We thank Dr. Estella for his thoughtful letter.1 We agree that the specific strategies evaluated in previous communication studies may not be universally generalizable for all worldwide intensive care units. However, we believe that the weight of the supporting evidence for enhanced communication is globally applicable. Enhanced communication, regardless of the method, helps intensive care unit (ICU) professionals achieve the widely-shared goal of optimally caring for patients and their loved ones in a manner that respects their autonomy, minimizes their anxiety, and facilitates good medical decision-making. In our viewpoint, we emphasize that enhanced communication helps achieve these goals, rather than focusing on unproven financial savings or questionable changes in ICU length of stay.2 We also should highlight the importance of customizing enhanced communication strategies to fit the culture of individual ICUs, since it is well-known that ICUs are remarkably different from each other, even if they are in the same hospital, city, or country.

We also want to emphasize that intensivists retain a leading role in communicating with patients. We strongly agree with the letter writer that intensivists have the duty and obligation to clearly communicate with patients and family members and need to be able to effectively lead multidisciplinary family meetings. Thus, intensivists, along with other ICU staff, need extensive training in communication skills. Experiential training leads to greater familiarity and comfort with family meetings and allows intensivists to smoothly lead discussions.3 Ultimately, this may lead to increased patient and family satisfaction, as well as possible improvements in medical decision-making processes.3,4 In addition, we believe that ICU staff with different professional backgrounds are also needed, because they can significantly augment the intensivist's communication efforts, resulting in enhanced overall communication and social support. Social workers, chaplains, and additional nurses all have unique skills and further insights valued by patients and their family members. They are also critical in arranging multidisciplinary family meetings, gathering the concerns of patients and families beyond the usual conversation of rounds, coordinating discharge plans, and participating in goals-of-care discussions.

In summary, we agree with Dr. Estella's major points. Effective communication is important, needs to be emphasized, and should be led by intensivists. We also support the hiring of additional allied ICU personnel, not to lead family meetings, but to help facilitate communication and to offer additional support for patients and families. Finally, we encourage ICU leaders to think about more innovative strategies to enhance communication and remind them to tailor evidence-based strategies for their particular ICUs.