A Qualitative Study ofPhysicians’ Perspectives on Communication and Therapeutic Relationships in the ICU During the COVID-19 Pandemic

Rationale: Effective patient-clinician communication is a central component of high-quality patientcentered care in the intensive care unit (ICU). The Coronavirus Disease 2019 (COVID-19) pandemic has strained critical care delivery systems worldwide and considerably increased burnout symptoms experienced by frontline healthcare workers;however, its influence on patient-clinician communication and therapeutic relationships within the ICU is not well described. Methods: We purposively selected seven hospital dyads from regions in the United States that experienced early and/or large surges of patients hospitalized with COVID-19 during the winter or spring of 2020. Each dyad included a hospital from the national Veterans Affairs (VA) HealthCare System and its university-academic affiliate. We used semi-structured interviews of intensivists to explore facilitators and barriers to patient-clinician communication and the formation of therapeutic relationships during the COVID-19 pandemic. We then utilized inductive thematic analysis to identify themes describing the influence of the pandemic and hospitals' responses to it on patientclinician communication and therapeutic relationships in the ICU. Results: Overall, 24 intensivists from seven dyads of VA hospitals and academic-affiliate hospitals participated. We identified several barriers and facilitators of patient-clinician communication and the establishment of therapeutic relationships as perceived by intensivists. Barriers included physicians' fear of becoming infected with COVID-19, causing some to minimize contact with patients, and their use of personal protective equipment, which served as an obstacle to effective physical and verbal interactions. Additionally, intensivists noted the disproportionate effect of the pandemic on racial and ethnic minorities, describing how language barriers and restrictive visitation policies exacerbated institutional mistrust among patients and their families and compromised physicians' ability to develop therapeutic relationships. Facilitators to patient-clinician communication included the presence of on-site interpreters, use of virtual technology to interact with family members, and designation of a care team member or specialist service (e.g., palliative care) to provide consistent, daily updates to families. Conclusions: The COVID-19 pandemic has threatened patient-clinician communication and the development of therapeutic relationships in the ICU, particularly among racial and/or ethnic minority patients and their families. We identified several facilitators to improve patient-clinician communication as perceived by intensivists that may help improve trust and foster therapeutic alliances between patients, families, and clinicians in the ICU setting.