Communication with families facing life-threatening illness: a research-based model for family conferences

Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies

BACKGROUND

Frameworks are the conceptual underpinnings of the study. Both conceptual and theoretical frameworks are often used in palliative and end-of-life care studies to help with study design, guide, and conduct investigations. While an increasing number of investigators have included frameworks in their study, to date, there has not been a comprehensive review of frameworks that were utilized in palliative and end-of-life care research studies.

AIM

To summarize conceptual and theoretical frameworks used in palliative and end-of-life care research studies. And to synthesize which of eight domains from the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care (fourth edition) each framework belongs to.

DESIGN

Systematic review.

DATA SOURCES

Four electronic databases (EMBASE, the Cumulative Index to Nursing and Allied Health, PsychINFO, and PubMed) were searched from July 2010 to September 2021.

RESULTS

A total 2231 citations were retrieved, of which 44 articles met eligibility. Across primary studies, 33,801 study participants were captured. Twenty-six investigators (59.1%) proposed previously unpublished frameworks. In 10 studies, investigators modified existing frameworks, mainly to overcome inherent limitations. In eight studies, investigators utilized existing frameworks referenced in previously published studies. There were eight orientations identified among 44 frameworks we reviewed (e.g. system, patient, patient-doctor).

CONCLUSIONS

We examined palliative and end-of-life research studies to identify and characterize conceptual or theoretical frameworks proposed or utilized. Of 44 frameworks we reviewed, 21 studies (47.7%) were aligned with a Clinical Practice Guideline's single domain, while the rest two or more of eight guidelines in quality palliative care domains.

Facilitated case conferences on end-of-life care for persons with advanced dementia-a qualitative study of interactions between long-term care clinicians and family members

BACKGROUND

Prognostic uncertainty and the need for proxy decision-making owing to cognitive impairment in advanced dementia, adds complexity to end-of-life care planning within the long-term care setting. Case conferences provide a structure to facilitate difficult conversations and an opportunity for family and clinicians to engage in prospective planning, and reach agreement on goals of end-of-life care.

OBJECTIVE

To explore interactions between multidisciplinary healthcare clinicians and families during facilitated case conferences on end-of-life care for residents with advanced dementia.

METHODS

A qualitative approach was used. Transcripts of audio-recorded case conferences facilitated by a trained registered nurse were coded by two independent researchers and analysed inductively. Transcripts were selected from an available pool until thematic saturation was reached. Emerging themes were confirmed with the wider research group.

RESULTS

Thematic saturation was reached after 25 transcripts. An overarching theme concerned the ways in which clinicians and families bridged medical and person-centred perspectives. Subthemes included: details of day-to-day care versus establishing overall goals of care; expression of emotion versus retreat from emotion; and missed opportunities versus expressed cues. Successful facilitation served to 'bridge the gap' between family and clinicians.

CONCLUSION

Facilitation of case conferences for residents with advanced dementia should focus on ensuring that: clinicians do not miss opportunities to discuss end-of-life care; discussions on the minutiae of care regularly return to the resident's broader goals of care; and information on dementia and treatments provided by clinicians is integrated with advice by family members regarding the resident's premorbid values and likely preferences.

Patients Receiving Palliative Care and Their Families' Experiences of Participating in a "Patient-Centered Family Meeting": A Qualitative Substudy of the Valuing Opinions, Individual Communication, and Experience Feasibility Trial

Background: Family meetings are used in palliative care to facilitate discussion between palliative patients, their families, and the clinical team. However, few studies have undertaken qualitative assessment of the impact of family meetings on patients and their families. Objectives: To explore inpatients receiving palliative care and their families' experiences of participation in a patient-centered family meeting ("Meeting"), where the patient sets the Meeting agenda. Design: This qualitative study used the constant comparative method for thematic content analysis of the data. Setting/Participants: The setting was a specialist palliative care (SPC) inpatient unit in Australia. Nine palliative care inpatients and nine family members were interviewed. Measurements: Semistructured interviews were used evaluate the patients' and their families' experiences and perceptions of the Meeting. Results: Three overarching themes described the experiences of participating in a patient-focused family meeting, namely that the Meeting: (1) provides a forum for inpatients receiving SPC to speak openly about their end-of-life concerns, clarify issues, and is of comfort to patients; (2) provides the family members with a voice, and an opportunity to discuss their concerns and have their needs addressed; and (3) helps to ensure that everyone is "on the same page" and patient care plans can be discussed. Conclusions: These Meetings are a potentially effective means of supporting certain palliative care patients and their families to articulate, confront, and address end-of-life issues in the presence of the interdisciplinary team. It is important to undertake further research to further examine the evidence for this Meeting model and to identify the patients and families who would most benefit from this type of Meeting.

Telehealth-Based Family Conferences with Implementation of Shared Decision Making Concepts and Humanistic Communication Approach: A Mixed-Methods Prospective Cohort Study

Smartphone-enabled, telehealth-based family conferences represent an attractive and safe alternative to deliver communication during the COVID-19 pandemic. However, some may fear that the therapeutic relationship might be filtered due to a lack of direct human contact. The study aims to explore whether shared decision-making model combining VALUE (Value family statements, Acknowledge emotions, Listen, Understand the patient as a person, Elicit questions) and PLACE (Prepare with intention, Listen intently and completely, Agree on what matters most, Connect with the patient’s story, Explore emotional cues) framework can help physicians respond empathetically to emotional cues and foster human connectedness in a virtual context. Twenty-five virtual family conferences were conducted in a national medical center in Taiwan. The expression of verbal emotional distress was noted in 20% of patients and 20% of family members, while nonverbal distress was observed in 24% and 28%, respectively. On 10-point Likert scale, the satisfaction score was 8.7 ± 1.5 toward overall communication and 9.0 ± 1.1 on meeting the family’s needs. Adopting SDM concepts with VALUE and PLACE approaches helps physicians foster connectedness in telehealth family conferences. The model has high participant satisfaction scores and may improve healthcare quality among the pandemic.

Key Physician Behaviors that Predict Prudent, Preference Concordant Decisions at the End of Life

BACKGROUND

This study introduces an empirical approach for studying the role of prudence in physician treatment of end-of-life (EOL) decision making.

METHODS

A mixed-methods analysis of transcripts from 88 simulated patient encounters in a multicenter study on EOL decision making. Physicians in internal medicine, emergency medicine, and critical care medicine were asked to evaluate a decompensating, end-stage cancer patient. Transcripts of the encounters were coded for actor, action, and content to capture the concept of Aristotelian prudence, and then quantitatively and qualitatively analyzed to identify actions associated with preference-concordant treatment.

RESULTS

Focusing on codes that describe characteristics of physician-patient interaction, the code for physicians restating patient preferences was associated with avoiding intubation. Multiple codes were associated with secondary measures of preference-concordant treatment.

CONCLUSIONS

Prudent actions can be identified empirically, and research focused on the virtue of prudence may provide a new avenue for assessment and training in EOL care.

Creating a Seat at the Table: How Family Meetings Elucidate the Palliative Care Social Work Role

Background: Palliative care social workers (PCSWs) play a crucial role in optimizing communication and family-centered care for seriously ill patients. However, PCSWs often struggle to demonstrate and receive open acknowledgment of their essential skill set within medical teams. Objective: This case discussion focuses on the care of patients and families surrounding family meetings to highlight the crucial role of the PCSW in (1) preparing the family; (2) participating in the provider meeting; (3) participating in the family meeting; and (4) following up after the meeting. The aim is to illuminate how the PCSWs can demonstrate their unique and essential skill set to medical teams and as a means of furthering the work of psychosocial clinicians throughout medical systems. Conclusion: As the medical model continues to shift toward family-centered care, it is crucial for medical teams to optimize their partnership with patients and families. PCSWs can offer a trauma-informed biopsychosocial-spiritual lens that is instructed by continuity of care and exemplary clinical and rapport-building skills. PCSWs can play a critical role in optimizing communication, support, collaboration, and family-centered whole-person care.

Medical Decision-Making in Foster Care: Considerations for the Care of Children With Medical Complexity

OBJECTIVE

To explore how medical decision-making for children with medical complexity (CMC) occurs in the context of foster care (FC).

METHODS

Together with a medical FC agency, we identified 15 CMC in medical FC and recruited eligible care team members (biological and foster parents, medical FC nurses, caseworkers in medical FC/child welfare, and pediatricians) for each child. Semistructured interviews were conducted, and conventional content analysis was applied to transcripts.

RESULTS

Fifty-eight interviews were completed with 2-5 care team members/child. Serious decision-making related to surgeries and medical technology was common. Themes regarding medical decision-making for CMC in FC emerged: 1) Protocol: decision-making authority is dictated by court order and seriousness of decision, 2) Process: decision-making is dispersed among many team members, 3) Representing the child's interests: the majority of respondents stated that the foster parent represents the child's best interests, while the child welfare agency should have legal decision-making authority, and 4) Perceived barriers: serious medical decision-making authority is often given to individuals who spend little time with the child.

CONCLUSIONS

Medical decisions for CMC can have uncertain risk/benefit ratios. For CMC in FC, many individuals have roles in these nuanced decisions; those with ultimate decision-making authority may have minimal interaction with the child. Pediatricians can assist by clarifying who has legal decision-making authority, facilitating team communication to promote truly informed consent, and serving as a resource to decision-makers. Further research should explore how to adapt the traditional model of shared decision-making to meet the needs of this population.

Interprofessional Team Member Communication Patterns, Teamwork, and Collaboration in Pre-family Meeting Huddles in a Pediatric Cardiac Intensive Care Unit

CONTEXT

Interprofessional teams often develop a care plan before engaging in a family meeting in the pediatric cardiac intensive care unit (CICU)-a process that can affect the course of the family meeting and alter team dynamics but that has not been studied.

OBJECTIVES

To characterize the types of interactions that interprofessional team members have in pre-family meeting huddles in the pediatric CICU by 1) evaluating the amount of time each team member speaks; 2) assessing team communication and teamwork using standardized instruments; and 3) measuring team members' perceptions of collaboration and satisfaction with decision making.

METHODS

We conducted a prospective observational study in a pediatric CICU. Subjects were members of the interprofessional team attending preparation meetings before care meetings with families of patients admitted to the CICU for longer than two weeks. We quantitatively coded the amount each team member spoke. We assessed team performance of communication and teamwork using the PACT-Novice tool, and we measured perception of collaboration and satisfaction with decision making using the Collaboration and Satisfaction About Care Decisions questionnaire.

RESULTS

Physicians spoke for an average of 83.9% of each meeting's duration (SD 7.5%); nonphysicians averaged 9.9% (SD 5.2%). Teamwork behaviors were present and adequately performed as judged by trained observers. Significant differences in physician and nonphysician perceptions of collaboration were found in three of 10 observed meetings.

CONCLUSION

Interprofessional team members' interactions in team meetings provide important information about team dynamics, revealing potential opportunities for improved collaboration and communication in team meetings and subsequent family meetings.

Critical Care Nurses' Qualitative Reports of Experiences With Family Behaviors as Obstacles in End-of-Life Care

BACKGROUND

Critical care nurses (CCNs) frequently provide end-of-life (EOL) care for critically ill patients. Critical care nurses may face many obstacles while trying to provide quality EOL care. Some research focusing on obstacles CCNs face while trying to provide quality EOL care has been published; however, research focusing on family behavior obstacles is limited. Research focusing on family behavior as an EOL care obstacle may provide additional insight and improvement in care.

OBJECTIVES

We wanted to gather firsthand experiences of CCNs regarding working with families of dying patients. We then wanted to determine the predominant obstacle themes noted when CCNs share these rich experiences in EOL care.

METHODS

A random geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Responses from a qualitative question on the questionnaire were analyzed.

RESULTS

Sixty-seven EOL obstacle experiences surrounding issues with families' behavior were analyzed for this study. Experiences were categorized into 8 themes. Top 3 common obstacle experiences included families in denial, families going against patient wishes and advanced directives, and families directing care that negatively impacted patients.

CONCLUSIONS

In overcoming EOL obstacles, it may be beneficial to have proactive family meetings to align treatment goals and to involve palliative care earlier in the ICU stay.

Family Meetings in Inpatient Specialist Palliative Care: A Mechanism to Convey Empathy

CONTEXT

Family meetings are increasingly used in palliative care, yet have little empirical evidence of their impact in inpatient settings.

OBJECTIVES

To examine whether relatives report more empathy after a family meeting in a specialist palliative care inpatient ward.

METHODS

Pre/post self-complete questionnaires measuring relational empathy and information needs were administered. Qualitative interviews were also conducted. Data were collected during nine months from one inpatient specialist palliative care unit. Participants from 52 family meetings completed pre/post questionnaires, and 13 relatives participated in an interview that was analyzed thematically.

RESULTS

Families reported more empathy from staff after a family meeting (Wilcoxon test: n = 47; P > 0.001; Z score -4.17). Some families with relatives who do not speak with each other reported that meeting facilitators were unable to manage the pre-existing dynamics.

CONCLUSION

Family meetings improve reported empathy. It would be beneficial to have more specific preparation and planning by the clinical team for meetings with people who have a history of familial conflict, and those where the staff's agenda is around discharge planning. Published guidelines could be adapted to better support staff to run meetings where there are complex family dynamics. Adoption of family meetings in outpatient settings has the potential to improve perceptions of empathy with a larger patient group.

The VOICE Study: Valuing Opinions, Individual Communication and Experience: building the evidence base for undertaking Patient-Centred Family Meetings in palliative care - a mixed methods study

Background

Despite family meetings being widely used to facilitate discussion among patients, families, and clinicians in palliative care, there is limited evidence to support their use. This study aims to assess the acceptability and feasibility of Patient-Centred Family Meetings in specialist inpatient palliative care units for patients, families, and clinicians and determine the suitability and feasibility of validated outcome measures from the patient and family perspectives.

Methods

The study is a mixed-methods quasi-experimental design with pre-planned Patient-Centred Family Meetings at the intervention site. The patient will set the meeting agenda a priori allowing an opportunity for their issues to be prioritised and addressed. At the control site, usual care will be maintained which may include a family meeting. Each site will recruit 20 dyads comprising a terminally ill inpatient and their nominated family member. Pre- and post-test administration of the Distress Thermometer, QUAL-EC, QUAL-E, and Patient Health Questionnaire-4 will assess patient and family distress and satisfaction with quality of life. Patient, family, and clinician interviews post-meeting will provide insights into the meeting feasibility and outcome measures. Recruitment percentages and outcome measure completion will also inform feasibility.

Descriptive statistics will summarise pre- and post-meeting data generated by the outcome measures. SPSS will analyse the quantitative data. Grounded theory will guide the qualitative data analysis.

Discussion

This study will determine whether planned Patient-Centred Family Meetings are feasible and acceptable and assess the suitability and feasibility of the outcome measures. It will inform a future phase III randomised controlled trial.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12616001083482 on 11 August 2016

Development and Validation of a Family Meeting Assessment Tool (FMAT)

CONTEXT

A cornerstone procedure in Palliative Medicine is to perform family meetings. Learning how to lead a family meeting is an important skill for physicians and others who care for patients with serious illnesses and their families. There is limited evidence on how to assess best practice behaviors during end-of-life family meetings.

OBJECTIVES

Our aim was to develop and validate an observational tool to assess trainees' ability to lead a simulated end-of-life family meeting.

METHODS

Building on evidence from published studies and accrediting agency guidelines, an expert panel at our institution developed the Family Meeting Assessment Tool. All fourth-year medical students (MS4) and eight geriatric and palliative medicine fellows (GPFs) were invited to participate in a Family Meeting Objective Structured Clinical Examination, where each trainee assumed the physician role leading a complex family meeting. Two evaluators observed and rated randomly chosen students' performances using the Family Meeting Assessment Tool during the examination. Inter-rater reliability was measured using percent agreement. Internal consistency was measured using Cronbach α.

RESULTS

A total of 141 trainees (MS4 = 133 and GPF = 8) and 26 interdisciplinary evaluators participated in the study. Internal reliability (Cronbach α) of the tool was 0.85. Number of trainees rated by two evaluators was 210 (MS4 = 202 and GPF = 8). Rater agreement was 84%. Composite scores, on average, were significantly higher for fellows than for medical students (P < 0.001).

CONCLUSION

Expert-based content, high inter-rater reliability, good internal consistency, and ability to predict educational level provided initial evidence for construct validity for this novel assessment tool.

Communication During Pediatric Intensive Care Unit Family Conferences: A Pilot Study of Content, Communication, and Parent Perceptions

While there is a robust literature describing family conferences (FCs) in adult intensive care units (ICUs), less information exists about FCs in pediatric ICUs (PICUs). We conducted a pilot study to describe the focus of discussion, communication patterns of health care team members (HTMs) and parents, and parents' perspectives about clinician communication during PICU FCs. We analyzed data from 22 video- or audiorecorded PICU FCs and post-FC questionnaire responses from 27 parents involved in 18 FCs. We used the Roter Interaction Analysis System (RIAS) to describe FC dialogue content. Our questionnaire included the validated Communication Assessment Tool (CAT). FCs were focused on care planning (n = 5), decision making (n = 6), and updates (n = 11). Most speech came from HTMs (mean 85%; range, 65-94%). Most HTM utterances involved medical information. Most parent utterances involved asking for explanations. The mean overall CAT score was 4.62 (using a 1-5 scale where 5 represents excellent and 1 poor) with a mean of 73.02% "excellent" responses. Update and care-planning FCs had lower CAT scores compared to decision-making FCs. The lowest scoring CAT items were "Involved me in decisions as much as I wanted," "Talked in terms I could understand," and "Gave me as much information as I wanted." These findings suggest that while health care providers spend most of their time during FCs relaying medical information, more attention should be directed at providing information in an understandable manner. More work is needed to improve communication when decision making is not the main focus of the FC.

What is the evidence for conducting palliative care family meetings? A systematic review

BACKGROUND

Structured family meeting procedures and guidelines suggest that these forums enhance family-patient-team communication in the palliative care inpatient setting. However, the vulnerability of palliative patients and the resources required to implement family meetings in accordance with recommended guidelines make better understanding about the effectiveness of this type of intervention an important priority. Aim and design: This systematic review examines the evidence supporting family meetings as a strategy to address the needs of palliative patients and their families. The review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

DATA SOURCES

Six medical and psychosocial databases and "CareSearch," a palliative care-specific database, were used to identify studies reporting empirical data, published in English in peer-reviewed journals from 1980 to March 2015. Book chapters, expert opinion, and gray literature were excluded. The Cochrane Collaboration Tool assessed risk of bias.

RESULTS

Of the 5051 articles identified, 13 met the inclusion criteria: 10 quantitative and 3 qualitative studies. There was low-level evidence to support family meetings. Only two quantitative pre- and post-studies used a validated palliative care family outcome measure with both studies reporting significant results post-family meetings. Four other quantitative studies reported significant results using non-validated measures.

CONCLUSION

Despite the existence of consensus-based family meeting guidelines, there is a paucity of evidence to support family meetings in the inpatient palliative care setting. Further research using more robust designs, validated outcome measures, and an economic analysis are required to build the family meeting evidence before they are routinely adopted into clinical practice.

ExCEL in Social Work: Excellence in Cancer Education & Leadership: An Oncology Social Work Response to the 2008 Institute of Medicine Report

ExCEL in Social Work: Excellence in Cancer Education & Leadership was a multi-year National Cancer Institute (NCI)-funded grant for the development and implementation of an innovative educational program for oncology social workers. The program's curriculum focused upon six core competencies of psychosocial-spiritual support necessary to meet the standard of care recommended by the 2008 Institute of Medicine (IOM) Report: Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. The curriculum was delivered through a collaborative partnership between the City of Hope National Medical Center and the two leading professional organizations devoted exclusively to representing oncology social workers--the Association of Oncology Social Work and the Association of Pediatric Oncology Social Workers. Initial findings support the feasibility and acceptability of this tailored leadership skills-building program for participating oncology social workers.

A Systematic Review of Family Meeting Tools in Palliative and Intensive Care Settings

PURPOSE

Family meetings can be challenging, requiring a range of skills and participation. We sought to identify tools available to aid the conduct of family meetings in palliative, hospice, and intensive care unit settings.

METHODS

We systematically reviewed PubMed for articles describing family meeting tools and abstracted information on tool type, usage, and content.

RESULTS

We identified 16 articles containing 23 tools in 7 categories: meeting guide (n = 8), meeting planner (n = 5), documentation template (n = 4), meeting strategies (n = 2), decision aid/screener (n = 2), family checklist (n = 1), and training module (n = 1). We found considerable variation across tools in usage and content and a lack of tools supporting family engagement.

CONCLUSION

There is need to standardize family meeting tools and develop tools to help family members effectively engage in the process.

Family conferences in palliative care: a survey of health care providers in France

CONTEXT

Family conferences are conducted to assist with end-of-life discussions and discharge planning.

OBJECTIVES

This study describes the current practices of family conferences in palliative care units (PCUs) in France.

METHODS

A cross-sectional descriptive survey was sent to each PCU in France (n = 113). Members of the interdisciplinary health care team (palliative care physician, nurse, psychologist, and social worker) who were active in each PCU at the time of the survey were asked to respond.

RESULTS

Two hundred seventy-six of 452 responses (61%) were obtained from members of the health care team in 91 units (81%). Two hundred seventy-two of 276 health care providers (HCPs) (99%) reported conducting family conferences in their clinical practice. Only 13 participants (5%) reported that they followed a structured protocol. Most respondents completed the questionnaire: palliative care physicians (n = 225; 82%), nurses (n = 219; 79%), and psychologists (n = 181; 66%). The three primary goals of family conferences were to allow family members to express their feelings (n = 240; 87%), identify family caregivers (n = 233; 84%), and discuss the patient's plan of care (n = 219; 79%). The primary reasons for conducting a family conference were: the patient's illness was terminal (n = 216; 78%), family caregivers requested a conference (n = 208; 75%), or terminal sedation was required (n = 189; 69%). One hundred six of 452 HCPs (38%) reported that patients were not invited to participate. The primary indications and goals for a family conference were significantly different among the four health care disciplines.

CONCLUSION

Most HCPs in our study conducted family conferences. However, most of the family conferences had no structured protocol, half of the participants preferred no patient participation, and a significant variation was noted in the primary indications and goals among disciplines.

The Pediatric Inpatient Family Care Conference: a proposed structure toward shared decision-making

Over the past decade, there has been a steady increase in the medical complexity of patients on the pediatric inpatient service while at the same time, there are few data to show that families are satisfied with communication of complex issues. Family care conferences are defined as an opportunity outside of rounds to meet and discuss treatment decisions and options. They offer a potential pathway for psychosocial support and facilitated communication. The lack of consensus about the structure of these conferences impedes our ability to research patient, family, and provider outcomes related to communication. The goal of the present article was to describe a structure for family care conferences in the pediatric inpatient setting with a literature-based description of each phase of the conference. The theoretical framework for the structure is that patient and family engagement can improve communication and ultimately health care quality. This proposed model offers guidance to providers and researchers whose goal is to improve communication on the inpatient service.

End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase

CONTEXT

In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.

OBJECTIVES

To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review.

RESULTS

The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan.

CONCLUSION

Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.

Physician Orders for Life Sustaining Treatment in US Nursing Homes: A Case Study of CRNP Engagement in the Care Planning Process

This case study describes changes in Physician Orders for Life Saving Treatment (POLST) status among long-stay residents of a US nursing home who had a certified registered nurse practitioner (CRNP) adopt the practice of participating in nursing home staff care plan meetings. The CRNP attended a nonrandomized sample of 60 care plan meetings, each featuring a review of POLST preferences with residents and/or family members. Days since original POLST completion, Charlson Comorbidity Index score, number of hospitalizations since index admission, and other sociodemographic characteristics including religion and payer source were among the data elements extracted via chart review for the sample as well as for a nonequivalent control group of 115 residents also under the care of the medical provider group practice at the nursing home. Twenty-three percent (n = 14) of the 60 care conferences attended by the CRNP resulted in a change in POLST status after consultations with the resident and/or family. In all cases, POLST changes involved restated preferences from a higher level of intervention to a lower level of intervention. Fifty-nine percent of the CRNP-attended conferences resulted in the issuance of new medical provider orders. CRNP participation in care conferences may represent a best practice opportunity to revisit goals of care with individuals and their family members in the context of broader interprofessional treatment planning.

The use of family conferences in the pediatric intensive care unit

BACKGROUND

Data about pediatric intensive care unit (PICU) family conferences (FCs) are needed to enhance our understanding of the role of FCs in patient care and build a foundation for future research on PICU communication and decision making.

OBJECTIVE

The study's objective was to describe the use and content of PICU FCs.

DESIGN

The study design was a prospective chart review comparing patients who had conferences with those who did not, and a sub-analysis of patients with chronic care conditions (CCCs).

SETTING/SUBJECTS

The study setting was an academic PICU from January 2011 through June 2011.

MEASUREMENTS

Medical events under consideration were placement of tracheostomy or gastrostomy tube; initiation of chronic ventilation; palliative care involvement; use of extracorporeal membrane oxygenation, continuous renal replacement, or cardiopulmonary resuscitation; care limitation orders; death; length of stay; and discharge to a new environment.

RESULTS

From 661 admissions, we identified 74 conferences involving 49 patients. Sixty-four conferences (86%) were held about 40 patients with CCCs. Having a conference was associated with (p<0.05): length of PICU admission; palliative care involvement; initiation of chronic ventilation; extracorporeal membrane oxygenation; cardiopulmonary resuscitation; death; discharge to a new environment; and care limitation orders. Twenty-nine percent of patients who had a new tracheostomy or gastrostomy tube placed had a conference. We identified two categories of discussion topics: information exchange and future management.

CONCLUSIONS

Most identified FCs involved complex patients or patients who faced decisions affecting the child's quality of life or dying. For many patients who faced life changing decisions we did not identify a FC. Further research is needed to understand how to best utilize FCs and less formal conversations.

A prospective study of family conferences: effects of patient presence on emotional expression and end-of-life discussions

CONTEXT

Limited research has taken place examining family conferences (FCs) with patients with advanced cancer and their caregivers in the palliative care setting.

OBJECTIVES

To characterize the FCs involving cancer patients in a palliative care unit at a comprehensive cancer center and examine the effects of patient participation on emotional expression by the participants and end-of-life discussions.

METHODS

A data collection sheet was completed immediately after 140 consecutive FCs that documented the number of participants, caregiver demographics, expressions of emotional distress, dissatisfaction with care, and the topics discussed. Patient demographics and discharge disposition also were collected.

RESULTS

Seventy (50%) patients were female, 64 (46%) were white, and 127 (91%) had solid tumors. Median age of patients was 59 years. Patients participated in 68 of 140 FCs (49%). Primary caregivers (n = 140) were female (66%), white (49%), and the spouse/partner (59%). Patients verbalized distress frequently (73%). Primary caregivers' verbal expression of emotional distress was high (82%) but not significantly affected by patient presence (82% vs. 82%, P = 0.936). Verbal expressions of emotional distress by other family members were more common when patients were absent (87%) than when present (73%), P = 0.037. Questions concerning advance directives (21%), symptoms anticipated at death (31%), and caregiver well-being (29%) were infrequent. Patient presence was significantly associated with increased discussions regarding goals of care (P = 0.009) and decreased communication concerning prognosis (P = 0.004) and what symptoms dying patients may experience (P < 0.001).

CONCLUSION

There was a high frequency of expression of emotional distress by patients and family members in FCs. Patient participation was significantly associated with decreased verbal emotional expression by family members but not the primary caregiver and was associated with fewer discussions regarding prognosis and what dying patients may experience.

Enhancing the social well-being of family caregivers

OBJECTIVES

To provide an overview of key issues and resources useful for oncology professionals to support the social well-being of patients and their families. A caregiver narrative highlights examples of the importance of addressing the social impact of illness.

DATA SOURCES

Review of the literature and Web sites related to social well-being of oncology patients and families.

CONCLUSION

Culture influences social well-being and impacts caregiving across the life span. Coping with cancer creates a myriad of social implications with potentially significant impacts on communication; sexuality, intimacy and sexual expression; education, finances, work, and leisure.

IMPLICATIONS FOR NURSING PRACTICE

Nurses spend the greatest amount of time with patients and their families and therefore have an especially important role in identifying and addressing social needs. An interdisciplinary approach to care that includes the assessment of those at high risk and family meetings increases opportunities to address the complex multidimensional social concerns associated with oncology care.

Palliative care in the pediatric ICU: challenges and opportunities for family-centered practice

The culture of pediatric intensive care units (PICUs) is focused on curative or life-prolonging treatments for seriously ill children. We present empirically-based approaches to family-centered palliative care that can be applied in PICUs. Palliative care in these settings is framed by larger issues related to the context of care in PICUs, the stressors experienced by families, and challenges to palliative care philosophy within this environment. Innovations from research on family-centered communication practices in adult ICU settings provide a framework for development of palliative care in PICUs and suggest avenues for social work support of critically ill children and their families.

Cultural perspectives in cancer care: impact of Islamic traditions and practices in Middle Eastern countries

People's attitudes to cancer and its treatment are influenced by the patient's and his family's faith, beliefs, societal traditions, and cultural taboos and stigmatism. In most Middle Eastern countries Islam is the dominant religion, yet there are differences as to people's acceptance of cancer, starting with the realization of the diagnosis and the subsequent treatment planning. In many societies in the Middle East, patients prefer that their families will be the first to know about the disease and to agree to the planned treatment protocols. Whereas in Western societies the patient is usually the first to know, understand, and agree to the proposed therapeutic procedures; this is not the case in various Muslim societies. Health care professionals have to accept these kinds of practices and find ways to cope with their patients' sensitivities, thereby preserving their dignity and faith.

The barriers to and evidence for palliative care

It is undeniable that there are barriers to providing palliative care. Recent research suggests there is value in palliative care for patients, families, and those providing this care. Specifically, the research suggests that the earlier a patient receives palliative care, the better outcomes they will receive. This article will serve 2 important purposes. First, this article will look at some of the barriers that sometimes prevent offering adequate palliative care to patient and families when the care is needed most. Second, this article will present results in a simplistic manner from actual research studies, which helps make the case through evidence of the value of palliative and quality end of life care.