Wednesday, 5 October 2011

Family Meetings and Decision-Making Capacity

To me,  a family meeting with the healthcare team is like performing an operation in the OR is to a surgeon -  it is an intervention that goes best with careful planning (who , what , when , where , why , how) . There is now another element to family meetings and that is decisional fatigue for both patients/families and for the healthcare workers too! In both the New York Times and in the Journal of Palliative Medicine there are articles that bring together data on the science behind decision making and how we need to take this into consideration both for the families and also for ourselves.

First there is the pre-meeting planning: 

  • Who will be there? Who should not be there? What is the ratio of professionals to family?
  • Where will it best held? 
  • How can we make sure that the family is represented and enabled to speak by reducing language barriers and inviting them to bring to the meeting anyone they think can help them?
  • Will there be a "pre" meeting of professionals to review some of the above issues , and decide how the meeting will go (who should "chair" the meeting) and what common objectives are?

Then at the meeting itself:

  • Providing choices and options (and showing respect)  by leaving seating open so that family chooses where to sit first and then the professionals sit next. (ie: some of us stand up away from the chairs when the family walks in to give them a chance to choose where to sit)
  • Self introductions of all at the table ( avoiding  "and those are the medical students" non-introductions)
  • Starting the meeting by asking what the family hopes to get out of the meeting and then asking what they understand about the situation.
  • Being clear about time available ("we have an hour..."), and what may not be possible.
  • Negotiating the issues in a priority sequence so that if time runs out the most important issues have been addressed first.
  • Addressing issues on both the family list and the professional list.
  • Summarizing and planning for concrete specific follow up
  • Offering "last  words" to the family just before the close of the meeting("Is there something else you would like to say?"

Now,  in addition to all the above,  we probably should also taking into consideration the time of day of the meeting - At the end of the day decision making may be quite different than at the beginning, especially if it has been a long day for the family who have had one heavy conversation after another and then at the end of the day are asked to "meet the palliative care/or other team".

Excerpt from the JPM blog :
Decision Science meets Decision Fatigue 
September 29, 2011 | Author Suzana Makowski MD 

When do we typically conduct family meetings?
Are you, and the families/patients hydrated, fed, or hungry and fatigued?

Add in decisions that palliative care teams are often brought into: at the height of crisis, at the end of the day, after a slue of options have been presented to patients over a day or series of days.  Now consider the NYTimes article about decision-fatigue or “ego depletion”:  We make poorer choices if decisions are made at the end of the day, after other decisions (difficult or not) have been made – i.e. if we have “decision-fatigue”, or if our blood sugar is low.

Given this information, and honestly, for me it was new “decision-science” information, consider the following questions:

Should we reconsider other aspects of when and how we schedule family meetings?
Is this an argument to study the outcome of meetings held early or late in the day?
Does it account for differing decisions made early in treatment course vs. late?
Should there be food and beverage offered during or prior to these meetings (not only for the clinicians, but for families?)

Tuesday, 20 September 2011

Self-compassion: A work in progress

Now on day 5 of a pretty awful cough I decided to stay home from work today, something I do maybe 2-3 days a year at most (my place of work is a children’s hospital). Yesterday I felt guilty for my loud coughing and had the feeling that my presence was likely unwelcome as a spreader of disease. So, I stayed home today, pager on, colleagues at work notified of my staying home, and switched my laptop on and started the day with the hope that I would get through editing a research paper that others are waiting for me to complete so they can then do their parts. What ended up happening was that I just felt physically unwell and achy all day and did not get any of my hoped for writing/editing done. Instead I did a bunch of tasks around the house I rarely have time for (putting up a bookshelf for example) and puttered around checking my emails pathologically often but not really doing anything with the ones that required more than a few minutes thought to answer. In the end I did not do much work at all – had I done no work it would have ultimately made no difference at all – I will continue to deal with the never-ending “things to do list’ when I feel better. But I spent most of the day with a vague sense of guilt (after all I am not really that sick) and dissatisfaction that in the end served no-one, myself included. If you ask me what I would advise a friend or colleague if they were to take a sick day I would say to them, with a semi-lofty combination of concern and loving-kindness “to stay home and take it easy, don’t do any work, just take care of yourself”. Why am I harder on myself than I am on others (at least for this kind of thing)? I suspect that many of us are the same – we would advise those we care about to rest when ill and put things in perspective, but are less likely to feel “ok” with applying that to ourselves. All of this is in the context of me being more frequently asked (and wanting to be asked) to write about “self care” in medicine. I am also the one who started a “work-life” balance email list at work and a dedicated  facebook group. It appears that I need to both listen to my own advice and put my words into practice (“walk the walk”), even as this rant/blog has me “talking the talk” yet again.

Sunday, 8 May 2011

MD's & Bullying

This article on MD’s and bullying in the NYT's - (actually it also includes RN’s as well) speaks to an ongoing problem in hospitals that, naturally, just reflects what is “out there” in the larger world. So how come this behavior continues even though we all recognize it when we see it? Well for one thing, maybe we don’t always see it. While I know when I feel bullied by someone else am I sure that I am aware of when my behavior is felt as bullying by another? Not necessarily. So what to do about a behavior that most of us, at one time or another are ourselves perpetrators of without us even knowing it? The NYT’s article points to some possible solutions (e.g. clear rules) but does not go far enough to the core of the issue to make a difference. After all, if we are not even aware of our behavior and its effect on others then what hope is there that we can change? A deeper answer is to be found in what Virgina Satir called the core concept of awareness of self, awareness of the other, and awareness of context (you can find lots on Virgina Satir on the web). So like in real estate where the 3 most important things are location location location, the 3 most important things in both not being a bully and how to best respond to bullying are awareness, awareness, awareness. (And I also hope that am more successful with awareness practice than I have been with real estate!)

Ok you think (maybe) that sounds reasonable but how to do I do this? What do I need to do to be more aware (of self other and context)? – One answer is that there is nothing to “do” other than stop doing for a moment and observe – observing your own reactions as they happen creates a tiny space between “me” and “my reactions”. When this is seen and felt then the space created holds the potential for changing a reactive (e.g. angry) response to one that fits better with what you really want and what would really be helpful and true. How do I know this? The only way anything is ever known or learned, I have seen  and felt  myself the difference in my life, in the moment, when I am aware and live that way and when I am not.