslakson RA, Long AC, et al Guidelines for familycentered care in the neonatal, pediatric, and adult ICU Crit Care Med 2017;45(1):103-128 Doorenbos A, Lindhorst T, Starks H, Aisenberg E, Curtis JR, Hays R Palliative care in the pediatric ICU: challenges and opportunities for family-centered practice J Soc Work End Life Palliat Care 2012; 8(4):297-315 Feudtner C Collaborative communication in pediatric palliative care: a foundation for problem-solving and decision-making Pediatr Clin North Am 2007;54(5):583-607, ix Greenway TL, Rosenthal MS, Murtha TD, Kandil SB, Talento DL, Couloures KG Barriers to communication in a PICU: a qualitative investigation of family and provider perceptions Pediatr Crit Care Med 2019;20:e415-e422 Hill C, Knafl KA, Santacroce SJ Family-centered care from the perspective of parents of children cared for in a pediatric intensive care unit: an integrative review J Pediatr Nurs 2017;S0882-5963(17):3053130536 Macdonald ME, Liben S, Carnevale FA, Cohen SR An office or a bedroom? Challenges for family-centered care in the pediatric intensive care unit J Child Health Care 2012;16(3):237-249 McGraw SA, Truog RD, Solomon MZ, Cohen-Bearak A, Sellers DE, Meyer EC “I was able to still be her mom”—parenting at end of life in the pediatric intensive care unit Pediatr Crit Care Med 2012;13(6): e350-356 Meert KL, Clark J, Eggly S Family-centered care in the pediatric intensive care unit Pediatr Clin North Am 2013;60(3):761-772 October TW, Fisher KR, Feudtner C, Hinds PS The parent perspective: “being a good parent” when making critical decisions in the PICU Pediatr Crit Care Med 2014;15(4):291-298 The full reference list for this chapter is available at ExpertConsult.com ... determine the benefits and potential barriers to this approach, many professional organizations endorse it According to several pediatric studies, this approach improves family satisfaction, improves... research to identify both the explicit and implicit practices and values within the ICU (Box 16.2).21 Using a model of PFCC, this research requires employing a collaborative approach in which all... in previous sections of this chapter.39 Yet when participating in care conferences, physicians use complex language, speak for the majority of the time, and miss one-third of families’ emotional