Background     Family meetings are important events in the care of hospitalized patients to ensure that patients & families understand what is happening medically, to support the patient and family emotionally, and to promote shared decision-making (1). Common topics include delivering bad news, discussing care goals, and clarifying the plan of care and patient disposition (see also Fast Facts #222 & 223). Pre-meetings among relevant clinicians are helpful for family meetings to run smoothly (1). This Fast Fact provides practical guidance to holding a successful pre-family meeting ‘huddle.’

Basics of the ‘Huddle’    The huddle typically occurs just prior to family meeting, ideally in a private setting (and not right in front of the patient’s room). Along with the primary medical team, the huddle may include key specialists/consulting team members including members of the palliative interdisciplinary team, the bedside nurse and/or unit charge nurse, the unit care coordinator and/or social worker, spiritual care, and other professionals as relevant such as speech language pathology, physical therapy, etc.  Huddles often take between 5-15 minutes. Goals of the huddle include: (1) achieving a common understanding of the medical situation and possible options and outcomes, (2) agreeing on the family meeting’s purpose, (3) sharing what is known about the family and their concerns, and (4) determining professionals’ roles during the family meeting. 

Data     There are no specific data on the effectiveness of huddles prior to family meetings. However, huddles have been used for improving care in different settings, ranging from facility safety huddles to perioperative settings. Evidence suggests huddles identify safety challenges (2), decrease laboratory and pharmacy costs (3), and improve family and provider satisfaction (4). 

Facilitating a common understanding of the clinical situation     The first task of the huddle is to ensure that everyone is on the same page about what is happening medically, what range of interventions/options are appropriate to offer the patient/family, and what range of likely outcomes should be outlined. The clinician leading the huddle might say, “I want to make sure we all have the same view about what is going on with the patient and what we think her future might be.” In cases where health care providers have divergent thoughts, it is helpful to discuss the best- and worst-case scenarios and the milestones that will help determine how the patient is doing (5). The goal is to generate a consensus and allow the meeting leader to present this information to the patient/family in a cohesive fashion.

Agreeing on the goals of the meeting     Second, the huddle participants should come to an agreement regarding the meeting’s purpose, incorporating what is known about the patient’s/family’s hopes for the meeting. The patient or family is likely to be confused if some health care providers are asking about the patient’s values while others are viewing the meeting merely an opportunity to update the family or discuss disposition. It is always a goal to make sure the patient/family leave the meeting better informed about the situation/options, and feel heard and valued. Clarifying the meeting’s purpose further than that “What’s the fundamental message we want to convey during this meeting?” and “What, from our point of view, are acceptable outcomes?”, helps avoid mixed messages. It is also very important to clarify in advance if decisions about the plan of care need to be made urgently. 

Sharing information & concerns     Third, the huddle is the time for health care providers to share information about the family structure, who the legal decision-maker is (if not the patient), how the patient/family make decisions, and places where the meeting might go “off track.” Given not all huddle members have met all family members, the huddle can update everyone on family dynamics (e.g., “The children always defer to their mom,” or “The cousin is a nurse and asks of biomedical questions”). Bedside nurses, social workers, and chaplains are particularly important as they may have spent much time with the patient/family and may have a different view and experience of the patient/family than other providers. Helpful questions include “What do we know about how this family makes decisions?” or “What are some specific concerns folks have about what might happen in the meeting?”

How to facilitate the family meeting     Finally, it is important to decide who will lead the family meeting, taking into account who the patient/family may have the strongest therapeutic relationship with, and to name key roles in the meeting as relevant (e.g., the surgical consultant will be sharing the news that the patient is no longer a surgical candidate, or the oncologist will be reviewing chemotherapy options and outcomes). Often the leader is a physician or an advanced practice nurse, especially if biomedical facts are being shared, but this depends on institutional culture and the purpose of the family meeting. 

References

1. Singer AE, Ash T, Ochotorena C, et al, A Systematic Review of Family Meeting Tools in Palliative and Intensive Care Settings. Am J Hosp Palliat Med. 2016; 33:797-806.
2. Setaro J, Connolly M. Safety Huddles in the PACU: When a Patient Self-Medicates. J. Perianesthesia Nurs. 2011; 26:96-102.
3. Chan AY, Vadera S. Implementation of interdisciplinary neurosurgery morning huddle: cost-effectiveness and increased patient satisfaction. J. Neurosurg. 2018; 128:258-261.
4. Awdish RL, Buick D, Kokas M, et al, H. A Communications Bundle to Improve Satisfaction for Critically Ill Patients and Their Families: A Prospective, Cohort Pilot Study. J Pain Symptom Manage. 2017; 53:644-9. 
5. Schwarze ML, Taylor LJ. “Managing Uncertainty — Harnessing the Power of Scenario Planning. NEJM.  2017; 377: 206-8.

Authors Affiliations: University of Pittsburgh Medical Center, Pittsburgh, PA. 

Conflicts of Interest: NoneVersion History: Originally edited by Drew A Rosielle MD; first electronically published in December 2018.