#222 Preparing for the Family Meeting

FAST FACTS AND CONCEPTS #222

PREPARing FOR THE FAMILY MEETING

David E Weissman MD, Timothy E Quill MD, and Robert M Arnold MD

Background A cornerstone procedure in Palliative Medicine is leadership of family meetings to establish goals of care, typically completed at a time of patient change in status, where the value of current treatments needs to be re-evaluated. As with any procedure, preparation is essential to ensure the best outcome. This Fast Fact reviews how to prepare for a Family Meeting. See also Fast Fact #16 for a concise overview of family meetings, as well as Fast Facts 223-227 for discussion of additional aspects of family conferences.

Data Review

· Review the medical history relevant to the current medical situation (e.g. history of disease progression, symptom burden, past treatments, treatment-related toxicity, and prognosis).

· Review all current treatments (e.g. renal dialysis, artificial nutrition, antibiotics) and any positive and/or negative treatment effects.

· Review all treatment options being proposed.

· Determine the prognosis with and without continued disease-directed treatments. Prognostic information includes data concerning future patient function (physical/cognitive), symptom burden, and time (longevity).

· Solicit and coordinate medical opinions about the utility of current treatments among consultants and the primary physician. If possible, families need to hear a single medical consensus—all relevant clinicians should be contacted and consensus reached prior to the meeting. If the consultants do not agree, then prior to the family meeting they should meet to negotiate these differences and attempt to reach consensus regarding the plan. If there is no consensus, a plan should be developed for how to describe these differences to families.

· If the patient lacks capacity, review any Advance Directive(s), with special attention to discover if the patient has named a surrogate decision maker, and if the patient has indicated any specific wishes (e.g. DNR status, ‘no feeding tubes’).

· Seek out patient/family psychosocial data. Focus on psychological issues and family dynamics (e.g. anger, guilt, fear) potentially impacting decision making. These issues may be long-standing, or due to the current illness. Note: talking to the patient’s social worker, bedside nurses, and primary and consulting physicians can help you get a better sense of the family and how they make decisions.

o Review what transpired in prior family meetings.

o Learn about particular cultural/religious values and/or or social/financial issues that may impact decision making.

Information Synthesis Based on your review of the medical and prognostic data, make an independent determination of which current and potential tests/treatments will improve, worsen, or have no impact on the patient’s function/quality of life (physical/cognitive) and time (longevity).

Meeting Leadership Leading a family meeting requires considerable flexibility to ensure that all relevant participants have the opportunity to have their points of view expressed. Though it is useful to have one person designated as the main orchestrator and coordinator of the meeting, the essential skills for making a family meeting successful can come from more than one participant. These skills include:

· Group facilitation skills.

· Counseling skills.

· Knowledge of medical and prognostic information.

· Willingness to provide leadership/guidance in decision making.

Invitations A decisional patient can be asked who he/she wants to participate from his/her family/community, including faith leaders; in general it is wise not to set any arbitrary limits on the number of attendees. The medical care team should likewise decide who they want to participate. Note: it is important not to overwhelm a family with too many health professionals. On the other hand, a physician from the primary team as well as a nurse and social worker should attend when possible; these individuals can help ensure the consistency of information as well as help deal with complicated dynamics. If the patient has a long-time treating physician whom he/she trusts, this person should ideally be present.

Setting The ideal setting is private and quiet, with chairs arranged in a circle or around a table. Everyone should be able to sit down if they wish. For non-decisional patients, the clinical team should negotiate with the surrogate whether or not to have the meeting in the presence of the patient.

The Pre-Meeting Meeting The participating health care members should meet beforehand to confirm: a) the goals for the meeting (e.g. information sharing, specific decisions sought), b) who will be the meeting leader to start the meeting, and c) likely sources of conflict and initial management strategies.

References

1. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York, NY: Cambridge University Press; 2009.

2. Curtis JR, Patrick DL, Shannon SE, et al. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. Crit Care Med. 2001; 29(2 Suppl):N26-33.
3. Lautrette A, Ciroldi M, Ksibi H, Azoulay E. End-of-life family conferences: rooted in the evidence. Crit Care Med. 2006; 34(11):S364-S372.
4. King DA, Quill T. Working with families in palliative care: one size does not fit all. J Pall Med. 2006; 9:704-715.
5. Weiner JS, Roth J. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. J Pall Med. 2006; 9:451-463.

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

Author Affiliations: Medical College of Wisconsin, Milwaukee, WI (DEW); University of Rochester Medical Center, Rochester, NY (TEQ); University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, PA (RMA).

Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc. Readers can comment on this publication at the Fast Facts and Concepts Discussion Blog (http://epercfastfacts.blogspot.com).

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE, Quill TE, Arnold RM. Preparing for the Family Meeting. Fast Facts and Concepts. December 2009; 222. Available at: http://www.eperc.mcw.edu/fastfact/ff_222.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.