A 78-year-old woman is brought to the emergency department by her family after they noticed her bumping into objects and talking nonsensically. Evaluation found fluent speech but with frequent word substitutions and neologisms and a visual field deficit predominantly affecting the right upper field. Brain imaging revealed an acute infarction in the territory of the inferior division of the left middle cerebral artery. The patient was admitted to the hospital for further evaluation and treatment. Her extended family is quite large and very involved in her care. Several relatives are constantly at the bedside. Family members often approach the physician and nurses to ask questions or make requests, and it is difficult for family members to restrict their time to the hospital's visitation hours. Although the patient's son is the legal surrogate decision-maker, the family prefers to arrive at all decisions by consensus. Which of the following is the most effective approach to ensuring appropriate communication with the patient's family?

Question

A 78-year-old woman is brought to the emergency department by her family after they noticed her bumping into objects and talking nonsensically.  Evaluation found fluent speech but with frequent word substitutions and neologisms and a visual field deficit predominantly affecting the right upper field.  Brain imaging revealed an acute infarction in the territory of the inferior division of the left middle cerebral artery.  The patient was admitted to the hospital for further evaluation and treatment.  Her extended family is quite large and very involved in her care.  Several relatives are constantly at the bedside.  Family members often approach the physician and nurses to ask questions or make requests, and it is difficult for family members to restrict their time to the hospital's visitation hours.  Although the patient's son is the legal surrogate decision-maker, the family prefers to arrive at all decisions by consensus.  Which of the following is the most effective approach to ensuring appropriate communication with the patient's family?

Quizplus · Accepted Answer

Explanation: This patient has an acute ischemic stroke with aphasia, which impairs her communication. In addition, her plan of care will likely be complex (eg, physical therapy, speech therapy), and optimal outcomes will require involvement of her family for decision-making and subsequent home care. However, communication with the patient's family is complicated by having numerous family members asking questions and attempting to direct her care. It may become challenging to balance respect for the family's communication style and cultural values with the need to provide clear and consistent information focused on the best interests of the patient. When communicating with a large family system, it often helps to establish a primary point of contact who is able to concisely communicate the family's questions and concerns to the health care team. In addition, a single contact person can minimize conflicting or redundant information and facilitate consensus for patients who prioritize family decision-making. To the extent that the patient has decision-making capacity, she should be the determinant of which family member is designated as the primary communicator. (Choices B and D) A patient's surrogate decision-maker has ultimate authority for consent or refusal of medical services and therefore must be provided with appropriate information, whereas the person most often at the bedside may have the best understanding of the patient's condition. However, these individuals may not be the most effective contact for communicating with other family members. (Choice C) Daily family care conferences are most helpful when questions and requests can be addressed at a single, designated time. However, this patient's family has been actively involved at multiple times of the day, and a single daily conference is unlikely to address their concerns adequately. In addition, this patient's condition may be dynamic (eg, frequent test results) and require frequent input from the family. Gathering all the family members at a single time may not be practical. (Choice E) Communicating individually with each family member is typically best for smaller families and families with only a few, straightforward concerns. However, attempting to communicate with each member of such a large family is likely to be redundant and impractical. Educational objective: When communicating with a large family system, it is often helpful to establish a primary point of contact who is able to concisely communicate questions and concerns to the care team. A single contact person can often minimize conflicting or redundant information being conveyed.

A 78-Year-Old Woman Is Brought to the Emergency Department by Her