Family updates are as important as any other job that comes with caring for a patient. Yet, it is one that receives minimal emphasis in medical education. It’s just a skill you are expected to intuitively pick up on the job. A HMO offers some advice on how best to look after families and yourself when tackling challenging conversations.
“Hey, do you mind updating the patient’s family? They need to know what’s happened,” the nurse in charge said.
“Absolutely,” I confidently answered with a grumbling dread in my stomach.
Liaising with family members is often a satisfying and rewarding experience. Many people are grateful for the care you’ve given their loved one, and appreciate regular medical updates to address their concerns and queries.
But this consult was not one of those situations.
I was on a late night cover shift when a patient from a different unit, who was not known to me, had abruptly decided to discharge against medical advice. As the doctor on the shift who had permitted the discharge, it was my responsibility to break this news to the patient’s next of kin. Unfortunately, yet predictably, by revealing this information I was met with multiple calls hurling incessant abuse, expletives, and threats of litigation from a family member that failed to recognise that their words were targeting a real person who was just doing their best they could.
There is no sole individual assigned to the task of updating patients’ family members, but commonly this role is left to the junior doctors and nurses. Much of the time however, speaking to family members is left as an afterthought on the list of jobs to be done for the day. In actuality, particularly during COVID when relatives cannot visit their loved ones as freely as before, family updates are just as important as any other job that comes with caring for a patient. Yet, it is one that receives minimal emphasis in medical education. It’s just a skill you are expected to intuitively pick up on the job.
Hospital can be a scary place. People are unwell and often at their most vulnerable. Aside from the few patients who may have a health background, it is not uncommon to come across patients and families with minimal health literacy. Family members are left even further in the dark when they do not hear from their loved ones due to various reasons such as unconsciousness, confusion, or even just unfamiliarity with using technology. In these cases it becomes even more imperative that the treating team is contactable, because much like the doctor-patient relationship, there is a vital doctor-family relationship that weaves itself throughout the patient’s experience of care.
As you progress in your experience, the types of updates you will provide to families will also change. They can range from more routine updates in treatment and medical progress, to goals of care and open disclosure discussions, and ultimately calls informing of significant deterioration and death.
As a starting point, it is good practice to establish the following information when you talk to family members:
- What do they already know?
- How much do they want to know?
- How much does the patient want them to know? (assuming the patient is fully competent or not under a compulsory treatment order)
In addition to these three points, also be prepared for different responses you may receive during the discussion. In particular with more serious conversations as a junior doctor, anticipate that you may not know the answer to every question, and the family member may not necessarily agree with decisions being made. In order to provide patient-centred care, it is up to the treating team to listen to any concerns and take these into account within reason.
With this being said, many healthcare workers will experience encounters with abusive or aggressive family members. The following principles for dealing with these types of patients are also applicable to dealing with their family members:
- Good communication – maintain body language and a tone of voice that is non-confrontational and demonstrates calm control of the situation. Provide an apology and open disclosure if appropriate.
- Try to de-escalate – Actively and genuinely listen to them, and use respectful language that conveys empathy and validation (such as “what can I do to help?” and “this must be very difficult”). Explore together possible solutions or alternatives that can be done instead, and clearly explain why some expectations cannot be achieved.
- Set boundaries and know what behaviour is unacceptable – if the conflict continues to escalate, know that your professional obligation to your patient does not involve accepting threats or abuse from their family members. You are justified to politely but firmly let them know their behaviour is unacceptable, and terminate the conversation.
- Document and debrief – especially with less experience, it is normal to feel shaken after any unpleasant encounters, so documenting and debriefing is not only a useful way to evaluate what has happened, but also to cover yourself medicolegally. Discuss with your senior on what could be done differently in the future, and don’t hesitate to escalate the situation higher if need be.
With time, you will begin to feel more comfortable with being a point of contact. Just remember the basic principles: communicate with family members in a way that you would appreciate being communicated to if it was your own loved one in hospital. And under no circumstance is it acceptable that you are abused in your job as a healthcare worker. You are only able to take good care of other human beings if you are treated like one yourself.
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