COVENANT HEALTH ETHICS CONFERENCE 2013 Conducting Family Conferences at End of Life Meg Hagerty Social Worker, Mel Miller Hospice, Edmonton General Ingrid de Kock Palliative Care Physician, Palliative Community Consult Team, Edmonton Zone Palliative Care Program
Introduction Communication about end-of-life issues impacts family members experience Family conferences are communication opportunity for health care professionals Mitigation of ethical tensions 2
Introduction (cont.) Significance of communication outcomes during EoL care (Spinello, 2010) Effective communication: - goal directed and patient centered - active listening (Delisser et al, 2010) Few healthcare professionals have formal training 3
Objectives of this presentation Increase participants understanding and knowledge regarding: - the significance and role of family conferences - indications for family conferences Enhance participants practical skills and confidence for conducting successful family conferences, specifically at the end-of-life (EoL) 4
Literature review Overall impression: Literature re family conferences at end of life generated in ICU, not palliative care Articles focused on physicians, written by physicians Development of model for conducting family conferences 5
When would a family conference be useful? Request by a family member or patient A decision is to be made Goals of care need to be established or clarified Family has unmet information needs Family conflict is observed or disclosed Difficult to resolve family complaints about care Reduced family capacity to cope or process information Family lacks information about the death and the dying process Disclosure of an error is required 6
Pre-conference preparation: The patient Pre-conference preparation is crucial to success of family meeting; often overlooked Requires consent of the patient If patient lacks capacity, discuss with legal decision maker or next of kin 7
Pre-conference preparation: patient and family Conversation with patient and each family stakeholder about their concerns and questions Pay attention to potential conflicts between family members Assess patient and family s cultural and faith perspectives (Spinello, 2010) 8
Pre-conference preparation: the clinical team Consider what team knows about patient and family Identify gaps in physician s knowledge of family situation Resolve conflicts between physicians and within clinical team Acknowledge clinicians anxiety, grief, and guilt Lautrette et al (2006) 9
Pre-conference preparation: practical points Ensure enough time has been set aside for the conference Arrange appropriate space Arrange appropriate seating all at same level, around a table or in circle Disperse health care team members appropriately (De Lisser, 2010) 10
Pre-conference preparation: general considerations Arrange special resources to meet family s unique needs Ensure that appropriate people are invited Aim for balanced # of family members and health care professionals Decide upon a conference facilitator 11
Conducting the conference: begin at the beginning Briefly outline purpose and goals of the conference Thank family members for attending Introduce health care team professionals Ask family members to introduce themselves 12
Conducting the conference (cont.) It is important to normalize a family conference as standard part of achieving good communication Find out what the family understands about the illness Be clear and sensitive when giving information about the patient s condition 13
Conducting the Conference (cont.) Review of patient s medications Provide honest and meaningful information about prognosis without discouraging hope (Lautrette et al, 2006) Speak in terms of hours to days, days to weeks rather than specific predictions Reassure family that the care will continue 14
Conducting the Conference (cont.) Encourage family to talk about the patient (De Lisser, 2010) Invite family to share information about the patient s preferences Ensure that these preferences are communicated to nursing/other caregivers after the conference 15
Conducting the Conference (cont.) Based on family s readiness, prepare patient and family for the dying process Signs and symptoms of the dying process Reiterate unpredictable nature of time frame Encourage family to rethink the boundaries of relationship with the patient 16
Conducting the Conference (cont.) Health care professionals should not be afraid to experience the emotions of the moment (DeLisser, 2010) Moments of silence are okay Respect the differences in beliefs and values about end of life care that you and your patient may have (Cottrell, 2008) 17
Post-conference follow up Patient and family may need time to reflect Record conference + decisions/plan of action in chart Communicate all relevant details to the appropriate health care team members Contact family spokesperson/decision maker to follow up Stand alone family meeting often not sufficient Hudson et al (2009) 18
Decision making in end of life conferences communication was identified in many studies as a major target for improving end-oflife care. In addition, intensive communication is crucial to shared decision making. (Lautrette et al, 2006) Establish what the patient s wishes are Rank options Decision-making responsibility 19
Pitfalls and Barriers to Successful Family Conferences Attention to detail can help ensure the result is effective and efficient Communication is the key Remember to define all terms Avoid use of acronyms 20
Pitfalls and Barriers to Successful Family Conferences (cont.) Be aware of language having more than one meaning and monitor for this possibility Be aware of body language Remember to listen Follow up on cues given by the family members 21
Pitfalls and Barriers to Successful Family Conferences (cont.) Most common missed opportunities during family conferences are: Not listening and responding to questions Not acknowledging and addressing emotions Not addressing basic tenets of palliative care (Curtis et al, 2008) 54% of family members did not fully understand diagnosis, prognosis, or treatment AFTER a conference with physician (Curtis et al, 2001) 22
Benefits of family conferences at end of life May relieve family s anxiety by updating information and options May identify potential areas of conflict and the way to getting it resolved Lautrette et al (2006) found that: family conferences improved communication between physicians and families of incompetent patients family conferences help alleviate the family s emotional burden 23
Benefits of family conferences at end of life (cont.) The health care team benefits from family conferences: Family members receiving same information at same time results in fewer questions posed to staff (Hudson et al, 2009) Team gains better understanding about family s knowledge and family dynamics Decisions can provide direction to the team regarding care 24
Conclusion Studies in ICU found that proactive communication, ethics consultations, and early involvement of palliative care teams are all interventions that improve end of life care End of life family conferences empower family members and enhance their autonomy by providing them with the information and support they need (Lautrette et al, 2006) 25