Conducting a Family MeetingConducting a Family Meeting

Sarah Beth Harrington, MD

VCUHS Division of Hematology/Oncology and Palliative Care

2007-8 Palliative Care Rotation

ObjectivesObjectives

1. Understand the importance of conducting a productive family conference.

2. Review 10 steps of the family conference process.

3. Describe management techniques when a consensus cannot be reached between families and physicians.

The Family ConferenceThe Family Conference

Why is it important?

Why is it so difficult?

1. PREPARATION What is medically appropriate? Review chart Review Advance Care planning documents Review/obtain family psychosocial issues Coordinate medical opinions among

consultants Decide who will be present from the medical

team Clarify your goals for the meeting Check your own emotions

2. ESTABLISH PROPER SETTING

Private, comfortable Everyone seated – circle if possible Be aware of “psychological size” Check personal appearance Silence pager

3. INTRODUCTIONS / GOALS

Introduce yourself (“Dr.”), allow everyone to state name and relationship to the patient

Identify the decision-maker Review your goals for the meeting; ask

family if they have other goals Establish ground rules Build relationship

4. DETERMINE WHAT PATIENT OR FAMILY KNOWS

Make no assumptions; determine what the patient/family already knows

Chronic illness:

“Tell me how things have been going for the past 3-6 months – what changes have you noticed?”

5. MEDICAL REVIEW / SUMMARY

Present medical information succinctly– Summarize hospital course / big picture– Use “dying” if appropriate– Current condition/ expected course– Speak slowly, deliberately, clearly– Avoid medical jargon/ too much detail

6. REACTIONS/QUESTIONS

Allow silence Give pt/family time to react and ask

questions– Acknowledge and validate reactions prior to

any further discussion

Be prepared for common questions

“Acceptance”

How much time do I have?

What will happen to me?– Will I suffer?

What do I (we) do now?

7. PROGNOSTICATION

Answering “how long do I have”– Confirm that information is desired– If you have a good sense of prognosis,

provide honest information using ranges

Allow silence, address emotional reactions

What if patients don’t ask about their prognosis?

OTHER REACTIONS

What are you trying to tell me?How can you be sure?I want a second opinion.There must be some mistake.I (we) will never give up.I have strong faith that things will get

better.

EMOTION-BASED CONFLICTWhen you hear conflict (“How can you be

sure?”), think emotion first, rather than assume an understanding problem.

Clarify any factual misunderstanding.Make an empathic statement . . .

– This must be very hard.– You have fought really hard for a long time.– All of this has happened so fast, so I know this

must be difficult to hear, since your father was feeling fine last week.

8. DECISION-MAKINGPresent options

Continue aggressive care aimed at restoring function

Withdrawal of some or all life-sustaining treatments

Make a recommendation based on your knowledge/experience

Assess reaction, listen to all feedback

Decisional patient: “What decisions are you considering?”

Non-Decisional Patient: “What do you believe that patient would choose if she/he were here?”

9. GOAL SETTINGAllow family/patient to state their goals

– Inquiry: We have discussed that time is short. Knowing that, what is important in the time that is left?

– Typical responses: Home, Family, Comfort, Upcoming life events

Confirm Goals

TRANSLATE GOALS INTO A PLAN

Mutually decide with patient on the steps necessary to achieve the stated goals

Common issues may include some or all of the following:– Future hospitalizations/ ICU visits– Diagnostic tests– DNR Status– Artificial hydration/nutrition– Antibiotics/ blood products– Home support (Hospice) or placement

NON-ABANDONMENT – withdrawing/withholding treatments does NOT mean withdrawal of care

When trying to decide among the various treatment options, a good rule of thumb is that if the test or procedure will not help toward meeting the stated goals, then it should be discontinued or not started.

Confirm Plan

To summarize, we have decided that you will not be re-intubated if your breathing gets worse; that we will use morphine to help control your shortness of breath. We will continue this course of antibiotics and if you improve, you will go home with hospice services, with the plan that you will remain at home unless new problems develop that cannot be managed at home. Following this hospitalization, you do not want further blood

tests or antibiotics.

When there is no consensus . . .Remember: Acceptance of dying is a process; it occurs at

different times for different family members– Don’t expect to have all decisions made in one meeting

A sudden illness or or illness in a young person makes acceptance of dying more difficult for everyone

Prior family conflicts, especially EtOH, drugs or abusive relationship, make decision making a challenge.

Root causes of Conflict/ Futile requests:The Patient/Family

– Lack of accurate information– Guilt/Fear/Anger– Grief– Lack of trust– Cultural/religious conflict– Dysfunctional family

The Physician– Inaccurate information– Guilt/Anger/Fear– Cultural conflict

Other contributing causes to conflict/futility issues?

Health Care System/Society– Too many doctors involved

Excessive information

– No leadership/ no recommendations– Unrealistic expectations - media

When there is no consensus . . .

Ensure that everyone in the family has the same information; information should be clear and unambiguous

Ensure that a relationship of trusts exists between doctor and family– Without trust, there can be no basis for shared

decision making

When there is no consensus . . . Establish a time-limited trial

Let’s continue full aggressive support for another 72 hours, if there is no improvement, lets meet again and re-discuss the options

Time is an ally – schedule a follow up meeting with specific goals in mind (define no improvement)

ASSURE NON-ABANDONMENT Discuss other options if necessary

– Ethics consult– Involvement of other mediators (e.g. personal minister)

10. CONCLUSION Summarize areas of consensus and disagreement Caution against unexpected outcomes - the dying

patient does not always die! Provide continuity Document in medical record

– Who was present, what was decided

Discuss results with relevant team members not present

Check your emotions

ReferencesReferences

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Cohen JJ. Moving from provider-centered toward family-centered care. Academic Medicine, 1999; 74(4) 425.

Curtis JR. Communicating about end-of-life care with patients and families in the intensive care unit. Critical Care Clin 2004; 20: 363-380.

Erstling SS, Devlin J. The single-session family interview. Journal of Family Practice 1989; 28(5): 556-560.

Walker MU. Keeping moral space open: New images of ethics consultation. Hastings Center Report 1993; 23:33-40.

Weissman DE. Conducting a Family Conference. AAHPM Conference, Salt Lake City, UT Feb. 2007.

Weissman DE. Decision making at a time of crisis near the end of life. JAMA 2004; 292: 1738-1743.