Hola a todos, mis queridos amigos.

Muy interesante artículo en open access en Intensive Care publicado por los Dres. Gerritsen, Hartog y Curtis sobre la evidencia existente en la relación familias-UCI.

Existe una corriente de conciencia mundial sobre la importancia de los miembros de las familias en la UCI, y los autores señalan cuatro razones por las que todo el mundo debería incorporar a los familiares en el equipo terapéutico.

  1. La enfermedad crítica de un ser querido tiene enormes efectos sobre los miembros de la familia (un 25% sufre síntomas psicológicos, pudiendo aparecer el síndrome post-UCI de la familia).
  2. La familia en muchas ocasiones se convierte en la responsable de la toma de decisiones, por lo que el apoyo y la comunicación eficaz es clave.
  3. Los pacientes quieren que sus familias compartan la toma de decisiones sobre su cuidados.
  4. El apoyo a la familia les convierte en cuidadores más eficaces.

En la reciente guía de práctica clínica sobre atención centrada en la familia del grupo de Davidson ya comentada en este espacio por José Manuel Velasco, se realizó una revisión sistemática de la literatura utilizando la metodología GRADE, realizándose 23 recomendaciones que se calificaron como débiles. Se trataban 5 áreas: presencia familiar en la UCI, soporte a las familias, comunicación con los miembros de la familia, uso de consultas específicas con especialistas/miembros del equipo de UCI y aspectos operativos y ambientales. No os perdáis la tabla del artículo que resume estos aspectos y su nivel de evidencia.

Recommendations supported by moderate or weak quality of evidence

Category

Recommendations

Quality of evidence (B = moderate; C = low)

Family presence in the ICU

Family members of critically ill patients be offered the option of participating in interdisciplinary team rounds to improve satisfaction with communication and increase family engagement

C

Family members of critically ill patients be offered the option of being present during resuscitation efforts, with a staff member assigned to support the family

C

Family support

Family members of critically ill neonates be offered the option to be taught how to assist with the care of their critically ill neonate to improve parental confidence and competence in their caregiving role and improve parental psychological health during and after the ICU stay

B

Family education programs be included as part of clinical care as these programs have demonstrated beneficial effects for family members in the ICU by reducing anxiety, depression, post-traumatic stress, and generalized stress while improving family satisfaction with care

C

ICUs provide family with leaflets that give information about the ICU setting to reduce family member anxiety and stress

B

ICU diaries be implemented in ICUs to reduce family member anxiety, depression, and post-traumatic stress

C

Among surrogates of ICU patients who are deemed by a clinician to have a poor prognosis, clinicians use a communication approach, such as the “VALUE” mnemonic (Value family statements, Acknowledge emotions, Listen, Understand the patient as a person, Elicit questions), during family conferences to facilitate clinician–family communication

C

Communication with family members

Routine interdisciplinary family conferences be used in the ICU to improve family satisfaction with communication and trust in clinicians and to reduce conflict between clinicians and family members

C

Healthcare clinicians in the ICU should use structured approaches to communication, such as that included in the “VALUE” mnemonic, when engaging in communication with family members, specifically including active listening, expressions of empathy, and making supportive statements around nonabandonment and decision-making. In addition, we suggest that family members of critically ill patients who are dying be offered a written bereavement brochure to reduce family anxiety, depression, and post-traumatic stress and improve family satisfaction with communication

C

Use of specific consultations and ICU team members

Proactive palliative care consultation be provided to decrease ICU and hospital length of stay among selected critically ill patients (e.g., advanced dementia, global cerebral ischemia after cardiac arrest, patients with prolonged ICU stay, and patients with subarachnoid hemorrhage requiring mechanical ventilation)

C

Ethics consultation be provided to decrease ICU and hospital length of stay among critically ill patients for whom there is a value-related conflict between clinicians and family

C

Family navigators (care coordinator or communication facilitator) be assigned to families throughout the ICU stay to improve family satisfaction with physician communication, decrease psychological symptoms, and reduce costs of care and length of ICU and hospital stay

C

Operational and environmental issues

Protocols be implemented to ensure adequate and standardized use of sedation and analgesia during withdrawal of life support

C

Hospitals implement policies to promote family-centered care in the ICU to improve family experience

C

A pesar de esta relativamente débil evidencia, hay muchas intervenciones que pueden recomendarse en base a las pruebas ya existentes. Cada UCI de manera individual debería revisar estas recomendaciones (como se revisan, se estudian y se conocen otras guías de practica clínica en otras áreas del conocimiento en cuidados críticos), para decidir qué intervenciones tienen sentido y son factibles según los resultados actuales, los intereses del equipo y los recursos disponibles.

La atención centrada en la familia debe considerarse como atención de máxima calidad en cada UCI: acciones de sentido común que puede implementarse sin grandes inversiones económicas o tecnología especial. Pero atención, implementar estos cambios sin prepararnos todos podría ser un error y para evitar esto, desde Proyecto HU-CI apostamos por la formación en #humantools.

En cualquier caso, sigamos investigando para demostrar la evidencia de lo evidente.

Feliz Miércoles

Gabi