Leading a Family Conference

Keri Holmes-Maybank, MDMedical University of South CarolinaJune 21, 2012

Residents will recognize the importance and complexity of breaking bad news and leading a successful family conference.

Residents will learn the framework and skills necessary for the successful facilitation of a family conference.

Residents will identify skills essential to successful communication.

Residents will identify pitfalls to avoid when leading a family conference and breaking bad news.

Learning Objectives

A successful family conference requires time and planning.

Patient and family satisfaction is directly related to the amount of time the patient or family spends talking. 

Be prepared for strong emotions from patients and families.

Good communication between providers and patients leads to better outcomes and less stress.

Key Messages

Skill Majority of physicians do not have a

consistent plan or strategy Physicians and residents report it as being

stressful Feel underprepared Many recommendations: VALUE, SPIKES,

ABCDE, Six-point protocol

Family Conference

Any news that drastically and negatively alters the patients view of her future

Generally held when ◦ Change from cure to comfort ◦ Patient is too ill to make decisions or would prefer

family to make decisions

“Bad News”

Information empowers family members by◦ Answering their needs◦ Enabling them to understand the patient’s

situation ◦ Reducing anxiety and depression

Major points of satisfaction◦ Time family spends talking ◦ Length of conference

Family/Patient

Roadmap

Review chart Coordinate with consultants

◦ Diagnosis and treatment options◦ Clear, consistent message

Review advanced care planning documents Review/obtain family psychosocial

information – who should come Know your goals for meeting

Step 1Preparation

Private Comfortable Everyone seated in circle One facilitator Limit health care personnel Turn pager off or to silent

Step 2Proper Setting

Allow everyone to state name and relationship to patient

Identify legal decision maker Find out how family makes decisions Express value of meeting

◦ “I appreciate you coming to this meeting today.”

Step 3Introduction

State your meeting goals◦ “I want to tell you how your father is doing

medically. I also want to make sure you understand what we are doing for him.”

◦ “We want to learn from you what your father’s values and goals are so we may make the decisions he would want if he could speak with us.”

Ask family to state their goals◦ “What would you like to discuss?”◦ “Those are great questions. Let me write them

down.”

Step 3State Meeting Goals

Build a non-medical relationship◦ “Tell me something about your father.”◦ “What kind of things did your father enjoy before

he became ill?” Encourage reminiscing- makes them feel life

had meaning

Step 3Relationship

Encourage all to respond◦ “Tell me your understanding of your father’s

medical condition.” If chronically ill, what have been changes in

function◦ “How have things been going the past few

months?”◦ “Has your father been doing the things he

enjoyed?”

Step 4 Family Understanding of Condition

Fire a warning shot ◦ “Unfortunately the CT scan of your father’s

abdomen did not show what we expected.” Big picture in a few sentences Avoid jargon – use 8th grade language Use the word dying if appropriate Answer questions Check comprehension –

◦ What you are saying may not be what they are hearing

Step 5Medical Review/Summary

Silence◦ Give family time to absorb information

Allow family to grieve Allow patient/family to fully respond to

questions Prepare for common reactions:

◦ Acceptance, conflict, denial Respond empathically

◦ “I can see that you are upset, this must be very difficult for you.”

Step 6Silence and Reactions

Provide prognostic data using a range Present goal-oriented options

◦ prolong life, improve function, return home, dignified death

Priority of comfort regardless of goal Make a recommendation based on

knowledge/experience◦ “What is important in the time you have left?”◦ What would your father think about all of this?”

Step 7Present Care Options and Set Goals

Make recommendations based on patient’s values

Review current and planned interventions Discuss DNR, hospice, artificial nutrition,

hydration, future hospitalizations◦ “What would your dad want us to do if he could sit up

and speak to us?”◦ “Thank you for telling me about your father and what

he would want. This helps us develop the best plan of care.”

Summarize decisions Plan follow-up

Step 8Translate Goals into Care Plan

Debrief with team members, consultants, nurses

Write a note◦ Who was present ◦ What decisions were made ◦ Follow-up plan

Step 9Document and Discuss

Listen Empathy

◦ “This must be very hard for you.”◦ “I imagine this is not what you wanted to hear.”

Remain neutral, respect everyone’s emotions◦ “I wonder if we can put these disagreements

aside so we may focus on what is going on with your father.”

Allow family to self settle if possible Clarify misconceptions

Step 10Managing Conflict

Determine source of conflict and explore values behind decisions: ◦ Guilt, grief, culture, family dysfunction, trust in

medical team◦ Feel giving up◦ Feel abandoning

Empathizing with family members’ emotions is critical to creating a neutral zone for productive communication

Step 10Managing Conflict

Do: If your mother could talk, what would she want us to do?◦ Don’t: What do you want us to do?

Do: How does your family make decisions like this?◦ You are the HCPOA, we follow what you say.

Do: How are you coping?◦ Don’t: I haven’t see you here at the hospital.

Pitfalls

Active LISTENING ◦ Verbal and non-verbal cues◦ Yes, I see , head nod, hmmm – Eye contact

Language clear, understandable Open body language

◦ Lean forward, uncrossed arms, sit Open-ended questions Repeat last 2-3 words from their sentence Summarize patient’s concerns Compassionate HONESTY

Do’s

Dr. Paul Rousseau – Aging Q3 – 10 steps for a family conference or giving bad news

Back A, Arnold R, Tulsky. Mastering communication with seriously ill patients. Balancing honesty with empathy and hope 2009. Cambridge University Press.

Lautrett A, Darmon M, Megarbane B, et al. A communication strategy and brouchure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478.

Azoulay E. The end-of-life family conference. Communication empowers. AmJ Respir Crit Care Med 2005;171:803-805.

Parker PA, Baile WF, de Moor C, et al. Breaking bad news about cancer: Patients’ preferences for communication. J Clin Oncol 2001;19:2049-2056.

Harrison ME, Walling A. What do we know about giving bad news? A review. Clinical Pediatrics 2010;49(7):619-626.

Barker C, Foerg M. Long term care intensive train the trainer series. Communication skills at the end-of-life. Hospice of Michigan.

Education in Palliative and End-of-life Care. Medical College of Wisconsin Research Foundation, Inc. David E Weissman MD, Timothy Quill MD, and Robert M Arnold MD.

References