Response to comments from Dr Vahedian-Azim related to our recent article Understanding and addressing a ‘difficult’ family in ICU

We thank Dr Vahedian-Azim for taking the time to respond [1] to our commentary [2]. We aimed to discuss mentalisation, a process already known to psychotherapists but less so to critical care clinicians [3]. The main point of our commentary was to explore the possible role of mentalisation in the highly emotive environment of ICU, as a tool in conflict prevention and resolution. You are very right to point out that the actual impact of the process on outcomes is far from evidenced-based; however, being curious about one’s own reactions and endeavouring to understand the reactions of others is an attitude with strong face validity and hence conceptually attractive. Yet, robust scientific evaluation is needed to ensure that the anticipated benefits materialise and are not offset by unanticipated consequences.

We completely agree with your second comment on the importance of culturally competent communication in ICU. Indeed, in an increasingly diverse world, ICU patient and family communication must incorporate skills that accommodate the language, ethnicity and religious differences that exist. Logically, the capacity to understand other people’s intentional or inner mental states while acknowledging one’s own (mentalisation) would improve with increased cross-cultural awareness. Despite the implicit link, this positive association between cultural competence and improved patient/ family outcomes is also lacking [4]. It is obvious that the impact of such educational interventions (cultural competence, mentalisation techniques) requires better quality studies in order to provide robust conclusions about their effectiveness.

No datasets were generated or analysed during the current study.

1. Vahedian-Azimi A. Enhancing cultural competence and communication in ICU: addressing family conflicts. Crit Care. 2025;29:53. https://doi.org/10.1186/s13054-025-05298-7.

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2. Metaxa V, Nacul FE, Morris AC. Understanding and addressing a ‘difficult’ family in ICU. Crit Care. 2025;29:22. https://doi.org/10.1186/s13054-024-05244-z.

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3. Lüdemann J, Rabung S, Andreas S. Systematic review on mentalization as key factor in psychotherapy. Int J Environ Res Public Health. 2021;18(17):9161. https://doi.org/10.3390/ijerph18179161.

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4. Lie DA, Lee-Rey E, Gomez A, et al. Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research. J Gen Intern Med. 2011;26:317–25. https://doi.org/10.1007/s11606-010-1529-0.

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Authors and Affiliations

1. Department of Critical Care, King’S College Hospital NHS Foundation Trust, London, UK

   Victoria Metaxa

2. Critical Care Medicine, Federal University of Rio de Janeiro and Pro-Cardiaco Hospital, Rio de Janeiro, RJ, Brazil

   Flavio E. Nacul

3. Specialist Psychiatry Services Directorate, Cambridgeshire and Peterborough Foundation Trust, Cambridge, UK

   Anna Conway Morris

4. Centre for Education, Faculty of Life Sciences and Medicine, King’s College London, Strand, London, WC2R 2LS, UK

   Victoria Metaxa

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1. Victoria MetaxaView author publications

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All authors wrote, reviewed, and approved the final version of the manuscript.

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Correspondence to Flavio E. Nacul.

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Metaxa, V., Nacul, F.E. & Conway Morris, A. Response to comments from Dr Vahedian-Azim related to our recent article Understanding and addressing a ‘difficult’ family in ICU. Crit Care 29, 145 (2025). https://doi.org/10.1186/s13054-025-05337-3

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• Received: 09 February 2025

• Accepted: 22 February 2025

• Published: 01 April 2025

• DOI: https://doi.org/10.1186/s13054-025-05337-3

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