In exploring participants' experiences of the family meeting, seven dominant themes were identified. Within these themes frequent reference was made to most characteristics of the domain of spirituality as described in this study, which were a web of relationship with places, things, ourselves, significant others, a power beyond ourselves and the significance of these relationships in the finding of meaning and purpose. The family meeting also enabled a process of review which was appreciated by participants and confirms the findings of other studies which not only found that life review was an important process for those near end of life, but could also be instrumental in the finding of meaning and purpose .
Significant relationship with places and things did not, however, feature strongly in the majority of participants' described experience of the family meeting. One reference to this was made by a participant who was planning a future family picnic "in a place most of us love" and indicating the importance of this environment in relaxing and encouraging participation in conversation about matters previously not discussed by this family.
The main focus of most participants' experience of the family meeting was concerned with relationship with themselves and with significant others. Examples of these are numerous in themes one to four described above, although they are also implied in some aspects of themes five to seven. References to 'getting real about it', new understanding of self and others (theme1), initiating contact with estranged relatives and letting go of past hurts (theme 2), new degree of openness, new understandings (theme 3), strengthening of bonds, allowing grief to have a different focus (theme 4), changed experience of relationship (theme 5), a desire to have another meeting so others not present can also experience this (theme 6) are all examples of how the meeting contributed to strengthening the web of relationship with self and significant others for the participants of the family meetings.
Three participating families were quite open about their religious affiliations and regular participation in the life of a religious community, although only one participant made direct reference to this as an outcome of the meeting experience when they said that it had reconnected them to 'God the Father'. Murphy's family meeting model is however flexible enough to allow open discussion of religious issues and also to incorporate religious practices into its expression, especially, for example in the closing of the meeting which could include prayer, readings, lighting of candles and blessings if these are consistent with the practices and desires of the family involved.
The concept of finding meaning and purpose was also directly mentioned in several themes as an outcome of the family meeting experience. Two examples are: making a contribution to research, other families and our family (theme 2) and a person finally understanding how much they are valued (theme 5). There were however numerous examples where the adding of value and meaning were implied in the descriptions of participants' experience.
It is evident that significant psychosocial issues were also addressed in these family meetings. Communication within the family was identified especially in the first three of the seven themes which emerged in the data. Considerable emphasis was placed on greater than normal openness of family members and the opportunity this provided for people to connect with each other in a stronger more meaningful way. Good, clear, open communication has been acknowledged as vital in overcoming "conspiracies of silence" relating both to information about the illness and the care needed but also in overcoming built in family barriers to real connection with each other . The realisation of 'not being alone' and that others 'think much more highly of you than you think' are very important contributors to social and mental well-being and self esteem.
Although not specifically identified by participants, it became apparent as interviews progressed, that the needs of some individuals to speak one on one with another person had not been met by the family meeting. There were issues that some participants couldn't or wouldn't raise in front of the family, but also others that arose afterwards having been stimulated by the meeting. The use this family meeting model as a means of providing spiritual care would not eliminate the need for some people to have the opportunity for more individual care.
It is also important to consider how broadly Murphy's model could be applied as an instrument for spiritual and psychosocial care . Genograms and family profiles for each family were created utilizing the available data, but it was not possible to draw conclusions from these about the relationship, if any, between individual or family characteristics and outcomes of the family meeting. However, there are some observations worthy of note.
The findings suggest that a family's expressed view of their closeness and degree of openness are not reliable guides to the likelihood of members experiencing greater than normal degrees of openness in themselves or others during the family meeting, or to whether they are likely to come to new understandings as a result of the meeting. This is consistent with the concept of positive self-presentation and impression management . Although, in our study there was a range of families from the perspective of socio economic status, religious expression and evidence of family conflict, there appeared to be no relationship between these factors and positive outcomes from the family meeting as they have been described.
The question then arises, 'Could there be a reliable way of determining which families would most benefit from this family meeting which works with a very subjective area of care, and which ones are most likely to decline to participate?' It is possible that the family relationships index may be a useful screening tool to identify those most likely to benefit . Ethical requirements did not allow any pursuit of reasons for declining to participate, however, on the basis of the work of Kissane and Bloch it can be surmised that poor family communication, low cohesiveness, low levels of emotional expression and family conflict may have been contributing factors to the decision not to participate in our study, in some cases . However definite conclusions cannot be drawn from our findings in this regard.
The differing environmental factors which may have impacted on the outcomes of this study are the location of the patient at the time of referral (home/hospital/hospice) and the cultural environments of the two palliative care service providers. This latter factor has been discussed in Tan, Wilson, Olver and Barton .
Patients who were at home at the time of referral were twice as likely to agree to participate, as those who were in a hospice, and about three times more likely to participate than those who were in hospital. Five of the participating patients are known to have died within two weeks of the family meeting intervention, three of these being in a hospice at the time of referral and two at home. These factors, although certainly not conclusive, suggest the possibility that willingness to participate may be improved for patients living at home, contrary to the results of another study, but would seem to be unrelated to imminent death .
Other circumstances which may have impacted on the outcomes, apart from family characteristics already discussed are; the nature of the illness (malignant or non-malignant), the time since diagnosis and the prognosis of life expectancy from the perspective of the patient and family members. Apart from a few comments about the timing of the meeting in relation to illness trajectory, this study did not provide data relating to these circumstances.