The family meeting can be a source of dread, or it can be a form of advocacy for your patient and catharsis for the family (and us). How many times have we as healthcare providers been in situations where we think to ourselves, I am only prolonging this patient’s suffering, or, I don’t understand why the family won’t let this person go? A good family meeting can be very satisfying for all involved. It should not be feared.
Here are strategies I have found useful for navigating family meetings:
Outline what your goals for the family meeting are. It is NOT the goal of every family meeting to make a patient comfort care only. Sometimes the goal is just to have everyone in the same room at the same time, or for family members to see the pain that their loved one has to endure from fighting to survive. Sometimes the goal is to learn about the patient’s wishes, but not necessarily do anything about it just yet.
Make introductions (read: make a good first impression). A good way to start a meeting is to go around the room and have everyone say their name, and their relation to the patient. This puts everyone else at ease, and gives you more time to understand who really cares about being here, and how to target your message. It also allows the patient’s family to see just how many members of the healthcare team are involved.
Keep it simple. It is especially hard for patients and their families to process information when we are discussing life-or-death decisions and sometimes discussing whether a patient should be allowed to die. Use PLAIN language. For example: “Your kidneys are very sick. We can do everything for you, but even with that, we don’t think you can recover from this. Is it more important for you to be at home? Take some time to think about that.” Be frank, if you have to be. Drawing pictures or using analogies can also be helpful; giving them something they can remember even when the meeting is over.
Body language.This is ESSENTIAL. We subconsciously communicate so much through the way we sit, eye contact, or what we are doing with our hands while we talk. Beware letting frustration, fatigue from taking care of other patients, or irritation show through your body language–just as you can pick up on signals from other people, they pick up on your signals, too, and may become more defensive. Make the room a close, intimate space by arranging chairs in a circle ahead of time and leaning in. Make sure to have tissues available. Calm down the tone of your voice. Make good eye contact. Do not fidget or check your phone. Use dramatic pauses for emphasis.
Refer to other cases. It can be comforting to remind the family that they are not the first who have had to face this disease. It is not wrong to say, “I have seen people with alcoholic hepatitis decompensate quickly,” or “One question people often ask with metastatic cancer is…”
Make it about fulfilling the patient’s goals. Although you enter a family meeting with your own objectives, you may not be able to accomplish everything you want to in a single meeting. Things will not go your way. Remember that above all else, the purpose of a family meeting is learn the patient’s goals of care, provide answers and space for the patient and their family. You should work towards their goals, whether you agree with them or not. Don’t evaluate the family meeting as a success or failure.
Prognosticate as comfortably as you can. There are different opinions about whether or not to prognosticate. The fact is, we’re not great at it. But another fact is, that’s one of the things patients/their families most want to hear: how long do I have? Over time, you will develop a “sense” for how long someone might have based on their disease and clinical appearance. If you feel comfortable telling the family, then do–with the caveat that we’re not always 100% accurate. If you don’t feel comfortable, then tell the family that, and tell them why.
Give them time. I once took care of a woman with cirrhosis and hepatorenal syndrome who we transfused daily, who was so edematous that she screamed in pain every time she was turned, and was barely conscious. It took the husband two weeks of daily conversations with the team to accept that she was dying, and that “fighting” was not an option anymore. If we had forced him to see this on the first day, he would have become defensive and angry, but by giving him time, even if we did not agree with his decision to continue medical care, the outcome was better–she was sent to Hospice, where she passed away shortly thereafter, and the family felt grateful for having time to have her friends see her and say goodbye.
Repeat if necessary. It bears repeating that you usually will not accomplish everything you want to in one family meeting. It is important to make yourself available and open to dialogue, to field family members’ questions whenever they come in, and repeat information whenever necessary. The family meeting is not one point in time, but a process, and if done right, can provide great relief and peace for the patient and their family.