Leading a Family Conference

1. Leading a Family Conference Keri Holmes-Maybank, MD Medical University of South Carolina June 21, 2012

2. Learning Objectives • 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.

3. Key Messages • 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.

4. Family Conference • 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

5. “Bad News” • 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

6. Family/Patient • 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

7. Roadmap

8. Step 1Preparation • 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

9. Step 2Proper Setting • Private • Comfortable • Everyone seated in circle • One facilitator • Limit health care personnel • Turn pager off or to silent

10. Step 3Introduction • 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.”

11. Step 3State Meeting Goals • 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.”

12. Step 3Relationship • 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

13. Step 4 Family Understanding of Condition • 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?”

14. Step 5Medical Review/Summary • 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

15. Step 6Silence and Reactions • 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.”

16. Step 7Present Care Options and Set Goals • 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?”

17. Step 8Translate Goals into Care Plan • 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

18. Step 9Document and Discuss • Debrief with team members, consultants, nurses • Write a note • Who was present • What decisions were made • Follow-up plan

19. Step 10Managing Conflict • 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

20. 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

21. Pitfalls • 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.

22. Do’s • 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

23. References • 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. AmJRespirCrit 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 ClinOncol 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.