Family Meeting

Author: Linh Nguyen, MD

Overview

Family meetings are an important strategy for communicating and negotiating goals of care in geriatric and palliative patients.

A family meeting is typically indicated when delivering bad news, prognosis discussions, withholding or withdrawing treatments, or hospice discussions.

Meetings should be proactive when possible and not reactive to crisis situations. Family meetings should be offered routinely and conducted at pertinent times thereafter.

Provide a safe environment that is mutually beneficial.

 

Intervention/Management

Six-step patient-centered goal(s) approach:

  1. Prepare and plan:
    • Establish setting
    • Identify key stakeholders
    • Conduct a pre-meeting "huddle" to align agenda - do not have rigid pre-set expectations. 

  2. Find out what the patient and family want to know: 

    • Provide sufficient time for patients and families to "tell their story"
    • The more patients and families speak early on the better.
    • Build relationships, 
    • Actively listen, 
    • Respect differing preferences. 

  3. Medical review-share information: 

    • Discuss prognosis and the benefits and burdens of treatment options, 
    • Be mindful of overly optimistic and overly pessimistic predictions,
    • Deliver small amounts of information at a time, and 
    • Frequently pause to check for understanding.
  4. After the news-respond empathetically:
    • Listen more than talk, use silence;
    • Acknowledge, legitimize, explore, empathize; convey honesty and reframe hope.

  5. Identify and resolve conflicts:
    • Identify causes of conflict (information gaps, treatment goal confusion, emotions, family dynamics, and team dynamics), 
    • Help resolve conflicts and be prepared to make recommendations, 
    • Recognize that grief work takes time, and 
    • Use "I wish" statements.

  6. Goal setting and future planning:
    • Elicit values and preferences, 
    • Establish patient-centered goals, 
    • Be prepared to make a recommendation, 
    • Ask "What is most important to you?" 
    • Summarize, establish and implement plan, 
    • Follow-up.

Another way to recall this approach is the "SPIKES" acronym:

Setting up the interview, assessing the patient's
Perception, obtaining the patient's
Invitation, giving
Knowledge and information to the patient, addressing the patient's
Emotions with empathetic response, and
Strategy and summary (Baile, Buckman, Lenzi, Glober, Beale, & Kudelka, 2000).

A good rule to follow - discuss what you can do for the patient and family before discussing what you cannot do (Quill, Holloway, Shah, Caprio, Olden, & Story, 2010).

 

Key Points

In family meetings, family satisfaction is significantly associated with an increased proportion of time that the family speaks.(McDonagh, Elliott, Engleberg et al., 2004). 

 

References

Baile, W.F., Buckman, R., Lenzi, R., Glober, G., Beale, E.A., & Kudelka, A.P. (2000). SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist, 5:302-311.

McDonagh, J.R., Elliott, T.B,. Engleberg, R.A., et al. (2004). Family satisfaction with family conference about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Critical Care Medicine, 32:1484-1488.

Quill, T.E., Holloway, R.G., Shah, M.S., Caprio, T.V., Olden, A.M., Story, C.P. (2010). Chapter 6: Goal Setting, Prognostication, and Self-Care. In Primer of Palliative Care (5th ed., 109-137). Glenview, IL: American Academy of Hospice and Palliative Medicine.