Family Meeting

Palliative care for Primary Care doctors
Objective
1.Recognize goal of care clarification as a center of palliative care 2. Know key success and process of family meeting 3.Able to conduct Family meeting under supervision
Family Meeting
Patama Gomutbutra MD. Revised Jan 2012
Comprehensive palliative care

Pain, N/V etc.
Symptom control
Key success of palliative care

1. Aim is to find ways to reach PATIENTS goal not to make them accept our goal.
.
Goal of care clarification Ethic and law ie. consider withhold or withdraw life-prolongating intervention
Disease management Psychosocial spiritual support
2. Building TRUST before giving thought.

Depression Grief and Bereavent
3. Focus on what we CAN do more than what we cannot do.

Adapted form Back et al, 2009
Who make decision?

Patient ( except cognitive incompetence) Living will or Advance directive Duration Power of Antony(DPOA) Surrogate decision maker ( Family members/Physicians best interest)
Why families are important

Studies in Maharaj Nakorn ChaingMai hospital Patient preference about deferral of decision if lack competency ( Sittisombat S,2009) - 42.8 % prefer family participate in end of life care decision - 77.6 % prefer family participate in CNR decision. Physician practice ( Sittisombat S,2005) - 38.2% discuss CPR with patient - 90.9% discuss CPR option with family
When shoud clarify goal of care

Transform goal from mainly prolong life to mainly quality of life. Functional status (before patient too frail) - PPS > 70% give information - PPS 60%- 30% suggest - PPS <30% highly recommended If pt. and family dont want to talk -> fine Just continue building trust.
Trajectory of disease
Cancer Rapidly decline
Organ Failure Off and on
Frail elder Slowly progressive decline
Murray, S. A et al. BMJ 2005;330:1007-1011
Set up
Arrange for a quiet, private place to meet Invite all invested parties
Anatomy of Family meeting
Surrogate decision maker Care team members: MDs, RNs, SWs, RTs
Determine beforehand:
Adapted by permission form How to Run a Family Conference. Steven Z.Pantilat. UCSF
Goals of the meeting* Who will lead
Family meetings should not be used as an opportunity for health care professionals to debate a patients medical status
( CPCER guideline,2009)
Start
Introdroduce team to family. Assess the familys perception of the patients situation
I was wondering if you could tell me what you understand about your fathers condition
Stand point
Keep the focus on the patient
If she could sit up in bed What would she think of this? Not what you want for her, or what youd want for yourself, but what she would want for herself
When conflict occur among family members Express respect for each person love for patient And remind them to focus on what patient wish
Avoid intellectual debate You are talking with Emotional brain

Listen Listen Listen! As much we understand them As much they will understand us
Sincere and careful about prognosis

Honest to remind the family, the patient we are talking is dying Dont promise. - When patient will die - Where patient will die - How patient will die - That family can return to bedside in time to say goodbye
Share recommendation
Assume responsibility for the decision
Based on what I know about your mother and the medical situation Based on my clinical experience.. I recommend.. Dont force the family to decide
X There is nothing more we can do (abandon) I wish there was something we could to ( Empathic) X Would you like us to do everything possible (If they say yes??) How were you hoping we could help your mother ( Active listening) X Withdraw of care (No more care) Withdraw of life sustaining intervention ( Another way of care focusing on comfort)
Nobody is going to love you for what you do not do ( Hallenbeck JL,2003)
How to provide prognosis? - Need some knowledge about prognostification ( eg. Chronic renal failure off dialysis, sign of prominent death) - Ask if they want to know if not- Dont tell - Tell in range e.g.. hours to days, days to weeks weeks to months
Summarize
Check for agreement Accept for disagreement Arrange follow up contact Document the meeting
Duration of meeting should not more than 60 min (CPCER guideline,2009)
Support
Burnout / compassionate fatigue Strategies - Having opportunity to express feeling and problem with other people. - Having sense of competence - Having hobbies and healthy life style. - Ask yourself ( Reflection) Why do I do this? What inspired me today?
Conclusion
Set up who are key decision makers Start from what family know Stand on what the patient would want Sincere and careful about prognosis Share but not force recommendation Summarize and keep it up Support family, staff, and yourself !
Take home message

Conflicting opinion of family members, 90% can be resolved through repeated discussions But Conflicting and contradictory information from providers can be very distressing
Steven Z. Pantilat
Recommended reading
1. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York, NY: Cambridge University Press; 2009. 2. Hudson P, Quinn K,O.Hanlon B,Aranda S. Family meetings in palliative care: multidisciplinary clinical practice guidelines.BMC Palliative Care 2008, 7: 12. 3. Pantilat SZ. Communication Skills and How to Run a Family/Care Conference ( Handout from www.hospitalmedicine.org)

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Palliative care for Primary Care doctors

Comprehensive palliative care

Key success of palliative care

2. Building TRUST before giving thought.

3. Focus on what we CAN do more than what we cannot do.

Who make decision?

Why families are important

When shoud clarify goal of care

Organ Failure Off and on

Frail elder Slowly progressive decline

Murray, S. A et al. BMJ 2005;330:1007-1011

Anatomy of Family meeting

Goals of the meeting* Who will lead

Avoid intellectual debate You are talking with Emotional brain

Sincere and careful about prognosis

Take home message

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