The Family Meeting

There are many reasons to hold a family meeting. It’s important to establish the reason for the meeting prior to starting. This doesn’t mean you have too rigid, it’s ok to be flexible. However, when you are nervous and uncomfortable, having a plan before you start talking helps.

Possible purposes of a meeting include:

• General update
• Establishing goals of care
• Breaking bad news
• Futility and/or withdrawal of care

Depending on why you are having the meeting will determine where to have it and who should be involved. General updates and progress meetings can be easily had at the bedside. More difficult conversations regarding breaking bad news and re-direction of care often benefit from a private area, where you can sit down with family members.

Where possible try to involve your patient in these meetings. Obviously if they are sedated/obtunded or delirious this is not possible but don’t forget, that if you have a competent patient you can take the meeting to them.

Learning to talk to families and deliver bad news can be difficult and everyone reacts differently. If you can, watch how your colleagues communicate and pick out the skills that they use. Sometimes it helps to steal some of their commonly used phrases. It can help to view the family meeting like every other procedure you perform. It requires planning, delivery and follow up.

Planning

The extent of planning involved depends on what the purpose of your meeting is. General updates require less planning than meetings around goals of care/direction of care and bad news. Regardless of the type of meeting, try to do some planning before talking to family.

Who?

• Are you the right person to be conducting the meeting? Do you have the required knowledge of the patient and the plan? If not, who is the right person and if they are not available how can you gather the information needed.
• Apart from yourself who else should be involved? Are there other specialty teams caring for the patient? If so it is VITAL that you involve them in discussions around goals/direction of care. Do they want to come to the meeting as well? If there is going to be more than one specialty team in the room make sure you are all on the same page and agreeable to a plan BEFORE you start. The family want to see a team united in treating their loved one and tension between medical teams or contrasting opinions does not often inspire confidence.
• What family members need to be present? Who is the primary decision maker and who are their support people? It’s worth asking the next of kin and the patient who should be there.
• Bedside nurse! In ICU we find it very beneficial to have the bedside nurse present at family meetings, they often know the family better than we do and have already developed a trusting relationship. Additionally, the bedside nurse is the one delivering the care you are planning and often find it very beneficial to hear the planning discussions between medical teams and families. So please ask them if they are available and try and schedule the meeting at a time when they can also attend.
• Social workers are an extremely valuable resource, especially with complex care planning and large families. The social worker often has the best insight in to family dynamics. If they are available, involve them early.

Where?

• Pick the right setting. Long conversations delivering terrible and shocking news is rarely appropriate to do at the bedside of someone who is comatose. Find somewhere private. Find some chairs. Make it somewhere you avoid interruption.
• Find some tissues. You may need these, even when you think you won’t. It’s an awful feeling to watch someone wipe their tears with their sleeve and have nothing to offer.
• If you patient is aware and able to be involved in their own care planning, it is essential to be talking with them. You can bring the chairs and the meeting to them.
• With COVID-19 and the associated visiting restrictions we are more frequently going to be in situations where we are unable to have family and friends visiting. Consider use of technology in these cases. Can you use a phone on loudspeaker in the room with the patient? Can you hold conference calls with various family members dialling in? Obviously these processes can be difficult, slow and frustrating. Be prepared for this and try to be patient.
• Sometimes difficult conversations need to happen in less-than-ideal places (i.e. corridors of busy emergency rooms). If the conversation is time critical (e.g. a patient who is actively dying) and you have no alternate place to have the conversation, make sure you apologise (“I’m so sorry to be having this conversation here”) and do the best you can.

What?

• What do you need to talk about and cover today? Have a plan. If you are going to talk about goals of care, think about how you will have this conversation prior to it starting.
• Talk to someone else about your patient before you start your meeting. Ask your boss/colleagues what they think. Practice the way you might phrase things. This ensures you are delivering news that is in line with the thinking of the whole team.
• Spend some time reviewing the details of the case. Have a look at the latest pathology and imaging and try to have the most up to date information to share.

Delivery

• Introduce yourself, even if you’ve met them before. This family has no doubt met many people dressed in scrubs who all look similar, so remind them who you are and what your role is. Introduce the other staff in the room. It’s OK to go around in a circle and get everyone to say their name and what their role is (I’m Mary, I’m Bob’s little sister etc)
• Sit down. Don’t rush.
• Turn your phone / pager off or ideally palm it off to someone else. This may not be possible if you are the only doctor around. If you are unable to turn your phone off apologise at the start for having to keep your phone on you – most people are understanding.
• Make sure you know the patient’s name! It’s not uncommon to forget little details when you are nervous or uncomfortable but referring to a loved one as “the man in bed 17” is not OK. Ask the family what they call the patient, and what they want you to refer to them by.
• Start by asking the family some questions. “How are you going, this must be a very difficult time for you?”, “is everyone here who needs to be here?”, “what have you been told so far?”, “have you got any big questions you want me to answer before I go any further?”. This allows you to gauge where the family are at and what they understand and what their concerns are. It also allows you some time to shake your nerves. Make sure if you ask a question you let them talk and give them time to answer.
• Be honest. It’s OK to be unsure and say you don’t know. If you get asked a question by the family that you don’t know the answer to, don’t make something up. Say you’re not sure but assure them you will find out and get back to them.
• Be aware of the speed you talk. Talk slowly. Use simple language. Medicine is a foreign language.
• Don’t be afraid of silence and make sure you use it! If you are delivering big news, say what you have to say and give the family time to absorb it. Let them talk first. These silences can be long and feel painful but they are so valuable. You will want to fill these gaps with more information but this is because YOU feel uncomfortable. It’s not about you. If the family aren’t talking or asking questions it’s likely they are trying to absorb what you have said and adding more information at this point is not beneficial. Warn the other staff members in the room that you will do this so they don’t try to fill your silences with more information.
• Stop and ask “is this making sense”/”do you understand what I mean?”. You’d be surprised how much of what we say comes out as complete gibberish. You won’t know that you’re not making sense unless you ask.
• Say sorry. If you’re delivering horrible news phrases like “I’m so sorry I have to tell you this today”, “I’m so sorry this has happened to you” can be helpful.
• Make sure you are clear. Don’t skirt around words like death and dying. Sometimes phrases like “I am very worried about John today, I’m worried things could get worse and if they do he could die from this” help to convey the gravity of the situation. People don’t want to hear bad news and we don’t like delivering it. By expressing that you are personally worried it humanises you but does not take about from the severity of the news you are delivering.
• If making decisions about withdrawing care it is important to be very aware that asking family when to turn off life support is not a fair question and often leaves them with guilt. No one wants to decide when their mum/dad/partner dies. If it is time to redirect care or palliate a patient make it clear that you, as a medical professional, are taking responsibility for that decision. Obviously you will give them the time they need but at the end of the day it is up to you to relieve them of that burden.
• It’s OK to pause the meeting if things are getting tense or emotional, or you think the family need some time. If you do this though you need to ensure that you follow up and do it in a timely manner. Decision making in highly emotive situations is hard and taking a break and letting yourself and the family walk away for a bit can help.

Follow up

• This is for the patient, the family, for you and for your colleagues.
• Patient and Family: timing of follow up depends on the conversation you have had. Do you need to meet again that afternoon? Will you update them if things change? Whatever it is, make sure there is a plan in place and you follow through. If you meet again, recap what you covered last time. Don’t assume that what you said was understood in the way you intended.
• You and your colleagues: family meetings can be heavy, emotional, frustrating and sometimes very sad. Look after yourself and each other. Touch base with you colleagues after. Make sure everyone is OK and allow opportunities for colleagues to unburden themselves or vent.

Author: Alex Van Rijn