Thread by @laxswamy

My approach to family meetings in the ICU & some #TipsForNewDocs I've learned along the way. Here is my approach - - my favorite part is the mandatory interpreter!
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Set the stage: invite the right people (HCP, RN), consider ambiance & setup, have a plan w objectives but manage your own expectations! It's work to you, but life & death to the family.

Sometimes the patient's room itself is the best location, esp if they can participate!

✨The Jargonese Interpreter ✨
Empower someone to interrupt you & ask for clarifications before the meeting. "Can you explain what you mean by ventilation?"

We use way more jargon than we think, and the family may not ask for nearly as much translation as is needed.

Open w condolences. Most of us have absolutely no idea what it's like to be in their shoes. Ask for permission to speak about the patient, acknowledge & emphasize family's role: I only know them sick, you know who they really are.

Ask them for their understanding of the situation. You NEED this to move forward. They may be embarrassed, so help them out. What med probs did pt have? What isn't working in their body? This helps you avoid surprises: maybe someone didn't know the patient had cancer--it happens!

Build on their update w your medical update. Avoid jargon, rely on your interpreter!
I prefer an organ system based update:
lungs not working➡️ vent
Heart not working ➡️ drips
Kidneys not working ➡️ CVVH
and so on.
I use the words "life support" for many of these interventions.

If the meeting isn't in the room, go there immediately after and point out the machines, drips, monitors and what they're all doing. It only takes a moment and I have found families really appreciate this.

Next, respond to emotions. It is worth its own slot in the program. Take the time to ask how the family is doing hearing all of this.
"I know this must be hard for you" usually not nearly as authentic as "I can't imagine how hard this is for you."
Embrace long pauses and silence!

"it's so hard to see them like this" ➡️ a bridge to ask what the person was like. Use their responses to elicit values & goals, fears. Avoid prognostication! "If your sister were in this chair with us, what would she say she loved to do? Hopes to do? What goes she fear?"

Once you've got a sense of that, it's time for practical expectations of prognosis. You may be wrong about life or death but probably more accurate about regaining function. Hard to explain how to do this well, and it isn't always possible or appropriate.

Recognize where the family is. Never use force! Your acceptance & acknowledgement that they are informed & driving the care may help with your moral distress: acknowledge that the best outcome may be to just to build rapport & give support. They are suffering.

End the meeting by closing the loop about the current condition & plan. I also emphasize that we try to maintain dignity & comfort but we sacrifice these to achieve the goals discussed... until sacrificing dignity & comfort outweighs benefits. If that happens, we'll meet again.

I always encourage the family to speak to the patient and be present, but make sure you and your team understand real limitations that keep them from visiting: #SDOH, childcare, etc.

They should feel welcome to bring in pictures and do whatever they can to humanize the room!

Finally, remember that the more you treat the patient like a human during everyday care, the better the family meeting will go.

I hope this was helpful! Please share your own advice as clinicians, patients and family members - - always trying to do a better job with this. Every meeting, every family is a new situation and the same strategies that work in one case may backfire in another.

I always open teaching this by asking for stories about the worst family meetings. That usually helps set this up bc the above are violated in most horror stories. Do you have any experiences w family meetings that were great or awful? Would love to hear your thoughts!