Family Meetings

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Family Meetings

• Shalina Shaik, MD
• Emory Family Medicine
• PGY 3

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Case presentation

• Ms W is an 80 yo f with multiple co- morbid
  conditions HTN, DM, ESRD HD, dementia, sick
  sinus syndrome s/p permanent pacemaker, heart
  failure, severe aortic regurgitation, stage 4
  sacral decubitus ulcer , s/p multiple ICU
  admissions , s/p resolved polymicrobial sepsis
  and PEG
• Delicate balance between daily hemodialysis for
  pulmonary edema and hypotension (inspite of being
  on Miodrine)

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Case presentation cont..

• Pt alert, awake but non communicative and
  incoherent, does not follow commands. Non-
  ambulatory.
• Healthcare power of attorney daughter ( who was
  a judge)
• To establish goals of care

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Objectives of a family meeting

• Understand the importance of conducting a
  productive family conference
• Review 10 steps of family conference process
• Describe management techniques when a consensus
  cannot be reached between families and physicians

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Family meeting

• Why is it important?
• Why is it so difficult?

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1. Preparation of family meeting

• What is medically appropriate?
• Review chart
• Review advance care planning documents
• Review/obtain family psychosocial issues
• Coordinate medical opinions among various
  consults
• Decide who will be present from the medical team
• Clarify goals for the meeting

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2. Establish proper setting

• Private, comfortable
• Everyone seated, circle if possible
• Be aware of psychological size
• Silence pager
• Professional appearance

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3.Introduction/ 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

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4.Determine what pt or family knows

• Make no assumptions determine what family or pt
  already knows
• Chronic illness tell me how things have been
  going for the past 3 6 months what changes
  have you noticed?

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5.Medical review/summary

• Present medical information succinctly
• Summarize hospital course/big picture
• Use dying if appropriate
• Current condition/ expected course
• Speak slowly and clearly
• Avoid medical jargon/ too much detail

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6. Reactions/ questions

• Allow silence
• Give pt or family time to react and ask questions
• Acknowledge and validate reactions prior to any
  further discussion
• Be prepared for any common questions

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Common questions asked ..

• How much time does the pt have?
• What will happen from here?
• What do we do now?

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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 pts dont ask about their prognosis

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Other reactions..

• What are you trying to tell us?
• How can you be so sure?
• I want a second opinion
• There must be some mistake
• We will never give up
• We have strong faith that things will get better

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Emotionbased conflict

• When you hear, how can you be sure think
  EMOTION first rather than assuming an
  understanding problem
• Clarify any factual misunderstanding
• Make an empathic statement
• This must be very hard
• You have fought really very hard..
• This has happened so fastit must be difficult..

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8. Decision - making

• Present 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

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9. Goal setting

• Allow family or pt to state their goals
• typical responses home, family, comfort,
  upcoming
• life events
• Confirm goals

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Translate goals into plan

• Mutually decide with pt/ family on the steps to
  achieve the stated goals
• Common issues may include
• future hospitalizations/ ICU visits
• diagnostic tests
• DNR status
• artificial hydration/nutrition
• antibiotics/blood products
• home support/ hospice placement
• NON ABANDONMENT withdrawing treatment does NOT
  mean withdrawal of care

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• 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.

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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 control your
  shortness of breath. We will continue with 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.

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When there is no consensus..remember..

• Acceptance of dying is a process it occurs at
  different times for different family members.
  Dont expect to have all decisions made in one
  meeting.
• Involve Ethics committee

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Root causes of conflicts/futile requests

• The Patient/family
• Lack of accurate info
• Guilt/fear/anger
• Grief
• Lack of trust
• Cultural or religious conflict
• Dysfunctional family

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Other contributing causes to conflict/futility
issues?

• Health care system/ society
• too many doctors involved
• excessive information
• no leadership/ no recommendations
• unrealistic expectation - media

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When there is no consensus..

• Ensure that everyone in the family has the same
  information info should be clear and
  unambiguous
• Ensure that a relationship of trust exists
  between doctor and family
• without trust there can be no basis of shared
  decision making

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When there is no consensus..

• Establish a time limited trial lets continue
  aggressive treatment for another 72 hrs and if no
  improvement, lets meet again and re-discuss the
  options.
• ASSURE NONABANDONMENT

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10.Conclusions

• Summarize areas of consensus and disagreement
• Caution against unexpected outcomes the dying
  pt does not always die !
• Provide continuity
• Document in medical record
• who was present, what was decided
• Discuss results with relevant team members not
  present

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References

• Ambuel B. Conducting a family conference.
  Supportive Oncology Updates 2000 3(3)1-12.
• Butler DJ, Holloway RL, Gottleib M. Predicting
  resident confidence to lead family
• meetings. Family Medicine 1998 30(5)
  356-61.
• 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 2333-40.
• 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.

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• in the end , its not the years in your life
  that count. Its the life in your years
• Abraham
  Lincoln