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Keri Holmes-Maybank, MD Medical University of South Carolina June 21, 2012
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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.
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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.
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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
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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
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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
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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
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Private Comfortable Everyone seated in circle One facilitator Limit health care personnel Turn pager off or to silent
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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.”
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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.”
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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
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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?”
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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 8 th grade language Use the word dying if appropriate Answer questions Check comprehension – ◦ What you are saying may not be what they are hearing
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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.”
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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?”
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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
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Debrief with team members, consultants, nurses Write a note ◦ Who was present ◦ What decisions were made ◦ Follow-up plan
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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
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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
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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.
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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
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Dr. Paul Rousseau – Aging Q 3 – 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. 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. 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. 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. 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.
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