University of Illinois College of Medicine at Urbana-Champaign Internal Medicine Grand Rounds presentation on the elements, techniques, and tools of high-quality family meetings.

1. 1
The Family Meeting: The Procedure of
Patient-Centered Care
Michael Aref, MD, PhD, FACP, FHM
Assistant Medical Director of Palliative Medicine

2. 2
Conflict of Interest and Financial Disclosure
• None

3. 3
Objectives
• Understand the importance of high-quality family
meetings.
• Define the elements of a high-quality family
meeting.
• Discuss the communication techniques and tools
of family meetings.

4. 4
EXPERIMENT
THIS IS WHY YOU NEED A FAMILY MEETING

5. 5
Stages of Organizing a Family Meeting
Denial – “I have already explained
everything to the patient and they
understand it all.”
Bargaining – “Let’s hold off on the family
meeting and wait for dermatology’s input.”
Anger – “I didn’t get into medicine
to…talk…to people!!!”
Sadness – “*sob* This is going to take
forever. *sniff*”
Acceptance – “I
will be there 15
minutes early!”

6. 6
The Bomb Squad

7. 7
EXPERIMENT
RESULTS

8. 8
Is This What You Heard?
56 year old woman with pancreatic cancer wants to
eat a tuna fish sandwich. She is a DNAR but does not
have a POLST form.

9. 9
HIGH-QUALITY FAMILY MEETING
ELEMENTS

10. 10
Definition of High-Quality Family Meeting
↑ Satisfaction
↑ Symptom
Control
Plan of Care
↓ PTSD
↑ Satisfaction
↓ Burnout
Goals
Established
↓ $$$
↓ LOS
↓ Readmissions
↓ Mortality
↓ Resource
Requirements
Standardized
EMR
Documentation
↑ Efficiency
Plan Consensus
Among
Treatment
Team
↑ Listening
↑ Understanding
Process Outcome
Patient/Family
Provider
Institution

11. 11
Communication Components Associated with Increased Quality of Care, Decrease
Family Psychological Symptoms, and Improved Family Ratings of Communication
• Conduct family conference within 72 hours of ICU admission.
• Identify a private place for communication with family members.
• Provide consistent communication from different team members.
• Increase proportion of time spent listening to family rather than talking.
• Empathetic statements.
• Identify commonly missed opportunities.
• Affirm non-abandonment of the patient and family.
• Assure family that the patient will not suffer.
• Provide explicit support for decisions made by the family.
Crit Care Med. 2001;29:1893–1897.
Am J Respir Crit Care Med. 2005;171:844–849.
Am J Med. 2000;109:469–475.
Crit Care Med. 2004;32:1484–1488.
Crit Care Med. 2006;43:1679–1685.
J Gen Intern Med. 2008;23:1311–1317.
J Palliat Med. 2005;8:797–807.

12. 12
Family Meeting Formats
Format Roadmap Supportive Urgent Discharge Planning
Timing < 72 hours < 72 hours < 24 hours of clinical
change
> 24 hours prior to
discharge
Information
Flow
Patient  Provider Patient  Provider Patient  Provider Patient  Provider
Clinical
Participants
Primary Service
 Specialist(s)
Primary Service
+ Social Work
+ Chaplain
 Specialist(s)
Primary Service
 Specialist(s)
 Social Work
 Chaplain
Primary Service
+ Case Management
 Specialist(s)
Objective Possible treatment
courses of disease,
hoped for and worst
case scenarios
Hopes and fears of
patient and family,
identify educational and
resource deficits
Change in treatment
goals, code status, limits
on intensity of treatment
POLST form, follow-up,
out-patient support and
resources, negotiated
criteria for discharge

13. 13
V.A.L.U.E.
• Value family statements
• Acknowledge family emotions
• Listen to the family
• Understand the patient as a person
• Elicit family questions
Chest. 2008 Oct; 134(4): 835–843

14. 14
Silence
Type of Silence Clinician Intent
Awkward Often without clear intention (uncertainty), but also may reflect distractedness
or hostility, often masked by the clinician.
Invitational Wanting to give the patient a moment (or longer) to think about or feel what is
happening, often after an empathic response. The clinician deliberately creates
a silence meant to convey empathy, allow a patient time to think or feel, or to
invite the patient into the conversation in some way.
Compassionate Recognizing a spontaneous moment (or longer) of silence that has emerged in
the conversation, often when the clinician and patient share a feeling or the
clinician is actively generating a sense of compassion for the patient. The
clinician must:
• Give attention
• Maintain stable focus
• Have clarity of perception
J Palliat Med. 2009 Dec;12(12):1113-7.

15. 15
HIGH-QUALITY FAMILY MEETING
COMMUNICATION TECHNIQUES & TOOLS

16. 16
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

17. 17
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

18. 18
Pre-Meeting
• If you do this right, someone is going to need a tissue.
• Where is the meeting taking place and is the patient
participating?
• Is the meeting place clear of distractions and can everyone
sit down?
• What are the desired outcomes?
• Who is going to moderate the meeting?
• What is each person’s clinical communication
responsibility?

19. 19
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

20. 20
Sitting in the Right Setting
Actual and patient perceived time of provider at
bedside
1.04 1.28
5.14
3.44
0
1
2
3
4
5
6
Sit Stand
Actual
Time (min)
Perceived
Time (min)
Percentage of positive and negative comments by
provider posture
95%
61%
5%
39%
0%
20%
40%
60%
80%
100%
Sit (n = 20) Stand (n = 18)
K.J. Swayden et al./ Patient Education and Counseling 86 (2012) 166–171

21. 21
Impact of Physician Sitting Versus Standing
• 69 patient randomized to watch one of two videos
in which physician was standing then sitting or
sitting than standing:
– 51% preferred the sitting physician
– 23% standing
– 26% no difference
J of Pain and Symp Management 2005; Vol 29 (5). 489-497

22. 22
An AIDET Application
• Acknowledge
– “Nice to meet you.”
– “Great to see you again.”
– Not: “You look great” (the patient might not feel great!)
• Introduce
– “Let’s go around the room so everyone knows who is who. My name is [x], and my role is
[y].
• Duration
– “We have about 30 minutes to talk today as a group. I would be happy to spend more time
with you afterward if needed.”
• Explanation
– “The purpose of this meeting is to talk about [z].”
• Thank You
– “Thank you all for taking the time to meet today.”

23. 23
Agenda Setting
Step What you say
Ask about your patient’s
main concerns for the visit
“What are the important questions you wanted answered today?”
“Is there anything you wanted to ask your physicians about?”
“Do you have anything to put on our agenda?”
“Anything else?” (often the most important issue is not first)
Explain your agenda “There are two things I wanted to make sure we talked about…”
Propose an agenda that
combines the patient’s and
your concerns
“How about if we talk about your question first, then cover my two things?”
or
“Given these things, what is most important for you to cover?”
Be prepared to negotiate.
“Ok, I understand that the most important issue for you today is ___.”
“I hear that you have a number of questions. Could we prioritize them so that we cover
the most important ones if we don’t have time to get through all of them?”
Ask for feedback “Do you feel like we’ve covered the agenda? How did we do?”
vitaltalk.org/guides/first-visit/

24. 24
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

25. 25
It Is All Going Downhill
Disease Trajectories
bioethicsarchive.georgetown.edu/pcbe/images/living_well_graph.gif

26. 26
Birth
Actively
Dying
Death
Diagnosis
Treatment
New
Problem
Life
Simplified

27. 27
Teach-Back
A Priori A Posteriori
• Patient has seen a specialist or
been referred from another
physician.
• Minimum: Review documentation.
Ideally speak with other physician.
• “To make sure I provide you with
the best care, it helps me to
understand if you can tell me, in
your own words, what Dr. X, the
[specialty] doctor, explained to
you.”
• You are finishing your visit and
want to assess that the patient has
increased understanding of the
clinic situation.
• “We talked about a lot today and
sometimes I can get a little
technical. For my benefit, if you
were to explain the most important
points of today’s visit to your
family, what would you tell them?”
JBI Database System Rev Implement Rep. 2016 Jan;14(1):210-47

28. 28
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

29. 29
E.M.P.A.T.H.Y
• Eye contact
• Muscle of facial expression
• Posture
• Affect
• Tone of voice
• Hearing the whole patient
• Your response
Academic Medicine 2014;vol 89 (8): 1108-1112

30. 30
Articulating Empathy
Tool Example Notes
Naming (1) “It sounds/looks like you are scared / sad /
frustrated”
Naming the emotion will usually decrease the
intensity of emotion
Understanding (<5) “This helps me understand what you are
thinking”
Use to convey acknowledgement while avoiding
implications that you understand “everything”
Respecting (1-2) “I can see you have really been trying to follow
our instructions”
Give the patient/family credit for what they have
done, praise is a motivator
Supporting (1-2) “I will do my best to make sure you have what
you need”
Commit 100% of what you can commit to without
committing to things beyond your control
Exploring (∞) “Could you say more about what you mean
when you say that…”
Open-beginning statement with a focused end
www.vitaltalk.org/sites/default/files/quick-guides/NURSEforVitaltalkV1.0.pdf

31. 31
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

32. 32
Identify Commonly Missed Opportunities
• Listen and respond to family members
• Acknowledge and address family emotions
• Explore and focus on patient values and treatment
preferences
• Explain the principle of surrogate decision making to
the family – the goal of surrogate decision making is to
determine what the patient would want if the patient
were able to participate.
Chest. 2008 Oct; 134(4): 835–843

33. 33
Three-step Approach to Patient- and Family-
Centered Decision Making
Assess prognosis
and certainty of
prognosis
Assess family
preference for
role in decision-
making
Adapt
communication
strategy based
in patient and
family factors
and reassess
regularly
SharedDecisionMaking
Parentalism
“Doctor Decides”
“Do you want a
recommendation?”
Autonomy
“Family Decides”
“Do you want
some time to talk
with your family
about this?
Chest. 2008 Oct; 134(4): 835–843

34. 34
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

35. 35
Disease-Specific vs Goal-Oriented
Outcomes depend on perspective
N Engl J Med 2012; 366:777-779

36. 36
Speaking and Translating Caring
Goals of Care
• Identify what is important to and
priorities for the patient.
• Identify what they hope to
achieve by receiving care.
• Identify what they fear will
happen because of the disease.
• Life review and legacy building
are separate, equal, but not
independent parts of care.
Plan of Care
• Representation of the goals of care in the form
of
– Documentation
• Advanced Directive
• Living Will
• HCPOA
– Orders
• POLST
• Code Status
– Medications
• Starting and stopping
– Services
• Social Work
• Chaplaincy
• Hospice
• Home Health
National Committee for Quality Assurance: Goals to Care

37. 37
S.M.A.R.T. Goal
• Specific
– What does the patient mean to accomplish with this goal?
• Measurable
– What observable shows we are meeting the stated goal?
• Agreed Upon
– Are the patient, family, and provider all on the same page?
• Realistic
– Is this possible – physiologically, clinically, financially, humanly, etc.?
• Time-Bound
– When will this be observable?
General goals cannot be translated into a plan of care
Management Review. AMA FORUM. 70 (11): 35–36
National Committee for Quality Assurance: Goals to Care

38. 38
Unclear Goals = Unplannable Caring
Goals of Care
• “I’m going to beat this [disease]!”
• “My family won’t let me go to a
nursing home.”
• “We’re going to fight this!”
• “I’m going to get my miracle.”
Plan of Care
• These are general, usually not
agreed upon, often unrealistic, and
do not meet a timeline consistent
with life expectancy.
• The plan of care in these case is to
explore:
– “Tell me what this means to you.”
– “Help me understand more about
this by telling me how you feel
about…”
vitaltalk.org

39. 39
Clear Goals Lead to a Care Plan
Goals of Care
• “I want to be able to enjoy the
holidays with my family,
particularly my grandchildren.”
Plan of Care
• This is specific, measurable, can be
agreed upon, may be realistic, and
has a set time frame.
• Perhaps a chemotherapy “holiday”
or stopping hemodialysis after the
holidays. Certainly documenting
code status and likely involving
some sort of home nursing care, be
it private duty, home health, or
hospice.

40. 40
Family Meeting Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

41. 41
Post-Meeting Reflection
• What worked well?
• What could have been better?
• What changes to the plan of care need to be taken
care of?
• What are the next steps?

42. 42
THANK YOU
QUESTIONS OR COMMENTS