Are you treating the patient, or their family?
Both, according to the newest society guideline update
Let’s start with something we can all agree on: families are good.
When we fall ill, our families rally to our side, to protect, to console, to ensure we get the help we need to recover.
If we cannot communicate for ourselves, our families are there to do so for us, and their authority to do so is enshrined in law.
This is based partly on the Western ethical principle of autonomy: our family members know us well and (it’s generally agreed) can best ascertain what care we would agree to, or not.
Yet it’s also important to acknowledge some correlated truths.
If we’re being honest, family members are (we are, since our loved ones can become critically ill, too) the least “objective” surrogate decision-makers who could be found.
Especially in the face of a loved one’s risk for death, it’s natural and common for family members to experience strong emotional reactions that may alter their perceptions and judgment. For example, they may sometimes unconsciously disregard a patient’s known preferences and insist on prolonged aggressive care in an attempt to forestall their own grief.
More generally, family members often cope with stress by attempting to exert control over the situation, to reduce their feelings of fear and helplessness.
All practicing intensivists have had the uncomfortable experience of interacting with a family member who, in the throes of anticipatory grief, begins a psychological-behavioral journey that includes distrust and disparagement of the care team, with daily demands for the initiation or cessation of specific care interventions, while ignoring medical counsel.
We’re really treating the family, goes the refrain heard in signouts to explain confusing or incoherent treatment plans. Sometimes, the mantra is invoked to relieve moral distress surrounding a “family-centered” plan that seems at odds with a patient’s stated values, or even outright detrimental.
New Guidelines: Yes, You’re Really Treating the Family
In its 2025 guidelines, the major U.S. critical care society explains that in their view, you are expected to also treat the family of your patient:
“Providing care in the ICU that is both patient-centered and family-centered is essential for clinical excellence. Care of families is a core component of high-quality care, as family support and engagement influence patients’ outcomes, and as ICU experiences have lasting impacts on family members themselves.” (emphasis added)
They provide a list of recommendations, such as:
Families should have liberal visitation privileges.
They should be invited to participate on rounds and even in the direct bedside care of the patient.
Families should be invited to be present during codes (CPR), with a dedicated staff member at their side.
They should be given educational programs, ICU diaries, and spiritual and bereavement support.
They should receive interventions to support their mental health, and this should include regular meetings with doctors.
They should have ample rest spaces, areas for personal care, and confidential meeting rooms.
Clinicians should communicate thoroughly and effectively with families in a standardized way using the society’s preferred VALUE mnemonic: making Value family statements, Acknowledging emotions, Listening, Understanding the patient as a person, and Eliciting questions.
The evidence for all these was low-quality.
Many or most of the proposals may be worthwhile, but as should be obvious on reading them, implementing them is not the responsibility of practicing clinicians. (Clinicians often could communicate with families better, but proclaiming one favored mnemonic-based method to be the new standard is unsupported.)
Through the rhetorical choice to never state who its document is intended for, the guideline authors blur the lines between “the system” and you. That’s a problem, as we’ll see.
Where Did The “F” Come From?
As more senior readers will remember, it used to be just the “ABCDE” bundle, promoted in 2013 to help patients get out of ICUs faster and in better shape.
An “F” for “family” was added to produce the “ABCDEF” bundle the following year.
Why? A billionaire wanted it to be so.
As Dr. Wes Ely, the influential architect and champion of the ABCDE bundle describes in his book, Every Deep Drawn Breath:
Gordon Moore, cofounder of Intel Corporation, had spent some time suffering with delirium in the ICU not too long before and had found the absence of his family hugely distressing. He wanted to be sure that others would have open access to their families and insisted that we increase bedside contact with loved ones.
I was more than happy to include family involvement as a cornerstone of the bundle, and we decided to invite family members to daily rounds with the ICU teams, in addition to implementing open visitation. I could see that this engagement should have been there all along.”
The Moore family foundation made a grant to the professional society, which thereafter made “family-centered care” an ongoing focus. This impetus and the timeline are also acknowledged on the society webpage.
The exact grant amount(s) and any ongoing funding were not apparent from a quick look at the society’s public Form 990s (grant figures are typically bundled together or redacted for privacy in nonprofits’ tax statements).
You Should Talk to Your Patient’s Family
Just to be clear:
We should talk to every patient’s family—because we need them to help take the best care possible of the patient.
We should keep them updated on a regular basis—so they can be in an informed position to act as her surrogate for important decisions.
It’s also very nice to be kind, friendly, compassionate, supportive, and as helpful as possible to the family and their needs.
But that is not your job.
Families Are Not Your Patients
Physicians do not have a duty to provide care to their patients’ families. This is a well-established principle.
Families must be engaged as surrogates for uncommunicative patients, and care is usually enhanced by physicians’ constructive attempts to build and maintain good relationships with patients’ families.
But this necessary engagement with the family originates from the physician-patient relationship, and while it can be confusing for everyone (since the patient never directly participates), the duty to the patient is always the source of and the focus of every interaction between the physician and the family.
Because resources and attention are limited, additional obligations to families would necessarily divert energies away from the patient (or other patients) and reduce the quality of their care.
In this sense, any added “family-centered care” by physicians would be inherently not patient-centered.
For their part, health systems could and perhaps should build systems, processes, and policies to better support families with loved ones experiencing critical illness.
To the extent that these efforts improve care of the patient, or families’ experiences, they’re all for the good.
But the research in this area has been generally of very low methodologic quality, and results have been highly inconsistent—with many studies showing no benefit to families of whichever intervention is tried. The usual outcome measured is a score on a questionnaire or survey.
How are physicians being considered in crafting these strategies—for example, in the many proposals to add multiple structured (“standardized”) family meetings to your day?
Almost not at all, says the guideline committee:
“We found a wide spectrum of programmatic approaches to promoting family-centered care, by observational, quasi-experimental, and RCT methodologies—but very few that included important clinician outcomes, such as burnout, stress, and mental health. Studies to date have been much less focused specifically on supporting clinicians and improving these outcomes.”
Which “Family-Centered Care” Would the Patient Choose?
We’ve already considered the example of distraught family members who insist on the provision of care that (according to other family members) the patient would likely have declined.
In other cases, estranged family members who haven’t talked to the patient for years suddenly arrive and start asserting control. Do they have the patient’s interests in mind, or are they acting out decades-old family conflicts?
It’s also disturbing to consider that while infrequent, psychological, physical, or sexual abuse occur in some families. Nurses commonly notice signs of apparent distress or agitation during specific family members’ visits. Who are we to assume that a patient wants whichever family member who volunteers to be allowed to participate in his bedside care?
Conclusions
A loved one’s critical illness is extremely stressful to their family, who may experience significant emotional distress and suffering. They deserve kindness, compassion, respect, and clear communication. Family members are vital partners as surrogate decision-makers for uncommunicative patients.
But physicians have no duty to directly address or treat patients’ families’ distress and suffering. To assert otherwise is inappropriate, as it may detract from the physician’s essential focus on her patient.
The major U.S. critical care society accepted significant funding around 2014 in exchange for promoting “family-centered care” as a cornerstone of critical care. This policy change occurred as a result of an ultrawealthy individual’s distressing and unfortunate experience of illness and isolation from his family.
By extending its purview far beyond the protection of family visitation rights, the expanding “family-centered care” agenda, with its implied new duty of family care for physicians, represents a detrimental distraction from physicians’ mission of caring for their patients.
Unlike physicians, health system leaders can institute family-supportive policies and practices. Some of these are obviously good and right (e.g., allowing access to family members when they are ill), while others proposed are of uncertain value. Even if they are not solidly “evidence-based,” such programs can convey respect and compassion to families. To the extent that they reduce distress or improve patient care, they’re for the best.
The system-level changes advised in this guideline should have been explicitly addressed to health system leaders, not practicing physicians. As written, the guideline’s effect is to blur and diminish the centrality of the patient-physician relationship, and to misdirect responsibility for whatever increased family-focused interventions ought to occur (which, due to the low-quality research, is far from clear).
Physicians’ efforts to engage with and support families are important and desirable, but they will always be undertaken to serve the patient, not their family.
We need more articles like this.
I enjoyed this-- the larger lesson is that a single clinician with enormous influence can still, in this supposed age of "Evidence Based Medicine," unilaterally push a trendy intervention on the field without any high quality evidence.