Incorporating families into the care team

I want to talk about the value of how we involve patient families, and how we can make that work from the clinical side to benefit our patients and work efficiency. This is something that I developed as a intentional and collaborative approach during training, useful for both inpatient and outpatient settings. This is also another step toward advance care planning discussions with patients and improves my transitions of care.

As busy as we are, it can feel like one additional step when family members get involved. But it actually improves the team-based approach that we are all encouraged to practice with the patient and family at the center, consistent with the advisories of the Agency for Healthcare Research and Quality, American College of Physicians, and American Medical Association.

You might get messages that are written by a family member or friend of the patient, saying that they're worried about their loved one and they want a visit to be set up [by you] to see that patient. In the inpatient setting, the nurse might page you that a family member is at the bedside and requests a clinical update. In both scenarios, those may be more reactive prompts to prioritize family in the clinical plan.

During initial appointments, I proactively ask patients about their medical power of attorneys or for permission to include the family and caregivers in medical discussions. My cues may include a patient that mentions his wife frequently as the reason he came to the appointment, patients of advanced age with complicating factors in terms of memory issues, or known comorbidities affecting cognitive status or falls risk, such as Parkinson's disease.

I will say to the patient during the appointment, “I'm glad you're here. You mentioned your wife is concerned about you. Would it help to include her now by phone or in our next appointment?” or if responding to family in the patient portal, “It seems like you really care about your mom; I would love it, if your mom is willing, for you to join our visit.” Family can participate by phone or video, or in person, depending on the comfort level of the physician and also the convenience of the family member. For many patients, some level of family involvement is implied, so including them proactively helps to lessen some of the anxiety that the family member or the patient may have.

When I extend that invitation, especially proactively, I've been able to make more gains during the appointment. If the patient is having a lot of issues, let's say with weight loss or incontinence, the family member can provide some of the daily habits of the patient during the history taking or share what has been helpful toward the plan. Therein lies the benefit of having that person actively participate during the visit.

The other advantage is potentially more follow-through after the appointment when the family member is able to help implement some of the recommendations for more efficient and safer outcomes for the patient. This becomes another member of the patient's health care team and identifies a consistent voice during advance care planning with the patient.

Oftentimes, from the physician perspective, time can be an intimidating consideration thinking that if we involve family that it'll become a longer discussion. While that might be true, setting the same healthy expectations for time and scope of discussion before and at the beginning of the appointment can really make this more productive.

The other factor is that it's so much more effective long term to set up that early collaboration with the family. The patient may have fewer falls if you're able to talk about why shoes must be different, or medications taken at certain times. The more that we address upfront, the better and more productive it is for everybody in achieving the patient's goals of care.