Communication

Question 1

Benefits of effective communication

Answer 1

• Reduces patient distress
• Improves treatment adherence
• Improves satisfaction with care
• Improves informed decision-making and increases likelihood that patient choices remain consistent with stated goals, values, and preferences
• May increase delivery of high value care, guiding patients away from ineffective treatments

Question 2

Barriers to effective communication

Answer 2

Patient

• Discomfort with asking questions
• Pre existing misinformation
• Lack of trust of healthcare system
• Language barriers
• Cultural differences contributing to discrepancies in expectations

Physician

• Physician fears of the impact of the diagnosis on their own reputation
• Difficulties in coping with patient emotion/reaction
• Uneasiness in their own ability to answer questions

Question 3

Effective communication despite barriers

Answer 3

FIFE method:

Feelings - related to illness, esp. fears
- “What are you most concerned about?”

Ideas

• “What do you think might be going on?”
• “What do you think X means?”

Function

• “How has your illness affected your life?”
• “What have you had to give up because of X?”

Expectations

• “What do you expect or hope I can do for you today?”
• “Do you have expectations about how doctors can help?”

Question 4

When faced with abnormal test results/findings how do you discuss and how much do you discuss?

Answer 4

• If results are not yet definitive, set up a clear plan for follow up and further investigation. Reassure the patient that you will obtain a conclusive result as quickly as possible.
• Inquire about fear and directly address it - e.g. “I hear you’re concerned about cancer. What made you immediately go there?” - the patient may share more information that could be relevant.
• Avoid giving false reassurance or leaping to a definite diagnosis without further investigation
• Present the info available

Ask the patient directly - would you like to discuss this further now, or would you prefer to wait until we have more information?
- If the patient wants, explore the possible outcomes (e.g. cyst, benign lesion, tumour, etc.)

Question 5

Physicians and truth telling

Answer 5

In the past, physicians commonly withheld a cancer diagnosis, now open disclosure is the norm.

Almost all patients want full info (particularly Anglo-Saxon origins)

The majority of patients want to participate actively in decision making (particularly those with higher education, younger patients, and female patients). Physicians often underestimate the degree to which patients want to be involved in decision making.

In some cultures, it is customary for family members rather than patients be told the diagnosis.

ALL patients should be asked at the outset how much information they want and with whom this information should be shared. Assumptions based on culture and demographics should never be made.

Question 6

SPIKES method for breaking bad news

Answer 6

Setting up

• Review the chart and test results
• Arrange for appropriate family members and HCPs to be present if possible
• Private setting with enough space
• Turn off phones/pagers
• Introduce all individuals
• Sit down, chairs for everyone
• Avoid breaking bad news over the phone

Perception

• Ask the patient what they understand about their medical situation
• Explore what has been done, but also the meaning of tests and interventions.
• May ask specifically about why a test was done, etc.
• Allows an established baseline of understanding, correction of misinformation, reframing of unrealistic expectations, and filling in of knowledge gaps
• “It would be helpful for me to know what you understand about your health at this point”

Invitation

• Verify whether or not the patient is open to receiving the information you have to share
• “Would you like me to talk about the test results now?”
• Can also check in with the patient that if they want more or less information, they should ask.
• Allows HCP to be reassured the patient wants the news, provides the patient with some control over the content of the meeting, and can guide the HCP with regard to how much detail to provide.

Knowledge

• Let the patient know the news is not food before giving further details (“E.g. the test results unfortunately . . .”
• Use non-technical language
• Use a slow pace with opportunities for the patient to ask questions and check in regarding understanding
• Use clear words without euphemisms, but avoid excessive bluntness
• Give news, but also plan for the future - including options for symptom control, treatment

Emotions

• Validate the patient’s emotion and give empathic results.
• “I know this isn’t what you’d hoped for.”
• “This is obviously upsetting. It would be for anyone.”

Strategy and Summary

• Pace the meeting so that it is not too long
• Ensure there is a plan for the future, whether it involves treatment, testing, or an appointment
• Patients vary in how detailed the plan will be (some will want to defer further decisions, others want to develop a preliminary plan)

Question 7

Evidence for SPIKES

Answer 7

• Shown to increase physicians’ set of competency

- Guideline allows it to be tailored to patients’ needs

Question 8

How to navigate family members’ requesting information regarding a patient

Answer 8

• Responsibility is to the patient, who has the right to choose who her health information is disclosed and from who it is withheld
• Remember that even disclosure that a patient is under your care can be a breach

Tell family members:

• It is not ethically permissible for you to disclose information about the family member without their explicit consent (this avoids family members thinking the HCP is being evasive)
• Suggest they ask their family member directly, and that if the family member wants they can always accompany her to an appointment
• Listen attentively to any concerns

Question 9

How to share info regarding prognosis

Answer 9

• Misunderstanding about prognosis and treatment aim (e.g. palliate vs cure) is common
• Lack of communication can influence treatment decisions - patients who overestimate their prognosis or do not discuss options with physicians are more likely to receive aggressive care

1. Why is the patient asking about prognosis? Is there a specific goal?
2. Clarify that it is impossible to know exactly how long any individual patient will live
3. Clarify that it is not curable
4. Give an approximate time frame as a range, if known to you - e.g. “Patients with your condition typically live for several months, though it’s impossible to know exactly how many . . . patients with serious illnesses, like yours, are also more likely to get unexpected complications, like a blot clot or infections, which is why it is important to plan ahead.”
5. Reassure that you will continue to provide close care as their condition changes, including with community resources.

Question 10

Does discussion of prognosis cause patients to lose hope

Answer 10

• Hope is important for patients and families to maintain
• Hope can take different forms and can be reframed by exploring realistic goals
• Prognostic information can still be shared in a way that respects a patient’s need for ambiguity, but also allowso them to plan to reach their goals. E.g. “I also hope that you will be able to go to the wedding in July, but it would be more certain that you could attend if the date was moved to January. Do you think that would be possible?”
• Wish statements can be useful to convey empathy and support, while gently acknowledging that their realization is unlikely. “I wish there was a treatment that could cure your cancer.”

Question 11

Indications for a family meeting

Answer 11

• Essential to ensure all family members are on the same page.
• Change in the status of the patient
• Change in the treatment plan
• Discord amongst family members
• Plan for discharging a patient home

‘Family’ refers to all those important to the patient, which may be relatives and friends alike. Key members of the healthcare team should also attend.

Question 12

Effective family meetings

Answer 12

Prep:

1. Prepare by familiarizing yourself with the chart, with attention to goals of care and objectives of the meeting
2. Consider a pre-meeting with healthcare providers to discuss goals, who will lead, potential sources of conflict and how to manage
3. Consider contacting other consultants in advance so that their opinion is available prior to the meeting (e.g. med onc)

Meeting:

• Private setting, with those in a circle
• If patient is unconscious, decide with the help of the SDM where to meet (e.g. with the patient present or not)
  1. Introductions
  2. Summary of goals of the meeting
  3. Clarify the family’s understanding of the patient’s condition and treatment plan (ensure that all family members are on the same page, especially if only one speaks)
  4. Summarize the current situation from the point of view of the treating team and clarify any misunderstandings. Listen and validate reactions, differing points of view, identify family concerns
  5. Direct the meeting toward a treatment plan and clarify family view of the future
  6. Clarify family coping, emphasise family strengths and commitment to one another
  7. End the meeting with a summary and clear goals for care. Also consider a family ‘spokesperson’ to be the main point of contact if the family member is large.

Question 13

Dealing with family members or patients with strong negative emotions (anger, denial, etc.)

Answer 13

NURSE acronym:

Name, Understand, Respect, Support, Explore.

1. Name the emotion you hear expressed.
   “It sounds like you are very distressed/upset/sad . . .”
2. Understand - normalise the emotion
   “ . . . which is understandable given how quickly/difficult/”
   - Convey understanding of the specific emotion, not the overall situation
   - Simply saying “I understand” can sound perfunctory and dismissive.
3. Respect - state appreciation of their efforts
   “You’ve provided a lot of care and support for your mother . . .”
4. Support - focus on the patient and their needs and offer help.
   “I’ll do my best to get more support at home/nursing care/work to find meds . . .”
5. Explore - open up discussion to the emotion or distress expressed
   “You mentioned . . . can you tell me more about that?”

Question 14

How to approach conflict between family members regarding goals of care

Answer 14

• Hierarchy of SDMs is in most cases:
  1. partner
  2. adult children
  3. parents
  4. Siblings

Families with higher levels of pre-existing conflict often tend to have stronger preferences for life-prolonging care

Advance care planning has been shown to decrease family conflict and allow open discussion of the patient’s wishes

Use the SPIKES framework to approach discussions with family members when patients lack decision making capacity. Consider:

1. Ensure there is time for all viewpoints
2. Emphasise that being an SDM is about not what they would want if they were the patient, but what they feel the patient would want if she could decide for herself
3. Ask if there is a written advance directive (can provide clarity)
4. Explore what the patient has expressed to her children or to the provider in the past about opinions/preferences
5. Recap the patient’s condition and treatment to date, including the severity
6. Discuss risks/benefits of each intervention, including impact on quality and quantity of life
7. Discuss the concept of ‘burden without benefit’ if you feel a procedure/intervention is clearly without benefit to either quality or quantity
8. Providence guidance on the basis of existing information, clinical experience, the balance of burdens and benefits for improving QOL and minimizing suffering

If no consensus emerges, three options:

1. Postpone decision making and recommend participants take time to think
2. Time limited trial of a given therapy, with a specific outcome that will determine whether it is continued or not
3. Call in a third party (palliative care, ethics, or spiritual care consult)

Question 15

Should families be told when death is imminent?

Answer 15

• Recognizing impending death is a clinical skill based on signs and symptoms of the dying process
• This is often not discussed with patients or their families.

Barriers

• Hope the patient will get better
• Lack of a definitive dx or event causing death
• Poor communication skills
• Concerns about what interventions/tx/meds may be requested
• Fear of shortening life
• Cultural and spiritual barriers

Consequences of not discussing

• Loss of trust
• Dissatisfaction
• Uncontrolled symptoms
• Family members not being present at or around the time of death
• Unmet cultural/spiritual needs
• Inappropriate interventions

Explicitly disclosing imminent death should involve discussing what the process looks like may help family cope and facilitate treatment planning

Question 16

How to interact with families after a death

Answer 16

• Ensure families have time for spiritual or religious rites
• Have answers or resources to questions around practical matters (e.g. what happens to the body, how to obtain a copy of the death cert, how to find a funeral director)
• ‘Close the cycle’ - members of the healthcare team or staff members very involved in the care make contact with the family at or after the time of death (in person, by telephone, or by mail)
• Consider bereavement supports after the death, and connecting with families at the time of the death and a week or two afterwards is helpful for this

Question 17

Strategies to avoid burnout

Answer 17

• Maintaining physical health
• Effective professional relationships
• Transcendental perspective
• Talking with others
• Engaging in hobbies
• Ensuring clinical variety
• Maintaining personal relationships
• Setting boundaries
• Interprofessional team environment with close working relationships
• Debriefing amongst team members about stressful discussions and deaths

Question 18

Criteria for ‘patient centeredness’

Answer 18

Institute of Medicine Committee on Quality of Health Care in America:

1. Eliciting and understanding the patient’s perspective
2. Understanding the patient’s psychosocial context
3. Achieving a shared understanding of the problem and its appropriate treatment in the context of the patient’s preferences and values
4. Empowerment, by involved patients actively in decision making

Question 19

Impact of affect on decision making

Answer 19

Affect - emotions associated with the content of the conversation

Strong negative affect, not improved by caregivers, can result in impaired processing of communication and understanding

Physician affect can also negatively impact patient understanding and result in higher anxiety

Question 20

Domains of effective communication between patients and doctors

Answer 20

1. Adequate information - straightforward, understandable
2. Receptive when patients are ready to talk
3. Balance between honesty and empathy
4. Doctors elicit and respond to patient concerns
5. Doctors to attend to emotion

Patients want an open-ended, empathic approach with maximal quality of interactions, rather than quantity.

Question 21

Tips for good communication

Answer 21

1. Ask patients and families around their communication preferences (discussion versus recommendation)

“Some patients like to consider all their options before making a decision, where others prefer their doctor makes a specific recommendation. Which of these styles appeals to you?”

“Some patients prefer their doctor acknowledges and discusses emotional issues that go along with having an illness, while others prefer not to discuss these kinds of things with their physician. What’s your preference about this?”

2. Ensure open ended questions
3. Respond to affect and prompt patients around emotional concerns as needed
4. Ask before telling (ask about understanding before telling)

Question 22

Evidence based communication strategies: Prepare in advance

Answer 22

Important medical information should be delivered during a scheduled meeting

• Allows patients to prepare for what they might hear and ensure other supports are present
• Allows physician to allocate sufficient time and come prepared with basic medical info
• Physician should prepare and consider their own emotional state

Question 23

Evidence based communication strategies: Communicate face to face

Answer 23

50% of communication is non-verbal. Avoid phone if possible, and eliminate distractions like pager or mobile

Question 24

EBM Communication Strategies: Open ended techniques

Answer 24

Patients/families tend to be more satisfied in encounters where they do more of the talking

Use open ended techniques to solicit information, yet efficiently.

E.g “tell me more about the back pain” rather than “Is it sharp or dull?”

Question 25

EBM Communication Strategies: Solicit the patient's agenda

Answer 25

# Define an agenda upfront to avoid the 'doorknob' question and ensure needs are met within the constraints of the appointment Start with "what were you hoping we could talk about today?" Then after the patient has said their bit, say "Anything else" and make a list of items to cover during the appt

Question 26

EBM Communication Strategies: Ask permission

Answer 26

Do not assume how much information patient's want. "I want to touch base about how we handle information we get about your illness. Some patients want to know everything, others want to know less and for me to speak more generally. Some would prefer I don't discuss bad news with them, and tell their family instead. Where do you think you sit?" Ask to move the conversation forward. "Would it be okay if we talked now about the latest tests and how your cancer is doing?"

Question 27

EBM Communication Strategies: Ask tell ask

Answer 27

Works well to frame a difficult conversation. 1. Ask what the patient understands (allows you to understand the patient's perspective and highlights misinformation that may need correction) 2. Tell - give news or info in small, digestible chunks 3. Ask again what the patient heard or understood

Question 28

EBM Communication Strategies: Empathise

Answer 28

Can be used to strength the relationship and improve communication efficacy Use clear verbal expressions of empathy from the menu below: NURSE acronym: Name, Understand, Respect, Support, Explore. 1. Name the emotion you hear expressed. "It sounds like you are very distressed/upset/sad . . ." 2. Understand - normalise the emotion " . . . which is understandable given how quickly/difficult/" - Convey understanding of the specific emotion, not the overall situation - Simply saying "I understand" can sound perfunctory and dismissive. 3. Respect - state appreciation of their efforts "I'm impressed with how well you've handled such a tough situation" 4. Support - focus on the patient and their needs and offer help. "I'll be here to help you through this." 5. Explore - open up discussion to the emotion or distress expressed "Tell me more about how you're feeling and what this means to you"

Question 29

EBM Communication Strategies: Praise

Answer 29

Can be used to create an alliance with a family, particularly in contexts where there is a family member or patient aggressively advocating for life prolonging therapies that are unlikely to benefit the patient. "You have been a truly remarkable advocate for your husband" - may help to turn the conversation

Question 30

EBM Communication Strategies: Wish statements

Answer 30

Useful in cases where patients express unrealistic hopes, or during breaking bad news to help acknowledge and deliver the bad news itself. Also allows the clinician to be aligned with the patient. "I wish things were different . . . " "I wish the scans showed the cancer had responded to the chemotherapy . . ."

Question 31

EBM Communication Strategies: "Hope for the best"

Answer 31

In situations where patients/families have unrealistic expectations, can be difficult to encourage discussion about less desirable outcomes. False hope should be avoided. "Let's hope for the best, but we should also prepare for other possible outcomes." Allows clinician to align with hopes while also exploring other outcomes in a less ominous way

Question 32

EBM Communication Strategies: "Are you at peace?"

Answer 32

"Are you at peace" is an effective screening question for spiritual and psychosocial distress

Question 33

EBM Communication Strategies: Use interpreters

Answer 33

Avoid the use of family members as interpreters - risks faulty translation or reinterpretation of the physician statements. Also puts family members in difficult situation of being the physician and patient's spokesperson Risks: - Family interpreter may filter, abbreviate, or omit important information - Important medical information may not be understood adequately or conveyed in full - Unfair burden to family members - Issues of confidentiality and fear of gossip

Question 34

Stage based model of grief

Answer 34

1. Denial, shock, numbness 2. Acute symptoms of grief (intense emotional pain, withdrawal, physical symptoms) 3. Return to normal functioning and reintegration Criticised for relatively passive role of the bereaved person, limited empirical evidence and early studies informing it were mainly white, middle class widows. Does not account for diversity or individual differences

Question 35

Tasks model of grief

Answer 35

Grief is seen as a series of tasks to work through (active rather than passive role) 1. Severing ties with the deceased 2. Adjusting to a new environment without the deceased 3. Creating new bonds with others And other variations thereof. Criticised for failure to recognise individual differences and other relevant factors that might trigger upsurges of grief throughout the bereaved person's life

Question 36

Continuing bonds theory of grief

Answer 36

Theory that rather than grief being about 'breaking bonds' (as in the tasks model and stages models), the purpose of grief is to maintain a continuing bond with the deceased, compatible with other new and continuing relationships

Question 37

Dual process model theory of grief

Answer 37

Grief as a dynamic process where there is alternation between focussing on loss (loss orientation) and avoiding that focus (restoration orientation) Loss orientation - Grief work - mourning Restoration orientation - Taking on tasks previously done by the deceased person - Dealing with wills, etc. Emphasis on each approach is according to the individual. Focusses on coping rather than finding a 'resolution' Difficult to apply to children.

Question 38

Principles of good interprofessional communication

Answer 38

1. Adopt an attitude of curiosity - Allows openness to the perspective, rational, and motivation of the other parties involved - Avoids risk of assumption or premature conclusions 2. Communication on many levels simultaneously - Attend to all elements of the conversation, including underlying emotions and issues of self-identity - Self awareness of triggers for conflict and own communication style, emotional reactions is key 3. Skill in managing conflict - Conflict managed well can be productive and necessary, rather than destructive - Healthy conflict elucidates and contextualises points of disagreement and promote sharing of new ideas and perspectives

Question 39

SBAR model for communication

Answer 39

Structured communication when reporting a concern. Situation " I am calling about X in room X who has X" Background "She is a 45F with X who has required XX" Assessment "I believe . . . " Recommendation "I think we should . . ."

Question 40

How to enhance interdisciplinary feedback

Answer 40

1. SBAR for handover or communicating a concern 2. Effective discussion and feedback - Dedicated forums for discussion feedback (instigated by any team member) - debriefs, M and M rounds, 'escalating patient care meetings' at the first sign of a difficult case to map out a plan. - 360 feedback so that all team members can provide critical feedback - Feedback must be separated from comepensation or performance evaluations so as not to be punitive. 3. Organization structure with flattened hierarchy (High reliability organizations approach) - Seek input from front line members and acknowledge expertise regardless of rank - Allows all team members to be empowered - Useful in situations with poor outcomes in debrief (solicit perspective of all involved, from ward clerk to physician) - Reduces tendency to blame those in a lower position of power 4. Open, no-fault culture when addressing medical errors - Ensure that people aren't afraid to speak up and report - Create an environment of psychological safety that forsters open reporting, questioning, and frequent sharing.

Question 41

Effective interdisciplinary team communication

Answer 41

CLAPS TC BASS 1. Closed loop communication - Acknowledge information received - Clarify requests - Follow up on outcomes 2. Leadership of team - Facilitates problem solving - Effective systems for conflict resolution - Communicate performance expectations - Clarify roles 3. Adaptability - Ability to modify processes as new information arises 4. mutual Performance monitoring - Debrief difficult cases - Use peer assessment tools (e.g. 360 evaluations) 5. Supportive teamwork behaviour - Anticipate, communicate, and respond to one another's needs - Adjust workload distribution - Accept shared responsibilities 6. Mutual trust - Discuss mistakes and accept feedback - Practice constructive (rather than blaming) feedback 7. Comfort with conflict and error - Raise concerns freely and openly - Recognise that conflict is inherent in healthy team process 8. Boundaries - Communicate roles and responsibilities - Acknowledge and communicate when boundaries are blurred or crossed 9. Accountability - Examine and take responsibility for won actions and those of colleagues 10. Shared mental model and team process - Acknowledge interdependence - Agree on team goals and their achievement - Commit to reaching team goals 11. Standardisation of communication - Prioritise frequent face to face communication - Structure models for interprofessional collaps (team rounds, daily goals of care forms, etc.) - Participate in interprofessional education

Question 42

Proven factors to improve referring physicians compliance with consultant's recommendations

Answer 42

1. Response within 24hrs 2. 5 or fewer recommendations 3. Identification of critical recommendations (versus routine ones) 4. Focus on central issues 5. Specific, relevant recommendations 6. Definitive language 7. Specificity in drug dosage, route, frequency, duration 8. Frequent follow up including progress notes 9. Direct verbal contact 10. Therapeutic (vs diagnostic) recommendations 11. Severity of illness

Question 43

Barriers to palliative care consultation

Answer 43

1. Fear that there is a 'palliative care agenda' to stop aggressive treatments or encourage patients to sign on to hospice, or would prefer 'supportive care' as a name. Interaction between PC docs and referring must be careful to provide clarification if need be early on. 2. Physician emotion in the context of disease progression and high emotion. PC docs must be able to manage emotions evoked by the situation and communicate clearly with the team. 3. Difficulties in addressing a specific question by palliative care, when our specialty is not defined by organ or disease, but rather the whole patient. The role of the consultant can seem restrictive.

Question 44

Communication strategies for the palliative care consult

Answer 44

1. Curiosity - Is non-judgmental and open to the perspective, rationale, and motivation of other docs 2. Humility - Remember that referring clinicians are always acting in what they understand to be the best interests of their patients, the referring clinician with an ongoing relationship may have knowledge the consultant does not, and certain cases will carry high levels of suffering regardless of expertise. - Acknowledge other clinicians' efforts and expertise 3. Transparency - Transparency about a viewpoint and prior experience, as well as though process can help to clarify rational and what factors are considered in palliative care - Models an attitude of openness, trust, and mutual respect 4. Clarity - Distil many elements of a patients care to provide clear information - Clear, specific documentation and recommendations - Contact the referring clinician with the recommendations 5. Judiciousness - Balance desire to advocate for their patients with the need to preserve the relationship with the referring physician and act within the bounds of the consulting relationship

Question 45

Key media issues relative to palliative care at present

Answer 45

1. Future provision and delivery of healthcare and social services to the population 2. Meeting the needs of the elderly, who are living longer, in greater numbers, with a corresponding increase in the incidence of long term illness or disability 3. Patient choice and dying with dignity (nearly always framed around patient choice)

Question 46

Opportunities to engage with the public around EOL care

Answer 46

- Public forums - Speaking to special or public interest groups - Engaging the news media - Establishing a 'speakers' bureau', a pool of local experts, who can speak with some authority on a given issue

Question 47

How to engage with politicians around EOL care

Answer 47

- Home care, end of life strategy, aging strategy can be a political minefield for policy makers - Risk of 'biting the hand that feeds you' in countries where there is government funding for PC - which may silence or neutralize physicians - Establish a dialogue with local, regional, provincial or national levels of government

Question 48

Interacting with news media around EOL care

Answer 48

- Stick to your own key messages and do not allow a reporter to 'manage' your interview or guide answers - No such thing as 'off the record' - Consider social media or the internet as the same as news media, but with less rules of engagement

Question 49

How to plan for media engagement, the public, or politicians?

Answer 49

1. Who are we talking to? - Consider your target audience 2. Where are we now in their minds - Consider researching your audience to understand their perceptions and stance on the questions at stake 3. Where would we like to be? - Consider your communication objective 4. How do we get to where we would like to be? - Strategy of communication - how and what do you say to elicit the response you want? 5. How do we know we are right? - Whenever possible, support the answers to the first four questions.

Question 50

Facilitation techniques for family meetings: Circular questions

Answer 50

Circular questions - Ask each family member to comment in turn on concerns and coping or others to promote curiosity and reflection by the group as a whole - E.g. "How are your parents and sisters coping? Who is most upset in your view?"

Question 51

Facilitation techniques for family meetings: Reflexive questions

Answer 51

Reflexive questions - Invite the family to reflect on possibilities, hypotheses, and a range of outcomes to stimulate their efforts to improve family life - E.g. "What benefits might come from caring for XX at home? In what ways might it be hard?"

Question 52

Facilitation techniques for family meetings: Strategic questions

Answer 52

Strategic questions - Word the question to more directly guide the family toward a preferable outcome - E.g. "At what level of agitation would need to occur for you to realise that admission to an inpatient hospice bed is necessary?"

Question 53

Facilitation techniques for family meetings: Integrative summary of family concerns

Answer 53

Integrative summary of the family's concerns - Family's views are reflected back to highlight levels of tension or discordance, while maintaining neutrality yet promoting further problem-solving. - E.g. "As a family, you recognise your father's desire to die at home, your mother's commitment to meet his wishes, yet your concern that his confusion is becoming unmanageable. There is no easy solution here, as whatever solution you adopt will demand more of each of you for a time."