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Table 1 Clinical Practice Guidelines for Conducting Family Meetings in Palliative Care

From: Family meetings in palliative care: Multidisciplinary clinical practice guidelines

1. Preparing for a family meeting
   a) On admission to the palliative care unit the relevant health professional should introduce the purpose of a family meeting and offer a family meeting to all lucid patients. This discussion should incorporate the role that palliative care has in supporting families as well as the patient.
   b) Ask the patient to confirm one or two key family carers and/or friends who they approve to be involved in medical and care planning discussions. Note this in the medical record.
   c) Conduct a family genogram to determine key relationships within the patient's family. It could be introduced thus: "Can I spend a few minutes just working out who is in your family?"
   d) Seek the patient's permission to arrange a family meeting and ask if they have any particular issues/concerns or questions they would like discussed at the meeting. If the patient does not want to attend, seek their permission to conduct a meeting with key family and/or friends (as above). If the patient is unable to make an informed decision, offer the meeting to the next of kin or key family/friends who have been identified to receive information and care planning decisions related to the patient. Note: Where a patient has no family or appropriate proxy a legal guardian may need to be appointed.
   e) Identify the most appropriately skilled person from the multidisciplinary team to convene the family meeting. This person will take responsibility for scheduling, invitations and coordination. Ideally this person should also act as the primary contact point for the key family carer(s).
f) Contact the primary family carer(s): provide an overview of purpose of the family meeting; offer to convene a meeting at a mutually acceptable time. Advise the carer that the meeting time will be confirmed in due course (i.e., once other attendees are arranged). Where pertinent, and if resources allow offer to conduct the meeting via teleconference. Establish the main questions and issues that the family carer would like discussed (refer Table 3). If the patient is participating in the meeting ask him/her to identify their key concerns.
Note: If significant family conflict (or other major issue) is identified consider referral to a practitioner who is trained to work with complex issues within families (e.g. family therapist or health psychologist).
   g) Determine which health care professionals should attend the family meeting. Invite key health care professionals based on the identified needs of the patient and family carer. The number of staff should be restricted, inviting only the relevant health professionals, so that the patient and family/friends do not feel overwhelmed. Note: Include a professional interpreter if required.
   h) Confirm the family meeting time and location. Inform attendees of the scheduled start and finish time for the meeting. A comfortable room free of interruptions (including pagers and phones), tissues made available and conducive seating arrangements is recommended.
2. Conducting a family meeting
   a) Introduction
Chairperson to:
i) Thank everyone for attending and introduce him/herself and invite others to introduce themselves and state their role.
ii) Establish ground rules in a non patronsing way e.g. "We would like to hear from all of you, however if possible could one person please speak at a time, each person will have a chance to ask questions and express views." Request no interruptions such as phones etc.
iii) Indicate the duration of meeting (recommended maximum time of 60 minutes).
   b) Determine the understanding of the purpose of the family meeting.
Chairperson to:
i) Briefly outline the broad purpose of the family meeting (based on previous steps), and then confirm with the family and patient that their interpretation of the purpose of the meeting concurs.
For example:
"We arranged this meeting to consider discharge planning options. Is this your understanding of the purpose of the meeting?" (If not reframe the meeting's purpose)
or
"From the things you mentioned on the questionnaire what is the most important thing you would like to discuss?"
or
"How could we be most helpful to you today?"
ii) Ask the patient/family if there are any additional key concerns, and if pertinent, prioritise these and confirm which ones will be attempted to be dealt with at this meeting (others can be discussed at a future meeting or can perhaps dealt with on a one on one basis).
iii) Clarify if specific decisions need to be made (e.g. if the patient is to go home or not).
   c) Determine what the patient and family already know. Possible questions may include,
"What have you been told about palliative care" as a way of clarifying, confirming etc.
"Tell me your understanding of the current medical condition or current situation?"
If pertinent provide information (in accordance with desire) on the patient's current status, prognosis and treatment options.
Ask each family member in turn if they have any questions about current status, plan and prognosis. Helpful questions may include, "Do you have questions or concerns about the treatment or care plan?"
For family discussion with non-competent patient (i.e. cognitively impaired or imminently dying).
Ask each family member in turn:
"What do you believe your relative/friend would choose if they could speak for himself/herself?"
"In the light of that knowledge, what do you think should be done?"
   d) Address specific objectives of the meeting (as previously determined).
   e) 'Check in' periodically throughout with the patient and family carer to see if the discussion seems to be valuable and is in keeping with their needs e.g. "Are we on track?"; "Is this what you wanted from today's meeting?"; "What haven't we touched on that's important to you?"
Also consider taking a short break during the meeting (to give participants time to digest information) and then allow some time to refocus.
   f) Offer relevant written or audiovisual resources. Examples include guidebooks, brochures, enduring power of attorney documents, advance care directive information and so forth.
   g) Identify other resources, including possible referral to other members of the multidisciplinary team. Suggest scheduling a follow-up meeting if pertinent.
   h) Concluding the discussion.
Summarize any areas of consensus, disagreements, decisions and the ongoing plan (i.e. clarify next steps) and seek endorsement from attendees (e.g. "Are we all clear on the next steps?")
Emphasize positive outcomes arising from the meeting.
Offer final opportunity for questions, concerns, or comments. E.g. "What hasn't been covered today that you would have like to discuss?" or "Are there any questions you had that haven't been answered yet?"
Remind patient and family carers to review the recommended written resources.
Identify one family spokesperson for ongoing communication.
Thank everyone for attending.
3. Documentation and follow-up
   a) Document who was present, what decisions were made, what the follow-up plan is and share this with the care team (see Table 4).
   b) Offer the patient/family a copy of the main content of the meeting and file a copy of this document in the patient's medical record.
   c) Liaise with the primary family carer within a few days after the meeting to determine if the meeting was helpful (see Table 5)
   d) Maintain contact with the key family spokesperson, including attending scheduled follow-up meetings or telephone calls as needed.