Ishna Poojary MD; Cara Levin BS BA; and Linda Snyder MD, University of Arizona College of Medicine
|TIPS FOR CONDUCTING FAMILY MEETINGS
Family meetings play an important role in the care of seriously ill hospitalized patients and patients with advanced disease. The meetings help identify patient-centered goals and guide decision making. They also improve patient's and family's satisfaction with their care.
What is the Purpose of a Family Meeting?
Family meetings are an opportunity for the patient, family, and health-care team to share their knowledge and concerns about all facets of a patient's care including physical and psychosocial aspects. Family meetings can prevent fragmentation of information in a rapidly changing clinical environment. They can also minimize misinformation, assist in care transitions, help patients and families navigate complex medical decisions, and provide support for those facing serious life-limiting diseases.
When is it Appropriate to have a Family Meeting?
There are many situations in which a family meeting should be considered as part of a patient's care. They include the need to share prognosis, explain changes in clinical status, or discuss the need to revisit care goals. It is particularly important to hold a family meeting, and to do so early in the course of care, when a patient is at high risk of dying. Family meetings are also helpful when there has been fragmentation of care, frequent readmissions, and/or situations causing family stress and anxiety.
Another important trigger for a family meeting is when your answer is "no" to the following question: "Would I be surprised if this patient died within the next year?"
Forming an Effective Family Meeting
It is important that family meetings include decision makers (e.g., medical power of attorney) and all pertinent stakeholders in the decision making process. It can also be helpful to ask the patient (if communicative) who they want to be present and to identify who they want to be a spokesperson to relay information to extended family or friends. Once participants are identified, several steps should be followed for effective family meetings:
Step 1. Prepare. Before the meeting you should have a solid foundation of knowledge about the patient, review advance care planning documents, and reconcile opinions and recommendations from inter-professional team members.
Step 2. Setting. Hold the meeting in an appropriate setting, assuring privacy and seating for all present, and making sure that phones and pagers are silenced.
Step 3. Introductions/Goals. Have all participants introduce themselves and identify their relationship to the patient. This is also a time to review your goals for the meeting and ask if the family has additional expectations.
Step 4. Assess Understanding. Assess what the patient and family know and how much they understand about the patient's medical situation. As an example, you can ask the patient to "tell us how things have been going over the past few months" or ask the family to "tell us what you understand about [your family member's] medical condition.
Step 5. Review Medical Condition and Prognosis. Once you have learned the patient's and family's level of understanding, you can present accurate information about the patient's medical condition. This should include succinctly outlining the current clinical situation, anticipated risks, and expected outcomes and prognosis. These explanations must be given in plain language, without medical jargon and technical detail.
After providing this information, it is important to give the patient and family time to react and ask questions. You also should allow time for silence as family members absorb what you have told them. Empathetic statements and clarifying misunderstandings is often necessary and useful. Be prepared for emotional reactions and questions.
Step 6. Present Management Options. It is important to present treatments that align with the patient's goals and values. If the patient has decision-making capacity, you can ask the patient "what decisions are you considering?" and then continue to discuss goals, options for care, and trade-offs based on what the patient has told you. If the patient does not state clear goals, you can help the patient develop goals by inquiring about what is important to the patient.
If the patient lacks decision-making capacity, you will need to explain the concept of surrogate decision making to the family and use known or expressed patient values and goals to establish a care plan. Often, this requires that you ask questions such as "what would your loved one say or think about her serious illness and current condition?"
Either way, you will often need to make medical recommendations based on your knowledge and experience. But, a shared decision-making strategy is generally the preferred approach.
Step 7. Formulate a Care Plan. Further discussions center on translating the patient's and family's goals into a treatment plan. This will often include discussions about whether it is appropriate to perform cardiopulmonary resuscitation, additional diagnostic tests, or interventional treatments. The language used in discussing the plan is important and some tips for discussing goals of care are outlined in Table 1.
|Table 1. Language to Use and Avoid When Formulating Care Plan|
|Statements to Avoid||Preferable Alternate Statements|
Step 8. Review the Plan and Document. At the close of the meeting, review what will be done to achieve the patient's goals and what will indicate if goals are being met and/or if the patient's condition is changing. If necessary, schedule a follow up meeting and be sure to document all discussions in the medical record. Encourage the family to consult with important people in their life (e.g., religious leaders or other family members) not present at the meeting.
Finally, there are several useful mnemonics that can help guide you though the key aspects of family meetings. These mnemonics (SPIKES and VALUE) are outlined in Table 2.
|Table 2. Mnemonics to Aid in Family Meetings|
|SPIKES (from Buckman reference below)
S -Set up meeting: do what you need to prepare
P -Perceptions: find out patient/family perceptions
I -Invitation: invite information sharing and preferences
K -Knowledge: give information in easy-to-understand terms
E -Empathy: respond to emotion with empathic statements
S -Summarize: outline next steps and plan of care
|VALUE (from Lautrette reference below)
V -Value family statements
A -Acknowledge family emotions
U -Understand patient as a person by asking questions
E -Elicit family questions and concerns
References and Resources
- Back A, Arnold R, Tulsky J. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. New York: Cambridge University Press. 2000.
- Buckman R. Practical Plans for Difficult Conversations in Medicine. Johns Hopkins University Press. 2010
- Bernacki RE, Block SD; American College of Physicians High Value Task Force. JAMA Intern Med. 2014:174(12): 1994-2003
- Palliative Care Fast Facts
- Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007; 356:469-478
- Powazki RD, Walsh D. The Family Conference in Palliative Medicine: A Practical Approach.. Am J Hosp Palliat Care. 2014:31(6): 678-84