Professional communication practices in intensive care: a systematic reviewAbstract
Communication is fundamental when exchanging information and providing emotional support in healthcare contexts, especially in critical illnesses and palliative care. Empathy allows professionals to understand the needs of patients and family members, promoting respectful and continuous communication that takes into account the preferences discussed during treatment. However, many of those involved face difficulties in receiving and conveying clear information. Issues such as the use of technical jargon, insensitive approaches, and professional distress are common. Training and practices that prioritize empathy and clarity are essential, as is the action of healthcare professionals in accordance with the specific legal precepts of each country. This is a systematic review that analyzes the attitudes of healthcare professionals in communicating bad news in intensive care units, in different cultural and legal contexts, focusing on the perceptions of the multidisciplinary team.
Keywords:
Hospital communication systems; Health communication; Psychology, medical; Health personnel; Professional-patient relations; Critical illness; Intensive care units
Resumo
A comunicação é crucial na troca de informações e no apoio emocional no contexto da saúde, especialmente em doenças críticas e cuidados paliativos. A empatia permite que profissionais compreendam as necessidades de pacientes e familiares, favorecendo uma comunicação respeitosa e contínua e que considere as preferências discutidas durante o tratamento. Entretanto, muitos dos envolvidos enfrentam dificuldades em receber e transmitir informações claras. Questões como uso de jargão técnico, abordagem insensível e sofrimento profissional são frequentes. Capacitação e práticas que priorizem empatia e clareza são fundamentais, assim como uma atuação dos profissionais de saúde em conformidade com os preceitos legais específicos de cada país. Este estudo consiste em uma revisão sistemática que analisa as atitudes dos profissionais de saúde na comunicação de más notícias em unidades de terapia intensiva, em diversos contextos culturais e jurídicos, com foco nas percepções da equipe multidisciplinar.
Palavras-chave:
Sistemas de comunicação no hospital; Comunicação em saúde; Psicologia médica; Pessoal de saúde; Relações profissional-paciente; Estado terminal; Unidades de terapia intensiva
Resumen
La comunicación es fundamental para intercambiar informaciones y en el apoyo emocional en contextos de la salud, especialmente en enfermedades críticas y cuidados paliativos. La empatía permite a los profesionales comprender las necesidades de los pacientes y sus familiares, lo que favorece una comunicación respetuosa y continua que tiene en cuenta las preferencias discutidas durante el tratamiento. Sin embargo, muchos de los involucrados enfrentan dificultades para recibir y transmitir información clara. Son frecuentes cuestiones como el uso de jerga técnica, el enfoque insensible y el sufrimiento profesional. La capacitación y las prácticas que priorizan la empatía y la claridad son fundamentales, así como la actuación de los profesionales de la salud de conformidad con los preceptos legales específicos de cada país. Este estudio consiste en una revisión sistemática que analiza las actitudes de los profesionales de la salud en la comunicación de malas noticias en unidades de terapia intensiva, en diversos contextos culturales y jurídicos, centrándose en las percepciones del equipo multidisciplinario.
Palabras clave:
Sistemas de comunicación en hospital; Comunicación en salud; Psicología médica; Personal de salud; Relaciones profesional-paciente; Enfermedad crítica; Unidades de cuidados intensivos
Communication is an essential element in informational and emotional exchanges between individuals and has a primary function in healthcare contexts, especially in interactions between professionals, patients, and family members 1. Breaking bad news (BBN) in healthcare refers to conveying information that radically transforms a patient’s prospect, which normally relates to diagnoses and management of serious illnesses 2. BBN in intensive care units (ICU) causes anxiety in families, hence the need for effective communication by healthcare teams 1. Scarce resources and lacking communication training can affect clinical practice 3.
Healthcare providers often view communication as a mere obligation and adopt indirect approaches in informational exchanges 4. Bidirectional interaction is fundamental for effective communication, which must balance honesty and optimism. The intervention of the multidisciplinary team is crucial in emotional support for families 5, with family-centered care being vital to promote dignity and collaboration 6. Also relevant is professional-targeted psychological support, which should include adaptation of work structures, self-care practices, meetings, and supervision 7.
Communication—improved by means of interaction and training—is essential to mitigate professional stress and increase patient satisfaction 4. However, BBN training is still deficient, which results in patient dissatisfaction and emotional challenges faced by professionals 2,8. Protocols have been established to guide this communication, such as SPIKES 8, PEWTER, and ABCDE, which have proven highly beneficial when implemented in training 4.
This systematic review aims to assess the role of healthcare professionals in BBN in ICU by analyzing the perceptions of professionals involved, the strategies employed, and the training necessary for such competence.
Method
The study objective was defined according to the SPIDER strategy 9, based on the following question: “What is the role of healthcare professionals and what are the perceptions of those involved in BBN in ICU?”. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 10 guidelines, with registration in the International Prospective Register of Systematic Reviews (PROSPERO) under identification CRD42024612860.
The article search was performed on October 12, 2024, in the indexing databases: PubMed, Scopus, Web of Science, Lilacs, SciELO, and PsycINFO. We used a combination of terms related to “breaking bad news” and “intensive care.” We filtered articles in English, Portuguese, and Spanish published since 2004: this time frame seeks to ensure the currency of the scientific debate with studies based on the SPIKES 8 protocol, whose subsequent influence standardized the communication of bad news and the training of health care professionals. Only original articles were included, i.e., review articles, book chapters, editorials, and conference proceedings were excluded. The exact search keys for each indexing database are presented in Chart 1.
The articles were analyzed in the Rayyan 11 application, in order to eliminate duplicates. In the selection of articles for full-text reading, two reviewers (ASL/LMB) independently analyzed titles and abstracts and resolved any conflicts by consensus. We selected articles that analyze, discuss, or describe the professionals’ perceptions of BBN in ICU. Articles involving only patient and family perceptions were excluded. We also excluded: studies of patients and/or professionals outside the ICU; articles that do not address the communication of news in ICU; studies that exclusively address other aspects, such as the professionals’ perceptions of patient and family suffering due to illness.
According to the same criteria, the three authors, divided into pairs and in independent analysis, selected the articles for review after full reading. Any conflicts were resolved by consensus among all authors. The articles included in the review were independently analyzed by the same pairs, with extraction of data, which were collected and managed in the REDCap application (Yale University) 12. Any discrepancies were resolved by consensus by the pairs of reviewers.
For each study, we extracted the following information, when applicable: author; year and journal of publication; country where the study was conducted; study objectives, design, and methodology; type of ICU; number of study centers; professional involved in communication; number of participants; professionals’ perception; authors’ conclusions; and protocols applied in BBN.
The quantitative and qualitative results, including the perceptions and attitudes of health care professionals, were presented in a table or described and discussed in the body of the article. As this is secondary research with no subjects directly involved in the study, this work was not submitted for approval by a research ethics committee.
Results and discussion
Of the 201 potentially relevant titles and abstracts found in the indexing databases, 46 articles were selected for full reading, 20 of which were included in the systematic review (Figure 1). Chart 2 presents a description of the included articles.
From the 20 articles, we extracted 308 different items related to the health care professionals’ perceptions and attitudes about BBN. The items were organized into six thematic groups, which are categorized and synthesized below.
Strategies and management
Interprofessional synergy is essential in the ICU, where collaboration has shown reduced mortality and improved quality of care 33. The multidisciplinary team is fundamental for providing holistic patient care. Nurses, psychologists, social workers, and physical therapists have specialized profiles that contribute to the therapeutic plan and patient care. Different countries have specific legislations that regulate professional practice. In Brazil, acts directly associated with nosological diagnosis, determination of clinical prognosis, and definition of therapeutic conduct are restricted to medical practice 34, and other team members can participate as facilitators in the adoption of conducts prescribed by the physician or in educational and emotional support initiatives 35.
BBN requires technical preparation and ethical sensitivity, and physicians cannot transfer such responsibility to other team members 35,36. However, the multidisciplinary team’s work is essential to expand care and provide comprehensive, patient-centered support complementarily, without replacing physicians 35. Physician skills are exclusive, but joint work with the multidisciplinary team enhances the quality of patient care 37.
Physicians often face insecurity in BBN, given the emphasis of their training on preserving life 18,26. The communication of death, due to being primarily a task of physicians, can result in the health care team lacking co-responsibility in supporting family members 18. Nursing work is crucial, as it fosters bonds with family members, enabling nurses to play their role as caregivers during these difficult times 21. Physicians often seek the collaboration of other team members in difficult situations, which favors a caring environment 21,32.
Encouraged to participate in conversations, nurses and physical therapists contribute to improving communication with families and providing information about patient care 30. The presence of psychologists and/or chaplains provides general support and is essential for improving communication and alleviating associated stress, helping patients and families find balance in critical times 16,32. Psychological support helps professionals manage emotions and understand familial dynamics 13,16. Co-responsibility among all is key for mitigating stress in BBN 13.
BBN is complex and can involve family and friends, many of whom wish to participate in the conversations. However, including everyone is not always possible, and physicians must assess who is most able to understand the information and make decisions on behalf of the patient 32. Choosing representatives is not always easy, as it is sometimes complicated by emotional, linguistic, and educational barriers 32. Physicians generally include in conversations close family members who exhibit the ability to understand medical information. In situations of family disputes, it is important to include representatives from both sides to avoid conflicts and ensure balanced communication 32.
Whenever possible, the patient should be included in discussions about their treatment 36. In the impossibility of doing so, the team must assess the wishes expressed by the patient in conjunction with the family 16. In situations of difficult understanding, it is essential to include other family members to provide support and facilitate the interpretation of the news 25. In the context of the neonatal ICU, meetings should be held with both parents in private settings, so communication is effective 30.
Meetings between professionals, patients, and families should be planned and are essential for decision-making, promoting comfort, facilitating understanding, and providing emotional support, in addition to improving treatment outcomes 38. BBN should occur in private and relaxing settings 4. However, the choice of setting is influenced by different factors, although it does not directly influence the outcome. Physicians prefer conference rooms, especially for discussing care redirection, such as transition to palliative care. Others choose bedside meetings for patient participation 27.
The effectiveness of BBN depends on the professionals’ sensitivity and flexibility in adapting communication techniques to the patients’ cultural context 39 and familial context 24. Preparation for conversation, both from a technical and emotional standpoint, involves setting aside special time for communication and managing one’s own feelings 26,31. As a strategy, physicians initially question family members as to their knowledge about the patient’s condition with open-ended questions, to check their prior understanding and perceived emotional states 25,32.
BBN is considered a task that requires a sense of involvement and responsibility from healthcare professionals 15. Understanding and managing the factors that contribute to conversational difficulty leads to a more effective and satisfying experience for both the team and the family members 40. Managing expectations is crucial, especially when curative treatment is not viable, and doctors should address the possibility of death with composure 13. Suggestions include improving sensitivity, using religiosity as support, dedicating time for listening, and valuing humanization in care 14.
Communication should be gradual and adaptive 40 and respect the family’s will to participate in decision-making 25. Unfavorable news should not be communicated abruptly 13. Whenever possible and relevant, professionals should involve relatives in the farewell process and allow them to participate in significant moments—for example, allowing the mother to hold her baby—if they wish, to facilitate grieving 25.
Humanized communication creates a caring environment and is essential for overcoming barriers. It should integrate verbal and non-verbal aspects, such as body language and emotions 16. The effectiveness of communication influences family experiences during delicate moments 15. Empathy is crucial in emotional management. Physicians must show availability and support, in addition to openness for accommodating family decisions as needed 16.
Empathy is considered an essential skill in BBN, which can be learned and developed 19,24. Providing “a word of affection” and emotional support is fundamental for valuing families during the process 21. Empathetic communication promotes co-responsibility and participation in treatment, which are essential for the well-being of everyone involved 16.
Compassionate approaches include complete explanations and supportive information, which help families feel well-informed 30. Clarity and honesty are essential to enable families to make decisions. Professionals must explain the pathology, treatment options, and prognosis in a direct and realistic manner 16,32. Despite adversities, honest and caring dialogue facilitates understanding and creates an environment of emotional support 13. Communication must be clear, without aggression 25, based on a bilateral exchange marked by equality and respect 3, in order to enable family members to understand the seriousness of the situation and make informed decisions. Guiding access to external information, when requested, and adopting an optimistic approach helps families cope with such a difficult period 5.
Emotional aspects of professionals
BBN causes significant anxiety in both the sender and receiver of information, which shows the complexity of this interaction 22. The factors that contribute to make conversations difficult can be related to the physician, the patient, the situation, or a combination of them 40. Breaking bad news can have a significant emotional impact on the physician, who often feels the burden of this negative information and anticipates negative reactions 41. Professionals experience anticipatory stress, which results in physical symptoms such as increased heart rate and anxiety 1,13, reflecting the emotional burden of the work 14. All team members face considerable distress due to patient pain. Manifest crying during conversations, anxiety, depression, and burnout syndrome are common among professionals 22.
Humanized care projects often do not include emotional support for professionals 14. Family despair exacerbates the emotional stress of professionals 26, who need to deal with pain and death, developing feelings of fragility and vulnerability, which are not always shared 25.
The unpredictability of the conversations increases anguish and impacts the professionals’ personal life and confidence, leading them to adopt emotional detachment strategies, which cause conflicts between care and self-preservation 7. Although professionals believe they are doing the best they can, they feel the emotional and physical burden of BBN 20. The tension between empathy and technical capacity makes emotion a problem, not a tool 14. The pressure for infallibility and the lack of support contribute to unrecognized stress and a feeling of isolation 7.
Professionals who develop closer bonds with patients, such as in pediatric oncology, experience especially intense emotional reactions in situations of loss 13,26. Often, the death is associated with feelings of guilt and failure 14,26 and its communication is considered an uncomfortable task for the physician. Death—not directly mentioned—is replaced with other expressions and not rarely with euphemisms, which precludes clear and empathetic communication 26. Its communication is often seen by physicians as a difficult and uncomfortable task 26. The conflict between the mission to save lives and the inevitability of death 26, associated with the recognition of one’s own limits, leads physicians to adopt defense mechanisms, such as emotional detachment from patients and families and manifest coldness 14.
Some professionals choose not to be present during BBN to avoid the emotional impact 14, while others suppress emotions during the conversations, resulting in formal and distant dialogues 24. Prioritizing technical resources over emotional expression exacerbates the detachment from the patient and family suffering and the emotional distance, further hindering communication 16.
The belief that BBN should be carried out by professionals that are more resilient or in superior positions 31 reaffirms the lack of training 14. To cope with suffering, some resort to psychological support 13,25. Others sustain themselves with family support and religious practices 13.
Relationship with patients and families
Proper attention in the communication process makes family members feel safer and more confident 16,19 and favors collaboration and acceptance of the clinical situation, which facilitates medical work 16. BBN must be transparent to establish a strong bond with the family, which is essential for conveying challenging information 13, with questions aimed at understanding the family’s feelings before communicating the news 31, thus providing the necessary time and privacy for complete and compassionate discussions. Getting closer to the “world of the other” implies understanding the psychological and imaginary aspects of the families, which have distinct realities and experiences. Proficiency in BBN is fundamental for patient-centered care, as it influences the patient’s understanding and adaptation 42 and optimizes choices in complex decision-making 16,30.
The use of technical language and lack of empathy during conversations cause dissatisfaction to families of patients in the ICU 1. The excessive use of technical jargon makes it difficult to understand essential information about the clinical situation 13. Some professionals use strictly objective, data-focused communication, which can result in emotional detachment 31. Patients and families want honest information, but they expect that the professionals respect their assimilation process, so they consider frank communication potentially stressful 43. Clear communication, with accessible examples and respect for the patient’s unique characteristics, such as cultural and social context 44, fosters more empathetic and caring understanding, emotional comfort for family members, and more participation in the treatment 16,25,32.
Healthcare professionals must respect and recognize as legitimate the emotional reactions and feelings of families of critically ill patients 16. Several professionals expect families to quickly accept the patient’s critical condition, ignoring the complicated emotional process they face 16. However, they must provide technical clarification, emotional support, and spiritual support 25, with openness to the family’s concerns and fears. Furthermore, they should understand that different members of the same family may react in distinct ways 31 and, in delicate situations, remain calm and request composure from those involved, with a view to promoting constructive dialogues and strengthening bonds 32.
Communication with family members should be carried out on a daily basis and contain information about the patient’s health status, in order to prepare them for potential difficult news and reduce the impact of unexpected information 25. It is important to have a reference physician, that is, to avoid rotating professionals. This continuity reduces the feeling of loneliness and provides confidence, emotional support, and security 25. It is necessary to train communication skills to provide more effective and empathetic service 25. Although caregiving activities are time-consuming and hinder communication, there should be investment in attentive listening, as it alleviates suffering and helps understand the family members’ needs as it respects concerns and resolves doubts 16,44.
In critical situations, professionals use non-verbal communication, such as hugs and touches, to provide emotional support and show recognition of the suffering of family members 44. Attentive gaze and expressive gestures promote effective interaction 1,26 and create a space of trust 25.
Barriers and challenges
BBN in ICU is complex and challenging. Hindering situational factors include time pressures during care, conflicts between patients and team, or complex social issues 40. The professionals already have a heavy clinical routine 15, with little availability for conversation due to overload in the work setting 16,45. Communication often involves a sedated or intubated patient 13, being an emotionally charged task, especially in case of unexpected events 13,22. It is seen as an unpleasant task for both the communicator and the receiver 24. As it is a painful and traumatic event, BBN can cause a detachment between professionals and family members, thereby affecting the therapeutic relationship 13,16,32. The management of personal and interpersonal skills is of utmost importance for the interaction with families of critical patients. Professionals must be prepared to deal with technical, ethical, legal, and relational aspects 13.
A systematic review of 40 studies with 3,242 participants showed that healthcare professionals often perceive communication as a mere obligation and adopt indirect approaches when communicating 4. Professionals tend to talk more and ask few questions to family members, without discussing the patient’s perspective, establishing a little comprehensive communication 32.
Many professionals avoid directly communicating the severity of the clinical condition and use ambiguous expressions, which lead to uncertainty in family members 31. Even when communicating death, albeit expected, physicians hesitate to use the word “death,” which reflects a denial of life’s finitude, and resort to euphemisms 26. By denying death through the choice of softer words, professionals face the inevitability of finitude without having to deal directly with pain 26. The lack of clarity in the information affects the family members’ perception and can lead to false expectations 26 and communication failures 31.
The healthcare team must adapt its communicational approach to the cultural needs 44 and preferences of family members, since effective communication strengthens the family bond and reduces stress 5. BBN becomes even more challenging when there are linguistic barriers, especially if there is a need to employ interpreters, who do not always produce accurate translations 32. Family members with communicational difficulties are not seen as adequate interlocutors in conversations, and ethnocultural contexts can further complicate discussions 32.
Another challenge is the family members’ lack of understanding as to the severity of the critical patient’s condition, which requires professionals to have sensitivity and multiple interactions to increase comprehension 16,32. Denial is a common reaction to BBN and results in the need to repeat information 13. The complexity of critical illness and the expectation of a “miracle” make understanding difficult, especially in socially vulnerable populations 16.
The professionals’ excessive workload, lack of time, and inadequate infrastructure compromise the communication of sensitive news 14, hinder the clarification of doubts and hamper discussions about care 19, further affecting the interaction between professionals and families 21. Conversations about bad news often occur at the bedside or in inappropriate spaces, such as the hallway 21, which causes discomfort and resistance in family members, who feel exposed 32, thus hindering the effectiveness of communication and affecting the understanding of the news.
Conflicts between family members and disagreements between patient will and family will make consensual decision-making difficult and compound the challenge for physicians. Financial issues and frustration feelings, especially among those who after long periods of estrangement try to obtain redemption at the time of a family member’s illness, affect people’s behavior, thus intensifying tensions in interactions 16.
In the event of conflicts and in order to understand the family’s needs, it is essential that professionals approach the subjective world of family members and recognize the uniqueness of each familial system 44. This understanding facilitates communication and promotes more humanized care 16.
Physicians report breaking news of clinical deterioration and death as the most challenging conversations 22. Communicating death is noted as the most difficult situation, and physicians underscore the association between death and the perception of “bad news” 26. In an interview on the issue, professionals associated the difficulty in BBN with patient age and noted that they face difficulties in associating the end of life with young individuals 18,26. The news of child death, an event that defies the natural order of expectations, and the communication of brain death in previously not ill young people, that is, whose lives are abruptly interrupted 26 are examples of difficult situations for both families and professionals.
Training, professional development, and tools
BBN is part of healthcare professionals’ routine, but many still feel unprepared for the task. Several physicians express difficulties in conveying this information appropriately and often get emotional with patients and families 24. Despite theoretical and practical knowledge, physicians generally feel unprepared to communicate death, without knowing the best approach for the situation. This lack of preparation is recurrent, as shown by one of the studies in the review, in which physicians, when invited to participate in the research, reported a need for change in how they communicate bad news 31.
The lack of specific training to deal with death makes communication even more challenging 45. Although some physicians feel capable, the theoretical training—scarce during undergraduate programs 46—does not guarantee security in practice 14,18,24,26,31. This gap results in approaches based on personal experiences and in confusing or rude messages 24. In medical practice, BBN is not sustained by formal technique, but is informed by the personal experiences and intuitions of physicians 31, with improvised approaches adapted to the needs of the situation, without a previously established strategy 32. The BBN practice is characterized by empirical and informal knowledge 22; thus, professionals act according to their own perceptions, conceptions, and experiences 24. The perception as to the need to develop communicational skills generally arises only in practice, so physicians devise empirical strategies 14.
The lack of specific protocols and theoretical frameworks is frequently reported, and several professionals suggest that structured techniques could improve patient understanding 24. Experience in BBN is generally acquired through practice, direct experimentation, or observation of more experienced professionals 24. The professor is seen as an essential reference when developing the skill, although BBN is not perceived as a formally taught technique, but rather predominantly learned in practice and by observation 31.
Participants in a study included in this review noted a significant change in their communicational approaches throughout their careers, which was attributed to personal and professional maturation 20. In another study, an interviewed resident noted that their first experience was traumatizing and that prior training would have been useful 19. Almost all professionals indicate the urgency of better training in the area. Macdonell and collaborators 30 report that, among physicians, even when self-declaring as experienced, 88% agreed on the need for more training. Residents, interns, social workers, and nurses also expressed the need for more preparation 30.
BBN requires a theoretical framework and specific clinical guidelines, and its skills can be developed through training 46, including practical activities such as role-playing and simulations, which improve communication among professionals 4,47 and, consequently, interactions and outcomes in intensive care 4,5,17.
A workshop was held to train residents and physicians in BBN, and 100% of the attending physicians recommended that this training be mandatory for ICU teammates and residents 28. Among residents, 95% recommended the training as a requirement. In another study, Ghoneim and collaborators 29 observed significant improvements after training 29.
The SPIKES protocol 8,42, with its six structured steps, emphasizes the need to involve the family, create an appropriate environment, practice empathy, and develop a clear care plan 1,14,23. An appropriate environment should be provided for sensitive communication, which includes, among other things, choosing the setting for the conversation 45. The SPIKES protocol has been effective in training residents in BBN 42. Other protocols, such as EMPATHY, emphasize the importance of accessible language and patient right to truth and clarification for decision-making 1.
Ethical, legal, cultural, and religious aspects. And hope…
According to Brazilian legislation, determining the prognosis related to a nosological diagnosis is an exclusive activity of physicians 37, meaning that only physicians have the technical and legal authority to establish predictions about the course of a patient’s health condition, based on the diagnosis obtained through clinical evaluation and complementary exams. A Federal Council of Medicine (CFM) resolution 35 reinforces that physicians are exclusively responsible for reviewing therapeutic strategies and defining conducts according to diagnosis. The Code of Medical Ethics 36, in turn, determines that omitting the diagnosis and prognosis is forbidden for physicians, except in situations where direct communication may cause harm to patients. In these cases, the law establishes that such information must be transmitted to the individual’s legal representative.
Physicians are responsible for providing objective information and sharing the seriousness of the situation in a clear and realistic manner, explaining the risks and allowing the family to follow the patient’s condition. There are ethical and medical legal implications in breaking bad news, which means that withholding vital information on the patient diagnosis and prognosis based on the assumption that they will not be able to “cope with” this information may not always be justifiable, given patient autonomy and “right to know” 36,41. The participation of family members in understanding the clinical situation strengthens the alliance with the healthcare team 44 and promotes better understanding and cooperation 16.
In some situations, family members ask that the patient is not to be communicated bad news, either for fearing they may lose hope or for cultural reasons 39. However, conscious patients have the right to know their condition, thus respecting their autonomy 32. Physicians have the ethical duty to communicate information to the patient—both good and bad information. Respect for truth and transparency are fundamental principles in medical practice 13,32. When the patient has the capacity to express their will, their decision must prevail 16.
The family’s lack of understanding often challenges the professional communicating bad news. People often do not accept a negative diagnosis due to certainty in curative treatments and interpretations based on ethnoreligious beliefs 32. Spirituality and religiosity profoundly influence treatment as they provide hope and inform the expectations of family members, who may believe in divine interventions until the very last moment 13,16. Faith and religion often interfere with medical decisions, and there are families who believe that the physician is merely an instrument of God and that efforts should be maintained until a miracle occurs. This view can lead to conflict between family expectations and the limitations imposed by the patient’s clinical condition 16, although beliefs can also sometimes aid in accepting the situation 13.
“Hope” emerges as an ethical imperative in medical practice, and its recognition is fundamental for communication and care. Maintaining hope is crucial for facing difficulties, as it provides an optimistic perspective that favors the process of acceptance, even in severe clinical cases. Physician must manage the ethical dilemma of balancing honesty about the clinical condition and preserving the family’s hope 13.
Addressing hope is especially challenging for a physician when they have already lost optimistic expectations, which affects the communication with the family 13,16. They are responsible for communicating the prognosis realistically but hopefully. In the study of Alves, Sarinho, and Belian 23, the major difficulty noted by the participating resident physicians was communicating the prognosis realistically without losing hope. However, training can develop such skill, which underscores the importance of emotional support in clinical practice 14,23.
Study limitations and strengths
This systematic review has some limitations. Initially, it is not possible to know if the professionals’ predominantly negative perceptions on the experiences of breaking bad news could indicate a focus, during data collection, on the difficulties of the task or a subjective bias due to preconceptions. The small sample sizes in a considerable proportion of the reviewed studies may have limited the spectrum of experiences reflected in the data and the insights obtained in the synthesis. Most studies did not include the specialization level of the healthcare professionals in palliative care and intensive care, which hinders the analysis of the added value of the specialization. Another limitation of the study is not having analyzed how the legal and juridical context of each country influences the roles of healthcare professionals. Normative aspects determine to varying degrees the responsibilities and participation of the multidisciplinary team in communication with families and can introduce biases in the understanding of these dynamics in different healthcare systems. Regarding BBN training, it is still insufficient the understanding of the “ceiling effect” during training, according to which professionals with prior training may react differently. There was no analysis of patient satisfaction and outcomes, nor of the mental and physical health of patients and families. A noted strength of this review is the employed strategy of comprehensively searching reputable indexing databases to select articles that are relevant to the research objectives, with approaches and impressions from professionals from diverse countries and, therefore, with major ethnocultural diversity.
Final considerations
The role of healthcare professionals in BBN in ICU is to provide clear and honest information, with empathy and respect for the family and their feelings. They should adapt the language to the family members’ level of understanding, avoiding jargon and minimizing emotional impact. Communication must be continuous and address technical and emotional aspects of care, while respecting cultural particularities and individual reactions. It is essential that professionals conduct a prior assessment of the family members’ knowledge, expectations, and emotional conditions.
An exacerbated level of anguish was observed among professionals, resulting from insufficient academic training and continuing education. Implementing specific training for ICU professionals is relevant for increasing the quality of care and mitigating adverse repercussions, especially regarding the emotional well-being of those involved. Developing skills such as empathy is essential and there should be continuous improvement through specific communication training, using tools such as the SPIKES protocol for more effective and humanized conversations.
The professionals’ preparation should include time to organize technical aspects and manage their own emotional state, in order to ensure a balanced approach. Healthcare professionals should implement strategies that foster humanization and interprofessional collaboration during BBN. It is recommended the careful selection of the family member involved in the communication, prioritizing those with a greater capacity to understand clinical information and make decisions representing the patient. The meetings should be held in private and suitable settings, in order to provide comfort, emotional support, and an appropriate atmosphere for dialogue.
BBN should be guided by the bioethical principles of autonomy, beneficence, non-maleficence, and justice, in order to guarantee that patient and family are provided clear, truthful, and comprehension-appropriate information, respect for personal and cultural values, and preservation of dignity at all stages of care.
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Data availability:
All data used or generated in this study are described and presented in full in the body of the article.
Edited by
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Editor in charge:
Dilza Teresinha Ambrós Ribeiro
All data used or generated in this study are described and presented in full in the body of the article.
