The Challenge of Family

Improving Communication with Families

“When the family member appears unresponsive, consider the context of the situation,” says Dr. Weber of the Alaska Native Medical Center in Anchorage. She works with many Alaska native grandparents who have become the parents of their grandchildren. Many elders are reserved people and have a tradition of not challenging an authority figure such as a physician.

“Sometimes they don’t ask tough questions that maybe you initially forgot to answer,” she says.

Dr. Weber finds it helpful in these cases to query the parents (or grandparents): Does that make sense to you? Can you repeat that regimen back to me so that I know we understand each other?

When she encounters an unresponsive family member, clinical social worker Hawgood of the University of California, San Francisco Medical Center invites the person to call her or meet with her privately, at their convenience. She recalls visiting the room of an aging father whose daughters were not talking and appeared angry.

“We thought it was strange,” she recalls, “because the treatment we were offering would have given him a good outcome and a good quality of life. We were perplexed about why he and the family were refusing treatment.”

Acting on a hunch that there might be an underlying family secret, Hawgood gave her card to one of the daughters. In a telephone call, the daughter revealed that the father had committed incest with all four daughters. This particular daughter was afraid she would be held responsible if the father died. Hawgood was able to reassure the daughter that the illness was not her fault, and that the father was refusing to be treated of his own volition.

If the family appears angry or demanding, it is important to define the difficulty, notes Dr. Baudendistel of California Pacific Medical Center in San Francisco.

“If the family is difficult because they are demanding of your time, that’s very different from the family who has unrealistic expectations—who want the MRI of the left foot done, for instance,” he says.

Whenever possible, Dr. Baudendistel partners with the patient’s primary care physician. “I think bringing in the primary care doctor or keeping that person in the loop is really important,” he continues. “That is the person with whom they had the continuity and the relationship, and it is who they trust.”

Sometimes the family member’s anger stems from a belief that the hospital is trying to discharge their loved one too soon. Often families don’t realize all that has actually been done during the hospital stay and what the plans of care are after discharge, and resolving any miscommunication satisfies them that the discharge isn’t premature, says Dr. Bennett, director of the Division of Hospital Medicine at Ohio State University. Such situations can arise when the hospitalist talks to one family member who didn’t communicate accurately with another, who then is angry and thinks the physician is ignoring their concerns.

“Often just sitting down with the family, reviewing everything, and making sure everybody understands and is on the same page with what is going on, can help a lot,” she says. “You likely have already considered or evaluated the issues. Families just need to feel they have been heard and know you have addressed all the issues. Unfortunately, there are some instances where that won’t help. I often found [at Newton Wellesley Hospital] that if we were at an impasse and had done our best with help from social work, that involving the patient ombudsperson could be very helpful.”

Some of her colleagues, especially those new to the hospital, were sometimes leery of involving the ombudsperson. Despite a perception that ombudspersons are adversarial, they can actually be a physician’s ally in negotiating with the family, she says, to help resolve conflicts about treatment decisions and discharge plans.—GH