1. Keri Holmes-Maybank, MD Medical University of South Carolina June 21, 2012

2.  Residents will recognize the importance and complexity of breaking bad news and leading a successful family conference.  Residents will learn the framework and skills necessary for the successful facilitation of a family conference.  Residents will identify skills essential to successful communication.  Residents will identify pitfalls to avoid when leading a family conference and breaking bad news.

3.  A successful family conference requires time and planning.  Patient and family satisfaction is directly related to the amount of time the patient or family spends talking.  Be prepared for strong emotions from patients and families.  Good communication between providers and patients leads to better outcomes and less stress.

4.  Skill  Majority of physicians do not have a consistent plan or strategy  Physicians and residents report it as being stressful  Feel underprepared  Many recommendations: VALUE, SPIKES, ABCDE, Six-point protocol

5.  Any news that drastically and negatively alters the patients view of her future  Generally held when ◦ Change from cure to comfort ◦ Patient is too ill to make decisions or would prefer family to make decisions

6.  Information empowers family members by ◦ Answering their needs ◦ Enabling them to understand the patient’s situation ◦ Reducing anxiety and depression  Major points of satisfaction ◦ Time family spends talking ◦ Length of conference

8.  Review chart  Coordinate with consultants ◦ Diagnosis and treatment options ◦ Clear, consistent message  Review advanced care planning documents  Review/obtain family psychosocial information – who should come  Know your goals for meeting

9.  Private  Comfortable  Everyone seated in circle  One facilitator  Limit health care personnel  Turn pager off or to silent

10.  Allow everyone to state name and relationship to patient  Identify legal decision maker  Find out how family makes decisions  Express value of meeting ◦ “I appreciate you coming to this meeting today.”

11.  State your meeting goals ◦ “I want to tell you how your father is doing medically. I also want to make sure you understand what we are doing for him.” ◦ “We want to learn from you what your father’s values and goals are so we may make the decisions he would want if he could speak with us.”  Ask family to state their goals ◦ “What would you like to discuss?” ◦ “Those are great questions. Let me write them down.”

12.  Build a non-medical relationship ◦ “Tell me something about your father.” ◦ “What kind of things did your father enjoy before he became ill?”  Encourage reminiscing- makes them feel life had meaning

13.  Encourage all to respond ◦ “Tell me your understanding of your father’s medical condition.”  If chronically ill, what have been changes in function ◦ “How have things been going the past few months?” ◦ “Has your father been doing the things he enjoyed?”

14.  Fire a warning shot ◦ “Unfortunately the CT scan of your father’s abdomen did not show what we expected.”  Big picture in a few sentences  Avoid jargon – use 8 th grade language  Use the word dying if appropriate  Answer questions  Check comprehension – ◦ What you are saying may not be what they are hearing

15.  Silence ◦ Give family time to absorb information  Allow family to grieve  Allow patient/family to fully respond to questions  Prepare for common reactions: ◦ Acceptance, conflict, denial  Respond empathically ◦ “I can see that you are upset, this must be very difficult for you.”

16.  Provide prognostic data using a range  Present goal-oriented options ◦ prolong life, improve function, return home, dignified death  Priority of comfort regardless of goal  Make a recommendation based on knowledge/experience ◦ “What is important in the time you have left?” ◦ What would your father think about all of this?”

17.  Make recommendations based on patient’s values  Review current and planned interventions  Discuss DNR, hospice, artificial nutrition, hydration, future hospitalizations ◦ “What would your dad want us to do if he could sit up and speak to us?” ◦ “Thank you for telling me about your father and what he would want. This helps us develop the best plan of care.”  Summarize decisions  Plan follow-up

18.  Debrief with team members, consultants, nurses  Write a note ◦ Who was present ◦ What decisions were made ◦ Follow-up plan

19.  Listen  Empathy ◦ “This must be very hard for you.” ◦ “I imagine this is not what you wanted to hear.”  Remain neutral, respect everyone’s emotions ◦ “I wonder if we can put these disagreements aside so we may focus on what is going on with your father.”  Allow family to self settle if possible  Clarify misconceptions

20.  Determine source of conflict and explore values behind decisions: ◦ Guilt, grief, culture, family dysfunction, trust in medical team ◦ Feel giving up ◦ Feel abandoning  Empathizing with family members’ emotions is critical to creating a neutral zone for productive communication

21.  Do: If your mother could talk, what would she want us to do? ◦ Don’t: What do you want us to do?  Do: How does your family make decisions like this? ◦ You are the HCPOA, we follow what you say.  Do: How are you coping? ◦ Don’t: I haven’t see you here at the hospital.

22.  Active LISTENING ◦ Verbal and non-verbal cues ◦ Yes, I see, head nod, hmmm – Eye contact  Language clear, understandable  Open body language ◦ Lean forward, uncrossed arms, sit  Open-ended questions  Repeat last 2-3 words from their sentence  Summarize patient’s concerns  Compassionate HONESTY

23.  Dr. Paul Rousseau – Aging Q 3 – 10 steps for a family conference or giving bad news  Back A, Arnold R, Tulsky. Mastering communication with seriously ill patients. Balancing honesty with empathy and hope 2009. Cambridge University Press.  Lautrett A, Darmon M, Megarbane B, et al. A communication strategy and brouchure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478. Lautrett A, Darmon M, Megarbane B, et al. A communication strategy and brouchure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478.  Azoulay E. The end-of-life family conference. Communication empowers. AmJ Respir Crit Care Med 2005;171:803-805. Azoulay E. The end-of-life family conference. Communication empowers. AmJ Respir Crit Care Med 2005;171:803-805.  Parker PA, Baile WF, de Moor C, et al. Breaking bad news about cancer: Patients’ preferences for communication. J Clin Oncol 2001;19:2049- 2056. Parker PA, Baile WF, de Moor C, et al. Breaking bad news about cancer: Patients’ preferences for communication. J Clin Oncol 2001;19:2049- 2056.  Harrison ME, Walling A. What do we know about giving bad news? A review. Clinical Pediatrics 2010;49(7):619-626. Harrison ME, Walling A. What do we know about giving bad news? A review. Clinical Pediatrics 2010;49(7):619-626.  Barker C, Foerg M. Long term care intensive train the trainer series. Communication skills at the end-of-life. Hospice of Michigan.  Education in Palliative and End-of-life Care. Medical College of Wisconsin Research Foundation, Inc. David E Weissman MD, Timothy Quill MD, and Robert M Arnold MD.