the family meeting: the procedure of patient-centered care

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The Family Meeting: The Procedure of

Patient-Centered Care

Michael Aref, MD, PhD, FACP, FHMAssistant Medical Director of Palliative Medicine

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Conflict of Interest and Financial Disclosure

• None

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Objectives

• Understand the importance of high-quality family meetings.

• Define the elements of a high-quality family meeting.

• Discuss the communication techniques and tools of family meetings.

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EXPERIMENT

THIS IS WHY YOU NEED A FAMILY MEETING

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Stages of Organizing a Family MeetingDenial – “I have already explained everything to the patient and they understand it all.”

Bargaining – “Let’s hold off on the family meeting and wait for dermatology’s input.”

Anger – “I didn’t get into medicine to…talk…to people!!!”

Sadness – “*sob* This is going to take forever. *sniff*”

Acceptance – “I will be there 15 minutes early!”

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The Bomb Squad

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EXPERIMENT

RESULTS

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Is This What You Heard?

56 year old woman with pancreatic cancer wants to eat a tuna fish sandwich. She is a DNAR but does not have a POLST form.

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HIGH-QUALITY FAMILY MEETING

ELEMENTS

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Definition of High-Quality Family Meeting

↑ Satisfaction

↑ Symptom Control

Plan of Care

↓ PTSD

↑ Satisfaction

↓ Burnout

Goals Established

↓ $$$↓ LOS

↓ Readmissions↓ Mortality

↓ Resource RequirementsStandardized

EMR Documentation

↑ EfficiencyPlan Consensus

Among Treatment

Team

↑ Listening

↑ Understanding

Process Outcome

Patient/Family

Provider

Institution

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Communication Components Associated with Increased Quality of Care, Decrease Family Psychological Symptoms, and Improved Family Ratings of Communication

• Conduct family conference within 72 hours of ICU admission.

• Identify a private place for communication with family members.

• Provide consistent communication from different team members.

• Increase proportion of time spent listening to family rather than talking.

• Empathetic statements.

• Identify commonly missed opportunities.

• Affirm non-abandonment of the patient and family.

• Assure family that the patient will not suffer.

• Provide explicit support for decisions made by the family.Crit Care Med. 2001;29:1893–1897.Am J Respir Crit Care Med. 2005;171:844–849.Am J Med. 2000;109:469–475.Crit Care Med. 2004;32:1484–1488.Crit Care Med. 2006;43:1679–1685.J Gen Intern Med. 2008;23:1311–1317.J Palliat Med. 2005;8:797–807.

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Family Meeting Formats

Format Roadmap Supportive Urgent Discharge Planning

Timing < 72 hours < 72 hours < 24 hours of clinicalchange

> 24 hours prior to discharge

InformationFlow

Patient Provider Patient Provider Patient Provider Patient Provider

Clinical Participants

Primary Service Specialist(s)

Primary Service+ Social Work+ Chaplain Specialist(s)

Primary Service Specialist(s) Social Work Chaplain

Primary Service+ Case Management Specialist(s)

Objective Possible treatmentcourses of disease, hoped for and worst case scenarios

Hopes and fears of patient and family, identify educational and resource deficits

Change in treatment goals, code status, limits on intensity of treatment

POLST form, follow-up, out-patient support and resources, negotiated criteria for discharge

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V.A.L.U.E.

• Value family statements

• Acknowledge family emotions

• Listen to the family

• Understand the patient as a person

• Elicit family questions

Chest. 2008 Oct; 134(4): 835–843

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Silence

Type of Silence Clinician Intent

Awkward Often without clear intention (uncertainty), but also may reflect distractedness or hostility, often masked by the clinician.

Invitational Wanting to give the patient a moment (or longer) to think about or feel what is happening, often after an empathic response. The clinician deliberately creates a silence meant to convey empathy, allow a patient time to think or feel, or to invite the patient into the conversation in some way.

Compassionate Recognizing a spontaneous moment (or longer) of silence that has emerged in the conversation, often when the clinician and patient share a feeling or the clinician is actively generating a sense of compassion for the patient. The clinician must:• Give attention• Maintain stable focus• Have clarity of perception

J Palliat Med. 2009 Dec;12(12):1113-7.

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HIGH-QUALITY FAMILY MEETING

COMMUNICATION TECHNIQUES & TOOLS

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Family Meeting MapStep What you say

Gather for a pre-meeting

Let’s decide who will talk about what.Could I propose a way to structure the meeting?When the meeting ends, what would be a constructive outcome?

Introduce everyone and elicit the agenda

Let’s start with introductions. My name is [x], and my role is [y].The purpose of this meeting is to talk about [z].Is there anything that you would like to cover in addition?

Explain what’s happening

Tell me what you took away from our last conversation.Could I hear from everybody?Here is the most important piece of news…

Empathize with each person

I can see you are concerned about [a].I am impressed that you have been here to support [patient’s name].

Highlight the patient’s voice

If [patient’s name] could speak, what do you think she would say?How would she talk about what is important to her?

Plan the next steps together

Based on what we’ve talked about, could I make a recommendation?I’d like to hear everyone’s thoughts about the plan.

Reflect post-meeting What did we learn?

vitaltalk.org/guides/family-conference/

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Pre-Meeting

• If you do this right, someone is going to need a tissue.• Where is the meeting taking place and is the patient

participating?• Is the meeting place clear of distractions and can everyone

sit down?• What are the desired outcomes?• Who is going to moderate the meeting?• What is each person’s clinical communication

responsibility?

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Sitting in the Right Setting

Actual and patient perceived time of provider at bedside

1.04 1.28

5.14

3.44

0

1

2

3

4

5

6

Sit Stand

ActualTime (min)

PerceivedTime (min)

Percentage of positive and negative comments by provider posture

95%

61%

5%

39%

0%

20%

40%

60%

80%

100%

Sit (n = 20) Stand (n = 18)

K.J. Swayden et al./ Patient Education and Counseling 86 (2012) 166–171

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Impact of Physician Sitting Versus Standing

• 69 patient randomized to watch one of two videos in which physician was standing then sitting or sitting than standing:

– 51% preferred the sitting physician

– 23% standing

– 26% no difference

J of Pain and Symp Management 2005; Vol 29 (5). 489-497

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An AIDET Application

• Acknowledge– “Nice to meet you.”– “Great to see you again.”– Not: “You look great” (the patient might not feel great!)

• Introduce– “Let’s go around the room so everyone knows who is who. My name is [x], and my role is

[y].

• Duration– “We have about 30 minutes to talk today as a group. I would be happy to spend more time

with you afterward if needed.”

• Explanation– “The purpose of this meeting is to talk about [z].”

• Thank You– “Thank you all for taking the time to meet today.”

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Agenda SettingStep What you say

Ask about your patient’s main concerns for the visit

“What are the important questions you wanted answered today?”“Is there anything you wanted to ask your physicians about?”“Do you have anything to put on our agenda?”“Anything else?” (often the most important issue is not first)

Explain your agenda “There are two things I wanted to make sure we talked about…”

Propose an agenda that combines the patient’s and your concerns

“How about if we talk about your question first, then cover my two things?”or“Given these things, what is most important for you to cover?”

Be prepared to negotiate. “Ok, I understand that the most important issue for you today is ___.”“I hear that you have a number of questions. Could we prioritize them so that we cover the most important ones if we don’t have time to get through all of them?”

Ask for feedback “Do you feel like we’ve covered the agenda? How did we do?”

vitaltalk.org/guides/first-visit/

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It Is All Going Downhill

Disease Trajectories

bioethicsarchive.georgetown.edu/pcbe/images/living_well_graph.gif

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Birth

Actively Dying

Death

Diagnosis

Treatment

New Problem

Life

Simplified

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Teach-Back

A Priori A Posteriori

• Patient has seen a specialist or been referred from another physician.

• Minimum: Review documentation. Ideally speak with other physician.

• “To make sure I provide you with the best care, it helps me to understand if you can tell me, in your own words, what Dr. X, the [specialty] doctor, explained to you.”

• You are finishing your visit and want to assess that the patient has increased understanding of the clinic situation.

• “We talked about a lot today and sometimes I can get a little technical. For my benefit, if you were to explain the most important points of today’s visit to your family, what would you tell them?”

JBI Database System Rev Implement Rep. 2016 Jan;14(1):210-47

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E.M.P.A.T.H.Y

• Eye contact

• Muscle of facial expression

• Posture

• Affect

• Tone of voice

• Hearing the whole patient

• Your responseAcademic Medicine 2014;vol 89 (8): 1108-1112

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Articulating Empathy

Tool Example Notes

Naming (1) “It sounds/looks like you are scared / sad / frustrated”

Naming the emotion will usually decrease the intensity of emotion

Understanding (<5) “This helps me understand what you are thinking”

Use to convey acknowledgement while avoiding implications that you understand “everything”

Respecting (1-2) “I can see you have really been trying to follow our instructions”

Give the patient/family credit for what they have done, praise is a motivator

Supporting (1-2) “I will do my best to make sure you have what you need”

Commit 100% of what you can commit to without committing to things beyond your control

Exploring (∞) “Could you say more about what you mean when you say that…”

Open-beginning statement with a focused end

www.vitaltalk.org/sites/default/files/quick-guides/NURSEforVitaltalkV1.0.pdf

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Identify Commonly Missed Opportunities

• Listen and respond to family members

• Acknowledge and address family emotions

• Explore and focus on patient values and treatment preferences

• Explain the principle of surrogate decision making to the family – the goal of surrogate decision making is to determine what the patient would want if the patient were able to participate.

Chest. 2008 Oct; 134(4): 835–843

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Three-step Approach to Patient- and Family-Centered Decision Making

Assess prognosis and certainty of prognosis

Assess family preference for role in decision-making

Adapt communication strategy based in patient and family factors and reassess regularly

Shar

ed D

ecis

ion

Mak

ing

Parentalism“Doctor Decides”“Do you want a

recommendation?”

Autonomy“Family Decides”

“Do you want some time to talk with your family

about this?

Chest. 2008 Oct; 134(4): 835–843

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Disease-Specific vs Goal-Oriented

Outcomes depend on perspective

N Engl J Med 2012; 366:777-779

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Speaking and Translating Caring

Goals of Care

• Identify what is important to and priorities for the patient.

• Identify what they hope to achieve by receiving care.

• Identify what they fear will happen because of the disease.

• Life review and legacy building are separate, equal, but not independent parts of care.

Plan of Care• Representation of the goals of care in the form

of– Documentation

• Advanced Directive• Living Will• HCPOA

– Orders• POLST• Code Status

– Medications• Starting and stopping

– Services• Social Work• Chaplaincy• Hospice• Home Health

National Committee for Quality Assurance: Goals to Care

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S.M.A.R.T. Goal

• Specific– What does the patient mean to accomplish with this goal?

• Measurable– What observable shows we are meeting the stated goal?

• Agreed Upon– Are the patient, family, and provider all on the same page?

• Realistic– Is this possible – physiologically, clinically, financially, humanly, etc.?

• Time-Bound– When will this be observable?

General goals cannot be translated into a plan of care

Management Review. AMA FORUM. 70 (11): 35–36National Committee for Quality Assurance: Goals to Care

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Unclear Goals = Unplannable Caring

Goals of Care

• “I’m going to beat this [disease]!”

• “My family won’t let me go to a nursing home.”

• “We’re going to fight this!”

• “I’m going to get my miracle.”

Plan of Care

• These are general, usually not agreed upon, often unrealistic, and do not meet a timeline consistent with life expectancy.

• The plan of care in these case is to explore:– “Tell me what this means to you.”

– “Help me understand more about this by telling me how you feel about…”

vitaltalk.org

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Clear Goals Lead to a Care Plan

Goals of Care

• “I want to be able to enjoy the holidays with my family, particularly my grandchildren.”

Plan of Care

• This is specific, measurable, can be agreed upon, may be realistic, and has a set time frame.

• Perhaps a chemotherapy “holiday” or stopping hemodialysis after the holidays. Certainly documenting code status and likely involving some sort of home nursing care, be it private duty, home health, or hospice.

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Post-Meeting Reflection

• What worked well?

• What could have been better?

• What changes to the plan of care need to be taken care of?

• What are the next steps?

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THANK YOU

QUESTIONS OR COMMENTS

the family meeting: the procedure of patient-centered care

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