Communication and shared decision-making in family meetings ICU Workshop

What is a “family meeting”? A family meeting is a discussion in which healthcare provider(s) and patient (and/or at least one member of the patient’s family or another authorized surrogate decision maker who has authority to make medical decisions for the patient) address the patient’s condition (diagnosis and prognosis), needs, values, and preferences with regard to goals of care and treatment. –Adapted from: Qual Saf Health Care 2006; 15:

What are the goals of a family meeting? Facilitate communication about the patient’s condition, prognosis and care preferences Listen to the family’s concerns, respond to questions, provide support Make decisions about appropriate goals of care

Why bother practicing how to run a family meeting? Family meetings happen often They are hard We don’t run them as well as we could Better communication results in improved outcomes –Improved quality of care –Decreased length of stay –Increased family satisfaction and decreased bereavement time

Appreciative inquiry Think about a meeting in which a physician and/or team was especially effective in providing support and communicating with a family. What characteristics or skills made the meeting effective?

The FAMCAT skills Manage Flow

Mr. Crosby, hospital day 10 Mr. Crosby is a 75 y.o. man with past history of severe COPD who presented initially with respiratory distress, relative hypotension, fever, and new infiltrate on CXR. He has now been intubated for 10 days. His BP has normalized but he remains ventilator dependent despite maximum treatment with w/antibiotics & steroids. He failed an extubation attempt (was re-intubated), and becomes tachypneic and agitated during subsequent daily spontaneous breathing trials. A decision must be made whether to proceed with trach/PEG or transition to palliative/comfort care You are about to meet with his family to discuss this.

Prepare for the meeting Who should be there? Family dynamics, cultural factors (RN may know) Who is the health care proxy? Know the patient’s hx Know prognosis, possible outcomes, time frames What info can family supplement? Pager coverage Focus yourself Sir Samuel Luke Fildes The Doctor

Set the stage Setting Introductions What’s your role and when will they see you again? Who else is on the team? Who’s in charge of the patient’s care? How much time is available for the meeting?

Open the discussion Explain reasons for the meeting Elicit questions and concerns Negotiate an agenda We wanted to meet to update you on your father’s condition and to discuss his care What questions or concerns would you like to be sure we discuss today? Anything else? Let’s begin with…we’ll meet again if we can’t discuss everything today.

Share information Elicit family’s understanding of the situation Use Ask-Tell-Ask Ask: Just so we know where to begin, can you tell us your understanding of your father’s condition? Tell: Small chunks, simple words Ask: Check in - What questions do you have so far?

Discuss prognosis Uncertainty: We can’t know the future for any individual What’s known: Of 100 patients with your father’s conditions, ‘x’ might die in the hospital rather than recover Hope and prepare: So while we hope, we also want to be prepared Time-frame: The condition of patients in the ICU vary from day to day, but overall we would expect to see some definite improvement by …if he is able to respond to treatment Benchmarks: These are the things we’ll be watching to know if he’s improving… Stop, listen, check.

Understand the patient’s perspective: Elicit substituted judgment We need to understand what your father would want in this situation. Imagine if he was sitting right here watching us, what would he have said was most important to him? How would he feel about our being aggressive in prolonging his life whatever its quality? How would he feel about our being aggressive in ensuring his comfort without prolonging life? How do you see your roles in making this decision? Is there anyone else you’d like to consult (e.g. chaplain)?

Build the relationship Use words that show care and concern: R2SVP!Use words that show care and concern: R2SVP! –Reflection: “I hear you saying…” “You look worried…” –Respect: “You’ve been here consistently to support him.” –Support: “We’re here to support you. Help us understand how best to do this.” –Validate: “Your concerns are certainly understandable given the circumstances.” –Partnership: “We see you as part of the team.”

Reach agreement and prepare family Summarize family’s discussion & make a recommendation Negotiate and agree on goals of care Provide explicit support for family’s decisions Describe next steps for withdrawal of life support –Protocol to withdraw mechanical ventilation –Management of pain and other symptoms –Family’s access to patient Tell the family that withdrawal of life support does not mean withdrawal of care – the patient will not be abandoned Reassure the family that the patient will be comfortable and will not suffer Redirect hope towards a comfortable death

Provide closure Restate the decisions Summarize what will happen next Ask if any further questions Let the family know how to reach you if they have questions Tell them who else on the team will be available and how to reach them