Family Interviews

1. Family Interviews Norman Jensen MD MS Professor of Medicine University of Wisconsin nmj@medicine.wisc.edu

2. Intended Learning Outcomesa.k.a. Learning Objectives • Review utility of family interviews (FI) • Enhance basic technique in FI • Preview advanced technique in FI • Encourage the doing of FI

3. “Most clinicians consider the individual patient to be the object of their primary concern. Occasionally, the patient’s family comes to the foreground, sometimes at the clinician’s request as a source of specific information, sometimes as a result of the family’s request for information and reassurance. These encounters between clinician and family often tend to be unplanned, episodic, and focused on an immediately pressing issue. Not infrequently, the encounter is awkward for all concerned.”Worby,1972:140

4. PROS Source of additional information Help implementing the treatment plan Help & support for patient CONS (Greene 1994) More time ~ 20% Patient less active Less rapport w pt? Ethical Privacy Confidentiality Agency Clinician must be more assertive Family InterviewsPros and Cons

5. Family Interview SituationsWhen to interview more than one SO* • Unexpected: SOs with pt, in/out-patient • Called for purpose • Hospital admission and/or discharge** • New dangerous or chronic disease • Treatment failure • Unexplained &/or regular recurrence of symptoms • Major change in care plan • DNR, palliative, residence, privilege restriction • Issues: competence; DPOA; guardian • Others ??? * Significant Others ** see notes

6. Family InterviewsBasic Skills • Greet & build rapport • Identify each person’s agenda • Check perspective of all present • Facilitate each to speak for him/herself • Recognize/acknowledge feelings of each • Respect privacy and maintain confidentiality • Interview patient alone for private matters - PE • Avoid siding with one against others • Check understanding and agreement with each Epstein, Lang, Zoppi 1999.

7. Family Interviews - Basic SkillsImportant Beginnings • Punctuality more important with a group • Comfortable room & seating for everyone • Greet & understand names & relationships • Make extra effort with those unfamiliar • “outsiders” more likely to triangulate • Actively decide who begins the discussion. • Least vs. most powerful • group decision. • Agenda setting for each person present • Objectives

8. Family Interviews - Basic SkillsPerspectives of everyone • Observations • Attributions • Fears & concerns • Expectations for “patient” • Expectations for “process”

9. Family Interviews - Basic Skills Help each to speak for themselves • One person speaks at a time • Discourage monopolization • Encourage the “quiet” or “uninvolved” • Discourage speaking for those present or not • Encourage speaking to others vs. about them • Incorporate in “ground rules” at beginning • Remind when necessary

10. Family Interviews - Basic SkillsRecognize & AcknowledgeFeelings of everyone present • Non-verbals = rich source of information: seating, position, eye contact, facial expressions, etc. • Inquire and acknowledge emotion (reflection) • Explore sources of emotion • Respond to emotion (PEARLS)

11. RespondingtoEmotionProfessional Rapport Building SkillsCohen-Cole SA & Bird J. • Partnership • Empathy • Apology • Respect • Legitimation • Support

12. Family Interviews - Basic SkillsConfidentiality & PrivacyComplicated issues • Other family members may be your patients. • Permission for sharing “private” information. • Agency • Who are you doctoring? • Who is the patient? • Time alone with patient • varies with why patient is accompanied

13. Family Interviews - Basic SkillsAvoid siding with any subgroup • Families may have triangles and coalitions within their membership • Physician may be asked to side with one side or another (Hahn 1988) • Reflect the issue and facilitate negotiation

14. Family Interviews - Basic SkillsCheck Understanding & Agreement of each one present • Each person’s concerns must be addressed. • Solicit each person’s opinion on the plan. • Agreement if possible by consensus or compromise • Acknowledge irresolvable differences • Arrange to revisit in follow-up.

15. Family InterviewsAdvanced Skills • Useful when family exhibits • ineffective communication • difficulty resolving a conflict • intense emotion

16. Family InterviewsAdvanced Skills • Guiding the communication • Conflict management • Reaching common ground • Referral when needed Epstein, Lang, Zoppi 1999.

17. Skills demonstration • Character played by • John Jenkins Skip Berigan • Sara Smith Liz Morrison • Susan Jenkins Jeanne Harris • Clinician script in your handout

18. BASIC SKILLS Greetings & rapport Agenda of each Perspective of each Each speak for self Feelings of each Privacy & Confidentiality of PT alone time No taking sides Understanding and agreement with each OBSERVE Basic skills (see left) Verbal skills Non-verbal skills Emotion handling Facilitation Session management Use of time Use of control Closure Your assignments

19. Review: Intended Learning Outcomesa.k.a. Learning Objectives • Review utility of family interviews (FI) • Enhance basic technique in F I • Preview advanced technique in F I • Encourage the doing of F Is

20. The lecture ends here! Questions? Answers $0.25Answers requiring thought $1.00Correct answers $2.50 Comments?

21. Partnershipto minimize fear of isolation & abandonment • “We’ll work together for the best possible results.” • “We’ll see you through this together” • “No matter what happens, you and I are partners in this until you die” • “We’ll work on problems together as they come up” • CAVEAT: don’t promise what you can’t deliver!

22. Empathy - ReflectionTo promote a sense of being understood • “How are you feeling right now?” • “I wonder if you’re feeling a bit upset…” • “That must have been a big surprise” • “It seems this is upsetting to you. • “You look a bit sad.” • “You were really pleased with that I bet” • CAVEAT: Accuracy is important

23. Apologyfor failures and suffering caused by self, group, institutions one represents & the profession • “I’m sorry I made you wait so long this morning.” • “I’m sorry no one’s talked much with you. I know doctors neglect that sometimes.” • “I’m sorry I did not call you when I promised.” • “I’m sorry Unity changes their formulary so often.” • CAVEAT: Saying “I’m sorry” after bad news, is not usually heard as an apology.

24. Respectfor suffering, coping, and results • “Your effort has really paid off.” • “I know you suffer a lot -- I admire how well you cope.” • “You’ve really made the best of the situation.” • “I can see you’re working very hard at this”

25. Legitimationagreeing & approving not required • “That could make one angry!” • “Most people would feel humiliated after an experience like that.” • “Its quite normal to feel frightened before getting test results.” • “Anyone would feel shocked after news like that!”

26. Supportto reduce fear of isolation & alienation • “I will help you make the best of this situation.” • “I’ll see you through to the end of this.” • “When you cannot come to clinic, I will come see you” • “I want to give you the best care until the day you die”

27. “Dr. Rogers, how much empathy should I do?” “ UNTIL IT WORKS ” Carl Rogers America’s preeminent 20th century Psychologist