Communication during high-stakes ICU family–clinician interactions: a realist review protocol

Background Communication is central to patient- and family-centred care in the intensive care unit (ICU), particularly during family meetings and other high-stakes interactions involving prognostic uncertainty, treatment limitation, end-of-life decision-making, conflict, or disagreement. Communication interventions have shown variable effects across settings, suggesting that outcomes depend not only on the intervention itself but also on contextual conditions and the mechanisms through which communication resources influence families and clinicians. Methods This realist review protocol is reported in accordance with the RAMESES publication standards for realist syntheses and, where applicable, is informed by the PRISMA-P principles. The review will examine communication practices during high-stakes interactions between adult ICU clinicians and patients’ families or surrogate decision-makers. Evidence will be sought from MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Web of Science, and relevant grey-literature sources. Eligible documents will include reports of qualitative, quantitative and mixed-methods research, intervention and process evaluations, guidelines, policies, and theoretical sources. Two reviewers will independently screen records and undertake theory-informed extraction. Realist synthesis will use juxtaposition, reconciliation, adjudication, consolidation and retroductive reasoning to develop and refine context–mechanism–outcome (CMO) configurations. Communication strategies will be examined to determine how they change the conditions that enable or constrain mechanisms. Normalisation Process Theory (NPT) will subsequently be used as an implementation lens. Conclusion The review will develop a provisional explanatory programme theory of how contextual conditions enable or constrain mechanisms involving family and clinician reasoning and responses, producing variable communication outcomes. The theory and subsequent NPT interpretation are intended to inform adaptation of communication practices across ICU settings; their usefulness will require further empirical assessment. Systematic review registration Open Science Framework (OSF): https://osf.io/qzndv