Communicating with families of dying patients- the family meeting

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					Cummunicating with Patients and Families about End-of-Life Issues
Steve Pantilat, MD
Professor of Clinical Medicine
Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care
Director, Palliative Care Program
Division of Hospital Medicine
October 23, 2008

1. Anatomy of a family meeting- a step by step guide
*Pre-meeting set-up
a. arrange a time and a quiet, private place to meet
b. invite all providers- MDs, consultants, RNs, SWs, chaplain, RT
c. invite all family members- make sure the decision-maker is present
d. determine beforehand who will lead the meeting- primary team representative
e. have medical team discuss goals of meeting and recommendations

Starting the meeting
f. have each person introduce himself
g. ask family to give their sense of the situation- “I was wondering if you could
   tell me what you understand of your father’s condition.”
h. start from where the family is

The business
i. explain the medical situation generally- don’t dwell on small details but strive
   to give an overall sense taking off from where the family is
j. ask if the patient made any prior statements about preferences for care in a
   situation like this one-
     “Did your father ever say anything about what kind of care he would want if
     he got seriously ill?”
     “Did your father ever see a relative or friend in a situation like this, or see it
     on TV, and say anything about what he would want if he was in a similar
     “What would your father say if he could sit up and tell us what he thinks
     about what is happening to him right now?”
k. determine who is the surrogate and whether the patient appointed one or if
   the family agrees about who is the right person

Wrapping up
l. ask if there are any questions
m. *arrange follow-up- who will talk to whom, when and how
n. summarize the decisions made
o. document the meeting and the plan in the chart

2. Important points
a. early in the course of the illness be more cautious with prognosis
b. offer prognosis- patients and families decide differently when they know
    prognosis (Murphy et al. NEJM 1994;330(8):545-9). Yet, acknowledge our
c. usually easier to move in steps- DNR order then withholding of new
    interventions then withdrawal of existing interventions
d. *emphasize desire to respect patient’s wishes- may need to return to this
    point often
    “If your mother could sit up in bed right now and tell us what she would want,
    what would she say?”
    “What we really want to do is respect your mother’s wishes. We might
    choose differently for ourselves and it might be different if we were to choose
    what we want for someone else, but our responsibility is to respect your
    mother’s wishes of what she would want for herself.”
    “Did your mother ever make any statements about the kind of care she would
    want if she were to get sick like she is now?”
e. need not achieve all decisions, or any decisions, in one conversation- these
    cases usually unfold over several conversations, as does the clinical situation
f. expect dysfunction (after all these are families we’re dealing with)
g. *avoid promises you cannot keep- where the patient will die, when the
    patient will die, how the patient will die, that family will have time to return to
    the hospital to say a last goodbye (“I wish I could…”)
h. be empathic and acknowledge the sadness of the situation- someone’s loved
    one is seriously ill and dying
i. *nearly all situations can be resolved through repeated discussions.
    Rarely will you need to invoke futility (and rarely will it apply) (Prendergast
    and Luce. Am J Respir Crit Care Med 155(1):15-20. 1997)

3. Common pitfalls
a. key family decision-maker is not at the meeting
b. clinical issue arises that cannot be addressed
c. medical team disagrees on plan

4. Key points*
a. attend to the pre-meeting set-up of a family meeting
b. emphasize desire to respect patient’s wishes
c. avoid promises you cannot keep
d. keep lines of communication open- trouble arises when communication
    breaks down


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