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The relevant clinicians

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Reach consensus

If outpatient, may require calls/email

Aim for prognostic alignment

Set the goal for the meeting

Identify a speaker

Discern whether this is a loser's or winner's game

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To the family meeting!

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🏠 Missing family

🥼 Missing clinicians

⚖ Misalignment in clinical / prognostic understanding

🎙 Multiple speakers

⏳ Forcing a non-urgent meeting

🚧 Ignoring limits

Do you or anyone else need food, caffeine, the restroom?

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The relevant clinicians

The relevant family

The news

Chairs (please sit!)

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Assess illness understanding

"What's the last update you received?"

"What have the doctors said?"

"I just want to make sure we're on the same page..."

Bottom line up front (1-3 sentences)

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Next phase of the conversation (exploring GOC)

or

Identify next steps (e.g., cool off period)

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🚨 Family unprepared to receive news

Ask permission! "Is it okay if I share what we've found?"

🚦 Assuming knowledge

Don't skip assessment of illness understanding

📜 Retelling the whole clinical course

Illness understanding may allow to jump right to GOC without a prolonged summary

😵 Jargon

Avoid specialized medical language

🌊 Jabber

Be succinct

🤢 Toxic knowledge

Avoid giving unactionable info that impairs decision-making

🧨 Ignoring emotion

Acknowledge, empathize, validate

Address an emotionally charged question at the emotional level before the cognitive level

Ask permission before moving through emotion

Beware the uncanny valley 🤖

😩 Family distrust

Anticipate and manage conflict

Acknowledge reality

Move slowly; listen to stories

Don't argue about claims that are impossible to refute (and even if they are, weigh burdens/benefits of arguing)

Apologize if necessary

Concrete, brief, avoid qualifications, outline steps to avoid issue in the future

✨ Belief in miracles

Acknowledge divine presence while also acknowledging human-level need for decision-making

Confer with chaplain

🎉Toxic positivity

Shift focus from losses to needs

Telephonic visit (if avoidable)

💀 Failure to diagnose + discuss dying

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The relevant clinicians

The relevant family

Shared understanding of illness (agree on the news)

Chairs (please sit!)

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Discuss medicine's goals of care

Longevity, function, comfort

Identify interventions that may be needed to clarify GOC (e.g., biopsy)

Explore expectations, hopes, worries

Assess disparity between clinician and family expectations

Assess and broaden hope portfolio

Look for stories, roles, metaphors, affect

For surrogate decision-makers

Substituted judgment if possible

Substituted interests often necessary

Best interests sometimes necessary

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Next phase of the conversation (prognosis & planning)

or

Identify next steps (e.g., cool off period)

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🔮 Assuming GOC

🚩 Naïve allocation

Addressing "everything"

Highlighting trade-offs

Attend to ambivalence

🔥 Answering hopes with "but"

Align with hopes

Share your worries with "and" (e.g., "I'm hoping this works, and I'm worried that...")

🧭 Preference-goal substitution

Discuss goals before preferences

Avoid preference entrenchment among clinicians

🔒 Inflexible goals

Promote flexibility (e.g., goal A in the short-term to facilitate a discussion about goal B)

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The relevant clinicians

The relevant family

Shared understanding of illness (agree on the news)

Share understanding of GOC + hopes + worries

Chairs (please sit!)

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Scenario planning

Best, worst, and most likely case scenarios

Holistic prognosis (time, function, symptoms)

Iterative (e.g., ICU) vs. one-time (e.g., surgery)

What does it look like to live well given everything we know?

Review previously discussed GOC/plans

Back-up and emergency planning

Who's the surrogate decision-maker? (ideally would have been known from initial eval/H&P)

Advance directive

Code status

Functional milestones

Retirement, driving, home safety, continence, diet

(Re)Hospitalization

Hospice

Disease-specific plans

For surrogate decision-makers

Broadening the role to include not just advocating for treatments, but protecting from harmful interventions

Substituted judgment if possible

Substituted interests often necessary

Best interests sometimes necessary

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Execute plans

Follow-up

Plan may feedback into another conversation

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Unprepared to plan

Ask permission

Pressure to decide (if not urgent)

Myopic procrastination

Focus on needs instead of losses ("Can I talk about what you might need in the coming months?")

Highlight trade-offs

Number avalanche

Focus on narrative-based scenarios (with numbers in back pocket if needed)

Unmoored preferences

Explore GOC first

Use preferences to clarify GOC ("Based on that choice, it seems like you might prioritize this the most?")

Sunk costs

Clarify holistic prognosis early, including expected milestones

Clarify limits early

Stalled decision-making

Diagnose mental state (e.g., ambivalence, depression, delirium, etc)

Bolster decision-making supports

Time-limited trial

Lack of recommendation

Requests for potentially inappropriate treatment

Clarify GOC - will the intervention serve the goal?

Acknowledge, empathize, validate emotions

Identify distrust and build rapport

If truly physiologically futile, can decline to provide based on clinical judgment (rare)

If irresolvable, may need ethics consult

Offering 3+ options

Sometimes necessary, but can often be avoided by simplifying to two

e.g., surveillance vs. ablation vs. or surgery can be simplified to surveillance vs. intervention

If they opt for intervention, exploring ablation vs. surgery