Improve hospice referrals by holding an expert family goal-setting meeting
Train medical staff in better communication skills
The initial meeting with families and patients can lay the groundwork for an end-of-life experience that is rewarding to all involved, or it can build obstacles to a hospice referral and obstruct true understanding between the family, physician, and hospice staff.
The key to achieving the rewarding experience rather than the latter is to train hospice and medical staff skills in conducting a family conference, an expert says.
"Leading a family conference is not a skill that's well taught for any health professional," says David Weissman, MD, director of the Palliative Care Center at the Medical College of Wisconsin in Milwaukee. Weissman discusses how to improve family goal-setting meetings at national conferences and is scheduled to speak next at the annual assembly of the American Academy of Hospice & Palliative Medicine and the Hospice & Palliative Nurses Association, held Feb. 14-17, 2007, in Salt Lake City, UT.
"It's a specific skill, much like performing an appendectomy," Weissman says. "You want to do the right things in the right sequence to get the right outcome, and it's the same with the family meeting."
There are four key skills needed for holding an effective family meeting, and these are: the skill of leading a group effectively, group counseling skills; knowledge of medical and prognostic information, and willingness to provide leadership in decision-making, Weissman says.
"If you've done the preparation work correctly and gotten people to first articulate what their goals and understanding are and made a strong explanation, then you're much more likely to have a hospice referral," Weissman says.
Family goal-setting meetings typically involve a team, including a doctor, nurse, social worker/chaplain, or some combination, Weissman says.
"Medical issues are really the physician issues, although some nurses may discuss these," he says. "Counseling skills typically are provided by the social worker or chaplain."
Each family meeting needs a designated leader, which could be the physician or someone else on the team.
"If the leader is the social worker, then after the basic steps they can turn to the doctor and say, 'Can you recap where we are medically?'" Weissman says.
A good way to train staff how to conduct these meetings is through role-playing, Weissman says.
"We train staff through role-playing, and they have to demonstrate they can do this as a skill, following a checklist," he adds.
Effective meetings might take 15 minutes to an hour or more, and if the issues are complex, it might need to be repeated, he says.
"The purpose is to discuss the current disease status, an expected future course, and establish goals for the future," Weissman explains. "And in palliative care, these meetings almost always involve some discussion of cessation of treatments."
Here are Weissman's suggestions for making a family goal-setting meeting as effective as possible:
1. Focus on introductions first.
Start with group introductions and then set out the purpose of the meeting, asking everyone to explain why they're present, Weissman says.
"The key first process step is spending time asking the patient and family for their understanding of the current illness and reflect on how things have been going on in the last few months," Weissman says.
Medical professionals often launch into a summary of medical information before first finding out what the family already knows and understands, he says.
The family should provide a lot of information, including an outline of what has been happening with the patient and the downhill course the patient has been on, he says.
"The mistake people make is to talk about hospice within the first 10 minutes, without providing the context," Weissman notes.
From the family's perspective, why should they think about hospice care when they're still pursuing chemotherapy, he says.
Instead, the medical team should discuss where the patient is with illness before bringing up the possibility of hospice care, Weissman suggests.
"If you've done the prep work correctly and gotten people to first articulate what their goals and understanding are and then gave them a strong explanation, you're much more likely to have a hospice referral," he says.
2. Do your homework before the family meeting.
Staff should always keep in mind what is medically appropriate and what will improve — rather than worsen or provide no benefit to — the patient's condition, Weissman advises.
Before meeting with the patient and family, the team should review the patient's medical history and treatment options, coordinate medical opinions, review advance care planning documents, and learn more about patient/family psychosocial background, he says.
Team members need to prepare to discuss a patient's case without using medical jargon and without presenting too much information, Weissman says.
"They don't present simple concrete facts and will say, 'The heart's not so good today, and the liver is a little better,'" Weissman explains. "And families have a hard time handling that information, and that's not what they want to know."
When training medical professionals the skills needed for an effective family meeting, Weissman continually points out which words they are using that should be put into layman language.
"We try to help people become self-aware of the words they are using and help them think about what other words they could use instead," Weissman says.
"The flip side is when I'm in a family meeting with another doctor and I let that doctor lead the meeting," he explains. "If the doctor uses medical jargon, I'll jump in and clarify it right there."
Medical jargon creates a barrier and emphasizes a power differential.
"Many patients and families are intimidated to ask questions and to say they don't know what that means," Weissman says. "From the physician's standpoint, it's done totally unconsciously — they don't throw the words out to impress patients, but we have our own language."
All families want to know is whether their dad, mom, or other loved one is getting better or worse, he adds.
3. Don't confuse a place for a goal of care when speaking with patients.
"Without first setting what the goals are, the doctor is thinking of hospice or the social worker is thinking of hospice, because they have made the leap that there should be a shift to comfort care, and the family hasn't gotten there yet," Weissman says. "First talk about the comfort care, and then find out what kind of setting would meet those goals best."
If a team doesn't follow these specific steps during the family meeting, then it likely will result in a failed meeting, Weissman says.
Then the meeting will need to be repeated.
"We often get called in after failed meetings," Weissman says.
Perhaps the physician attempted to obtain a do not resuscitate order and met resistance from the family, he says.
"You have to go through the original steps before you get to this point," Weissman says.
"These are emotionally-charged conversations, and a bedrock of different conversations is establishing a sense of trust," Weissman says. "The best way of doing this is to build a relationship that is outside the medical construct."
For example, ask patients and family members questions about their lives, such as "I heard your father was in the war. What kind of work did he do? What were his hobbies?"
Families need to hear that medical professionals care about them and the patient more than they care about the disease, Weissman says.
"Anything you can do to build a relationship is very helpful," he adds. "Often what we hear from families afterwards is, 'You asked about my father's hobbies, and that was so nice,'" he adds.
4. Keep in mind the emotional impact of the discussion.
If the family meeting is going very well, then the medical team will reach the point where they can say that the patient is dying, and the family will react with acknowledgement and acceptance.
The three most common questions asked at that point will be these:
- How long does he/she have?
- What will happen next?
- What do we do now?
"If the family doesn't ask these questions, I'll prompt them to ask them," Weissman says. "Particularly, I want to discuss the how-long question because you can't do goal-setting if you don't know how long it will be."
Typically, the how-long question is answered in ranges, as in hours to days, days to weeks, weeks to a few months, he notes.
When there is only partial or no acceptance of the patient's dying, then this means there has been an emotional reaction to the information, Weissman says.
"When you hear conflict, you think about emotions because that's what driving the conflict," he explains.
Patients and family members will express conflict by saying, "I don't agree with you," or "I don't understand — you must be wrong" or "I want a second opinion."
The medical team can help them resolve the emotional turmoil by making empathic statements, Weissman suggests.
"Their source of conflict isn't a knowledge issue; it's an emotional issue and making an empathic sentence allows the emotion to come forward, and people start to cry," Weissman says. "
An example of an empathic sentence is "You have fought really hard for a long time."
It's important to not walk out of the conference when the conflict begins because the team can help the family and patient work through the process of accepting what's happening, Weissman notes.
When acceptance is achieved, it's time to present care options and make recommendations.
"The goals are designed by the patient, and the typical one might be, 'I want to be home, comfortable, and get to my son's wedding,'" Weissman says. "These tend to be narrowly focused at this point in the meeting."
Once goals are established, it's time to establish a plan with regard to future hospitalizations, diagnostic tests, hospice/home support or placement, etc.
"You help them plan what medical procedures or tests are going to help them meet those goals and which aren't, and those that aren't going to help, you get rid of," Weissman says.
Need More Information?
- David Weissman, MD, Director of Palliative Care Center, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Froedtert Hospital, Milwaukee, WI 53226. Telephone: (415) 805-4607. Email: [email protected].
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