ABSTRACT
When poor communication between clinicians and family members of ICU patients, disparities related to social
determinants of health (SDOH), and a heightened distrust of healthcare professionals all coalesced during the
COVID-19 pandemic, “the perfect storm” emerged. Improving communication and trust in healthcare
professionals is critical in high-stakes ICU environments where the need for shared decision-making demands
that clinicians rapidly establish rapport and therapeutic alliance with family members of non-capacitated
patients. Many well-designed trials testing ICU communication interventions have had negative or minimally
impactful results, perhaps in part because we have only a rudimentary understanding of how SDOH impact
communication in the ICU, a clinical context where underrepresented individuals also suffer from disparities.
The goals of this R01 are to conduct a mediation analysis that will: 1) examine SDOH’s impact on
communication between family members and ICU clinicians; 2) identify mechanisms of action related to how
communication quality affects distrust of healthcare professionals and therapeutic alliance; and 3) determine
how these factors contribute to or mediate outcomes for family members of ICU patients. This longitudinal,
observational study will collect data from 320 family members from 5 ICUs serving underrepresented rural,
Black, and Hispanic communities in 3 states. Our primary health outcome is the provision of family-centered
care (as measured by the Patient Perceptions of Patient Centeredness questionnaire- Family Version).
Secondary health outcomes include family members’ psychological stress (anxiety, depression, symptoms of
post-traumatic stress disorder) and measures of patient ICU utilization (e.g., ICU LOS, ventilator days).
Mediating factors to be examined include communication quality, healthcare distrust, and therapeutic alliance.
Moderating factors include family members’ intrinsic traits (e.g., personality traits and decision-making style).
We hypothesize that: 1) poor SDOH yield poor outcomes and result in less attention to family-centered care
and worse ICU patient utilization outcomes; and 2) higher communication quality will improve the therapeutic
relationship and healthcare trust and result in improved attention to family-centered care and improved ICU
patient utilization outcomes among all patients regardless of SDOH. Using our results, we will adapt a
prominent conceptual model of communication to address the high-stakes communication needs of families
from underserved communities. Completing this work will advance the field by providing data to allow new
understanding of how SDOH and other factors (e.g., communication quality, trust) relate to provision of patient-
and family-centered care in the post-pandemic context. The knowledge gained will inform new content and
concrete communication strategies for future ICU interventions aiming to facilitate high-quality communication,
help to restore trust in healthcare, and improve therapeutic alliances in pursuit of achieving patient- and family-
centered ICU care.
