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?)

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