Background: Use of telemedicine has increased exponentially (1). It has been associated with reduced out of pocket health care costs, decreased emergency department visits, reduced clinic no-show rates, improved patient care satisfaction, and an increase in access to palliative care specialists (2-5). Consequentially, more serious illness discussions are being conducted via telemedicine platforms and more loved ones can participate in these discussions via telemedicine platforms. This has created unique considerations as sensitive and emotionally distressing information about prognosis and goals of care are often discussed in these meetings (6). This Fast Fact offers tips on how to navigate these considerations. See Fast Fact #423 for telemedicine tips when connecting inpatients with loved ones.

Technology considerations: Audiovisual (AV) interruptions can be distracting for patients, family, and clinicians alike. All attendees should be reminded to use stable Wi-Fi connections with adequate bandwidth; they should pull over if in a car; they should avoid getting on a train or elevator; and they should avoid using a cellular network so that connectivity during the meeting can be optimized. Clinicians must familiarize themselves with their health care institution’s AV equipment and preferred platforms and be aware if the telemedicine software will not allow multiple users to join the conversation. In case of AV equipment or connectivity failure, have a backup phone line with the ability to conference call so that important conversations can be continued (7). Conversely, not all conversations are compatible with telemedicine (e.g., family may not have the technical capabilities, hearing impairment, in person visit is desired before care decisions are made), so be willing to postpone the discussion if an in-person meeting proves to be necessary.

Clinician-based considerations: Conduct serious illness discussions from a quiet space, where the chances of being disturbed are minimized (7). Put a ‘do not disturb’ sign outside your office room if necessary. Noise-cancelling microphones can reduce distracting background sounds. To maintain visibility and professional appearance, a well-lit room with a neutral, virtual, or blurred background is preferred (7). Dress professionally, with the video focused on the face and upper torso (6,7). Avoid clanging, shiny jewelry which can add to AV noise. Multitasking (typing notes, texting, eating) should be avoided (6,7). Although virtual formats can promote a sense of informality, ask ‘Would I do this in an in-person meeting?’ to gauge appropriate behavior. Showing empathy can be challenging since body language is minimally transmitted via video but having a slightly bent over posture, nodding when in agreement, and utilizing exploratory verbal statements like ‘Tell me more about that” convey engagement and concern (7,8). If using multiple screens, focus eye contact on the screen with the camera.

Patient-based considerations: Early in the meeting make sure all relevant parties (e.g., the next of kin, healthcare proxy) have received a meeting link. Align with patient and families with less digital skills by acknowledging that telemedicine is not an ideal modality for these discussions and can be frustrating.  Make sure everyone who wants to participate is available before you begin the meeting, otherwise, repeated information may be required. To prevent unnecessary delays, make sure the patient or family can use the technology and have the necessary equipment prior to discussions (7).  If late arriving family members ask for a summary of what has been discussed, consider asking the patient or another family member to summarize the discussion up until that point to assess their understanding and perspective. If dealing with a language barrier, arrange for an interpreter, ideally in person, in advance (9).

Compliance-based considerations: Work with your institution to ensure an encrypted, password-protected connection so that privacy and HIPPA compliance is maintained (10).  Introduce other attendees in the room and their role in the care so the patient and family know who is participating and who is being made aware of the patient’s medical information (10). Although completion of advance directives and POLST forms are not always achievable via telemedicine (dependent upon state-specific laws), preliminary steps often can be completed. For example, an agreed, yet unsigned form may be initiated using share-screen functions (6).

Considerations during the serious illness discussions:  After introducing everyone in person or online, ensure that everyone can see and hear the proceedings, and they understand the reason for the meeting (7). When engaging with multiple participants, ask all to mute themselves unless speaking and reiterate that there will be a designated opportunity to ask questions later so that interruptions can be minimized. Even with the best oversight, technical issues prevent effective information transfer to key stakeholders during telemedicine encounters. To reduce the chances of confusion or incomplete communication disclosure, slow down the pace of the discussion.  Silence may feel particularly awkward over telemedicine, but it is necessary for patients/families to process complex medical information. Check in with participants frequently utilizing “ask-tell-ask” communication techniques to ensure key information has been heard.  At the end of the meeting, ask the patient or a key family member to summarize their key take-home points and assure they understand the next steps (6).

References:

1. Suran M. Increased use of Medicare telehealth during the pandemic. JAMA. 2022;327(4):313.
2. Bynum AB, Irwin CA, Cranford CO, et al. The impact of telemedicine on patients’ cost savings: some preliminary findings. Telemed J E Health. 2003 Winter;9(4):361-7. 
3. Gellis ZD, Kenaley B, McGinty J, et al. Outcomes of a Telehealth Intervention for Homebound Older Adults With Heart or Chronic Respiratory Failure: A Randomized Controlled Trial. Gerontologist 2012, 52, 541–552.
4. Nguyen M, Waller M, Pandya A, et al. A Review of Patient and Provider Satisfaction with Telemedicine. Curr Allergy Asthma Rep. 2020;20(11):72. Published 2020 Sep 22.
5. Reddy A, Arthur J, Dalal S, et al. Rapid Transition to Virtual Care during the COVID-19 Epidemic: Experience of a Supportive Care Clinic at a Tertiary Care Cancer Center. J. Palliat.Med. 2021, 24, 1467–1473.
6. Habib MH, Kota S, Davis MP. Telemedicine family meetings in palliative care: etiquette. BMJ Support Palliat Care. 2022 May 24:bmjspcare-2022-003733.
7. Tang M, Reddy A. Telemedicine and Its Past, Present, and Future Roles in Providing Palliative Care to Advanced Cancer Patients. Cancers. 2022; 14(8):1884.
8. Gustin TS, Kott K, Rutledge C. Telehealth Etiquette Training: A Guideline for Preparing Interprofessional Teams for Successful Encounters. Nurse Educ. 2020;45(2):88-92.
9. Joseph C, Garruba M, Melder A. Patient satisfaction of telephone or video interpreter services compared with in-person services: a systematic review. Aust Health Rev. 2018;42(2):168-177.
10. Bassan S. Data privacy considerations for telehealth consumers amid COVID-19. J Law Biosci. 2020;7(1):lsaa075. Published 2020 Sep 14.

Version History:  first electronically published in June 2022; originally edited by Sean Marks MD

Conflict of interest: none to report

Authors’ Affiliations: ¹Rutgers, Cancer Institute of New Jersey, Robert Wood Johnson Hospital, New Brunswick NJ; Clinic Barmelweid, Barmelweid, Switzerland