不同视角下的临终关怀学 (9).pdf

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1、BioMed CentralPage 1 of 12(page number not for citation purposes)BMC Palliative CareOpen AccessResearch articleFamily meetings in palliative care:Multidisciplinary clinical practice guidelinesPeter Hudson*1,Karen Quinn1,Brendan OHanlon2 and Sanchia Aranda3Address:1Centre for Palliative Care Educatio

2、n&Research,St Vincents and The University of Melbourne,PO Box 2900,Fitzroy,Victoria 3065,Australia,2The Bouverie Centre,La Trobe University,8 Gardiner Street,Brunswick,Victoria 3056,Australia and 3School of Nursing and Social Work,The University of Melbourne,Level 5,234 Queensberry Street,Carlton,Vi

3、ctoria 3010,AustraliaEmail:Peter Hudson*-peterhmedstv.unimelb.edu.au;Karen Quinn-karen.quinnsvhm.org.au;Brendan OHanlon-b.ohanlonlatrobe.edu.au;Sanchia Aranda-sanchiaaunimelb.edu.au*Corresponding author AbstractBackground:Support for family carers is a core function of palliative care.Family meeting

4、s arecommonly recommended as a useful way for health care professionals to convey information,discuss goals of care and plan care strategies with patients and family carers.Yet it seems there isinsufficient research to demonstrate the utlility of family meetings or the best way to conduct them.This

5、study sought to develop multidisciplinary clinical practice guidelines for conducting familymeetings in the specialist palliative care setting based on available evidence and consensus basedexpert opinion.Methods:The guidelines were developed via the following methods:(1)A literature review;(2)Conce

6、ptual framework;(3)Refinement of the guidelines based on feedback from an expert paneland focus groups with multidisciplinary specialists from three palliative care units and three majorteaching hospitals in Melbourne,Australia.Results:The literature review revealed that no comprehensive exploration

7、 of the conduct andutility of family meetings in the specialist palliative care setting has occurred.Preliminary clinicalguidelines were developed by the research team,based on relevant literature and a conceptualframework informed by:single session therapy,principles of therapeutic communication an

8、dmodels of coping and family consultation.A multidisciplinary expert panel refined the content ofthe guidelines and the applicability of the guidelines was then assessed via two focus groups ofmultidisciplinary palliative care specialists.The complete version of the guidelines is presented.Conclusio

9、n:Family meetings provide an opportunity to enhance the quality of care provided topalliative care patients and their family carers.The clinical guidelines developed from this studyoffer a framework for preparing,conducting and evaluating family meetings.Future research andclinical implications are

10、outlined.BackgroundPalliative care is expected to be holistic and multidiscipli-nary;it is provided to both the patient and their family1.Effective communication between the patient,thefamily and health care providers is integral to optimal pal-liative care.One method of facilitating communication i

11、sPublished:19 August 2008BMC Palliative Care 2008,7:12doi:10.1186/1472-684X-7-12Received:15 April 2008Accepted:19 August 2008This article is available from:http:/ 2008 Hudson et al;licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribut

12、ion License(http:/creativecommons.org/licenses/by/2.0),which permits unrestricted use,distribution,and reproduction in any medium,provided the original work is properly cited.BMC Palliative Care 2008,7:12http:/ 2 of 12(page number not for citation purposes)a family meeting,also referred to as a fami

13、ly conference2.Family meetings between the patient,their family andhealth care professionals are undertaken for multiple pur-poses including the sharing of information and concerns,clarifying the goals of care,discussing diagnosis,treat-ment,prognosis and developing a plan of care for thepatient and

14、 family carers 2-4.However despite the promotion of family meetings as anessential tool for information sharing and goal clarifica-tion in specialist palliative care settings,it has beenreported that sparse evidence exists to demonstrate theprocess for training staff to conduct or participate in the

15、m3.It has also been claimed that there is a dearth of pub-lished literature describing when such meetings should beinitiated,who should attend them,how they should beconducted and evaluated 5.We set out to develop practice guidelines for conductingfamily meetings within the context of the specialist

16、 palli-ative care setting,based on the best available evidence andcomplemented by consensus based expert opinion.Forthe purposes of these guidelines we define a specialist pal-liative care setting as a health care environment or servicethat specifically focuses on the care of patients with anadvance

17、d incurable disease and their family.An evalua-tion of the effectiveness of these guidelines in clinicalpractice will be reported separately.MethodsKey questions guiding the development of the guidelineswere:(a)How should family meetings be convened andstructured?(b)What content is essential?and(c)W

18、hoshould attend and lead them?Development of the guidelines was based on the follow-ing three methods:(1)A literature search using MEDLINE(1995 2007),CINAHL(1995 2007),and PsycINFO(19952007)databases.The principal search terms usedeither singly or in combination,were:family,carers,case,conference,me

19、eting,hospice and palliative care.Key pal-liative care textbooks(eg 6)and their reference sectionswere also hand searched for relevant information;(2)Theresearch team considered relevant models and theories tosupport the conceptual framework to underpin the guide-lines;(3)(a)The research team prepar

20、ed a draft version ofthe guidelines which was then reviewed by an expertpanel alongside the conceptual framework.Members ofthe panel were purposively chosen(based on their experi-ence in conducting family meetings)and invited by mailto participate;(b)The guidelines were further refined andtheir clin

21、ical applicability was assessed via two focusgroups.The first(focus group 1)comprised multidiscipli-nary specialists from three palliative care units and theother(focus group 2)comprised multidisciplinary pallia-tive care specialists from three large Melbourne hospitals.The inclusion criteria requir

22、ed that participants had expe-rience in participating in family meetings.Letters of invi-tation were sent to the managers of each of the servicesrequesting that potential participants contact the researchteam.Ethical approval was provided by St Vincents Hos-pital Melbourne,Australia and written cons

23、ent wasobtained from all participants.The focus group questionscentred on asking participants to briefly describe:currentpractice in relation to family meetings in their setting;keyelements of family meetings and then to provide com-ment on the draft version of the clinical guidelines.Data from the

24、expert panel and focus groups were audio-taped and transcribed verbatim.These data were then con-tent analysed in accordance with the structured questionsset by the research team.ResultsLiterature ReviewThe literature search revealed only three published articlesin peer reviewed journals specificall

25、y related to familymeetings in the specialist palliative care setting 2,3,7.Due to the limited amount of palliative care specific liter-ature;evidence from non-specialist palliative care settings,including intensive care and aged care was also reviewedand included for the purposes of the literature

26、review.One palliative care related article acknowledged that mosthealth professionals do not receive sufficient training toconduct family meetings 3.The authors reported on theevaluation of a training program focused on preparingmedical and social work students for conducting familymeetings in palli

27、ative care.However,the study was prima-rily about the outcomes of the educational initiativerather than specific details about how to convene and con-duct family meetings or whether or not family meetingswere beneficial 3.One article was prepared as an educa-tive tool for health professionals and pr

28、ovided recom-mendations for conducting family meetings in palliativecare,seemingly based on expert opinion in the most part7.The final article was an informational tool about fam-ily meetings designed for patients and families 2,although the process for determining the content was notoutlined.Recomm

29、endations for conducting family meet-ings were identified in some palliative care books,butthese were also based on expert opinion(for example 8).The opinion based family meeting guidelines for healthprofessionals advocated suitable planning and an overtpurpose in order to conduct an effective meeti

30、ng.Otherkey recommendations included giving consideration towho should attend,a meeting place that ensures privacyand a method for disseminating outcomes of the meeting.BMC Palliative Care 2008,7:12http:/ 3 of 12(page number not for citation purposes)Similar recommendations on how to conduct a famil

31、ymeeting exist in the aged care setting 9.While these sug-gested approaches appear useful(as was the case for palli-ative care based suggestions),the basis for their content isnot explicitly outlined and it is unclear as to whether theirutility has been tested.One qualitative study was identi-fied w

32、hich aimed to explore the opinions of participantsin family meetings in a geriatric rehabilitation hospital.Staff,patients and families participated in focus groups,completed surveys and individual semi-structured inter-views 5.Although high levels of satisfaction with familymeetings were reported,p

33、atient interviews revealed a lackof informed consent and lack of clarity regarding the pur-pose of meetings.An unclear agenda was identified bystaff,patients and families as the underlying reason forunsatisfactory meetings.A practice model for nurses working with families hasbeen developed 10.It inc

34、ludes family interviews con-ducted over approximately an hour,as well as 15 minuteinterviews designed to be conducted within the course ofnormal nursing duties.The key elements of a family inter-view identified by these authors included:therapeuticconversations;manners;family genograms and ecomaps;t

35、herapeutic questions and commending family and indi-vidual strengths.However,there does not appear to beresearch evidence supporting the effectiveness of thismodel in practice.The conduct of family meetings has also been described inthe context of training medical practitioners 11.Tworelated qualita

36、tive studies investigated the attitudes of res-idents(junior doctors)and their educators towards familyconferences.A survey of 65 residents revealed that familymeetings are:valued as a communication tool to providemedical information and reach consensus on care;occurprimarily in inpatient settings i

37、n the context of crisis;failto occur due to significant barriers;and are best taughtexperientially with the involvement of physician rolemodels 11.The accompanying survey of 12 teachingstaff revealed major themes including:family conferencesoccur on a continuum of formality;experiential,in vivotrain

38、ing for family conferences is the primary trainingmodality;specific skills are needed to conduct family con-ferences;and the barriers to conducting family confer-ences are formidable 11.Our review identified several studies that explored familymeetings within the context of the intensive care unit(I

39、CU)12-20.Even though the ICU setting is considera-bly different from a typical palliative care unit,given thelack of research related to family meetings in the specialistpalliative care setting we deemed it pertinent to highlightthese studies.Furthermore,there are some similaritiesbetween the two ca

40、re settings:a considerable proportionof the patients die in both ICU and palliative care unitsand patients are often too unwell to be involved in thefamily meeting.A study involving qualitative analysis of 51 family confer-ences across four ICUs in the USA and a survey of 169family members regarding

41、 their satisfaction with commu-nication found that increasing the frequency of three typesof clinicians statements during family conferences wasassociated with increased family satisfaction14.Thesestatements included(a)assurances that the patient willnot be abandoned before death,(b)assurances that

42、thepatient will be comfortable and will not suffer and(c)support for familys decisions about end-of-life care,including support for familys decision to withdraw or notto withdraw life-support.A related study used the samedata to explore missed opportunities for providing sup-port and information to

43、families 15.The researchersdetermined that in 29%of family conferences opportuni-ties were missed by the convenors of the meetings.Thesemissed opportunities fell into three broad categories:lis-tening and responding to family;acknowledging andaddressing emotions;pursuing key principles of medicaleth

44、ics and palliative care such as exploration of patientpreferences,explanation of surrogate decision makingand affirmation of non-abandonment.Another sub study,(drawing on similar data)explored shared decision mak-ing strategies in the ICU and concluded there was a smalldegree of empirical support fo

45、r this approach for familymeetings 19.Lilly and colleagues examined the effectiveness of a proac-tive patient and family centred communication strategywithin the ICU 20.The intervention involved focusedhealth professional meetings with the patient and/or theirfamily within 72 hours of admission and

46、incorporated areview of:the medical facts,the patients perspective onimpact of the illness/situation,and development of a careplan.Using a before-and-after study design,the interven-tion demonstrated reduction in the time spent in ICU andearlier withdrawal of advanced supportive technology.A study c

47、onducted in France aimed to measure theamount of time physicians in ICU spent with patientsfamilies by examining contact over a 24 hour period with951 patients 17.The median time spent providing infor-mation to families was 16 minutes per patient,with 20%of the time spent explaining the diagnosis,20

48、%onexplaining treatments,and 60%on explaining the prog-nosis.One third of the time was spent listening to familymembers.Subsequent analysis revealed that the presenceof more than one bed in the room was associated with lesstime spent on providing information,while a range ofpatient and family factor

49、s were associated with more timebeing spent on providing information.In an apparentlyBMC Palliative Care 2008,7:12http:/ 4 of 12(page number not for citation purposes)related study,a randomised controlled trial demonstratedthat family members who participated in a structured ICUfamily meeting format

50、 and received a brochure onbereavement,had less anxiety and depression than thosereceiving standard care12.A cross sectional study involving audiotaping familymeetings in the ICU concluded that family satisfactionwith communication was increased when they were givenample opportunity to voice their c