The ROYL Family Conference
The ROYL Family Conference - dedicated to crisis avoidance at End of Life Care
- Dedicated to doctor-patient-family/loved ones dialog as ongoing process
- Part of the long term doctor-patient relationship
- Customizable to individual situations
- Comprehensive and inclusive while remaining flexible
Review earlier preparation
- Existence and availability of advance directive
- Delineation and presence of health surrogate power of attorney
Review the current situation
Is the patient able to participate?
May require psychological, medical and legal input to determine patient capability
Different situations will have different emphasis on the ROYL domains (medical, legal, financial and insurance, social services, spiritual, and death.)
Patients with declining outcomes in the next six weeks need an emphasis on all six domains.
All patients benefit from a comprehensive and inclusive approach to Rest of Life planning.
Increase communications and transparency, facilitate the individual patient having her/his wishes met
Quiet, private and comfortable room
Patient, if able to participate, doctor, nurse, health care surrogate, family & loved ones, social service workers and clergy
Introduce the doctor and everyone present to each other. Identify the health surrogate and family spokesperson, if that person is different from the surrogate.
Everyone will speak, no interruptions, no arguments
- Economic surrogate power of attorney
- Plans in place?
- Financial inventory available?
- Financial plans aligned with legal situation?
- Catastrophic insurance available?
- Long term care insurance available?
- VA benefits available?
- Adaptive architecture
- Other social support agencies
- Clergy point of contact
- Social organizations
After Life Care
Discussion with patient: Patient spells out their wishes
- Letter to loved ones
- Doctors, nurses, family, clergy, social services strategize to support patient and family/loved ones
- Looking for a consensus
Discussion without patient:
- Recognition and support for health surrogate power of attorney
- Review advance directives and letter to loved ones if available
- Ascertain family/loved ones wishes, let them discuss in private if necessary
- May need follow up meeting
- Looking for a consensus
Ancillary help if no consensus available
- Other doctors and nurses
- Medical ethics committee
- Summarize goals and plans; include consensus and disagreements
- Advise that outcomes are unpredictable
- Identify family spokesperson, not always the surrogate power of health attorney
- Document wrap up in the medical chart/EMR
- Ongoing meetings
- Reassure no physician abandonment
Is the patient healthy or ill? May affect acceptance.
Is the patient symptomatic? May affect acceptance.
Acceptance may occur at different times
Traditional Stages of Grief are applied to being given bad news in addition to dealing with death. In variable sequence they are:
Note that acceptance isn't the start of the process!
A Note on the Stages of Grief
The Stages of Grief: denial, anger, bargaining, depression and acceptance are often used to describe reactions to getting bad news. Different patients have different reactions. These stages may occur in different order, not at all, or all at once.
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