Hello, everybody. My name is Paul Janssen and I'm an emergency and critical care physician at Massachusetts General Hospital, Brigham and Women's Hospital, and I'm a faculty member at Harvard Medical School. Today, I'll be talking to you about my approach to optimizing family meetings. I think of the family meeting like any other procedure in medicine. There are certain steps to the procedure that should be performed in the correct order so that you can obtain the outcome that you want. Just like any procedure, there are possible complications and fortunately, you can get better at it with practice. In fact, I think it's one of the more critical procedures that we perform because it can really drastically change the course of a patient's ICU stay. Let's go through the five steps that I use in order. Preparation is crucial for a successful family meeting. First, you want to identify the key decision makers. The healthcare proxy is the most important and he or she may not actually be the person at the bedside or listed first in the chart. I've seen it be the ex-wife, a grandchild, or even a priest. Also try to identify other key decision makers. Many times the family will want to consult with another family member who works in healthcare. Next, try to find out if there's any advanced care planning that has been done. Perhaps there is an advanced directive scanned someplace in the chart, a note from the patient's primary care provider, or even what the patient's code status was during a previous admission. It can be extremely helpful to the family if there is documentation of the patient's wishes. Finally, gather your team together. At minimum, it should be you and the patient's nurse. Depending on the structure of your hospital and your team, it may include a trainee, a charge nurse, a social worker, or a chaplain. Make sure the team is all on the same page. The last thing you want to do is get to the end of the family meeting and have someone on your team disagree with your recommendations. Once you've assembled your team and the key decision makers, it's time to start the meeting. After making introductions of everyone in the room, their relationship to the patient for family members, and the role of everyone on the care team for staff, I like to start meetings where I'm meeting the family for the first time by asking them to tell me about the patient. I'll typically say something like, tell me about your loved one before he came into the hospital. What was life like for him? What did he do for fun? This serves two purposes. First, it allows you to get to know the patient and make a personal connection with the family. Often in the ICU, we meet the patient after they've been intubated and sedated and never really get to know much about their personality. The second thing this does is allow you to establish the patient's pre-morbid level of functioning. Were they out jogging and golfing on the weekends? Or were they transitioning from rehab to nursing home and then back to the hospital and then back again? This knowledge is critical for the prognostication that you'll do later in the family meeting. After getting to know the patient, the next step is to establish what the family's current understanding of the patient's illness is. For patients who were previously chronically ill, I might say something like, it sounds like the last few years have been hard for him. While for patients who are suddenly critically ill from apparent good health, I might say something like, it must feel like this is all very sudden. And then ask the family, what is your understanding of what is going on right now? Being in an ICU can be an overwhelming experience with all the monitors, noises, and devices around their loved one. And this gives the family time to process everything they've seen and allows you to assess their understanding about their loved one's critical illness and allows you to prepare to correct any misunderstandings. Now that you know what the family understands about the patient's illness, this is the time for you to clarify any misunderstandings or explain what exactly is going on. I usually start by saying something like, I'm worried about him. For patients who may have been repeatedly hospitalized but who are now critically ill, I might say something like, we're in a different place right now. This allows you to both express concern for the patient and signal the family that the patient is seriously ill. Try to keep the medical explanation as simple as possible. For many critical care interventions, I try to explain things with terms that people have seen on TV using expressions like, he's in a medically induced coma, or he's on life support, or even his organs are shutting down. A common pitfall is to get too far into the weeds. If you hear yourself saying something like, we are titrating the pressers, take a step backwards. Now of course, some families will need to know more medical specifics, but I often find that using these as-seen-on-TV phrases allow many families to innately connect with some critical care concepts. Finally, before moving on, take a moment to ask what questions the family has. They will often make the transition themselves into the next section, discussing prognosis and establishing goals. Now that everyone is on the same page about the patient, at this point in the conversation, you know about the patient's baseline, and everyone should have a good understanding about what is going on medically, as well as the likely outcomes of the hospitalization. Hopefully, the family has been able to tell you about what the patient would find to be an acceptable quality of life. Now it's time to clarify the goals of care. For the patient, you are concerned may die imminently, you could ask something like, if time were short and he had to choose between quantity and quality of life, what would he say? He would say, if time were short and he had to choose between quantity and quality of life, what would he say? For patients whose prognosis isn't clear, or perhaps when the goals are not realistically aligned with the prognosis, consider suggesting a time-limited trial of aggressive care, whether a few days or a week, depending on the details of the case in the family. I personally don't bring up code status until the end of the meeting, and I try to never use the term code status. Instead, I typically say something like, if the worst were to happen and his heart were to stop and he died, would he want us to try extraordinary measures like chest compressions or injections of adrenaline? Similar to the prognosis earlier, I think it's really important to share with the family the realistic outcomes of in-hospital cardiac arrest. If it's a patient who I think should be DNR, I'll often ask permission to make a suggestion or a recommendation. I do think that families appreciate your medical recommendation. Finally, once we've landed on a DNR or DNI status, I'll clarify, in medicine, we call that a do not resuscitate status, which means that we continue to do everything we are doing right now, but if we get to the point where his heart stops, we would not try those extraordinary measures like CPR. So there you have it, my approach to the family meeting. As you've seen, I typically approach it like a procedure with specific steps in the same order every time. Of course, with time and practice, you'll develop your own style. I'd love to hear what your own tips and tricks are. Feel free to email me at pjansen at mgh.harvard.edu. I hope you've learned something today, and thanks for everything you're doing for our patients.

family meetings

preparation

patient

medical situation

goals of care