The whole Palliative Care community was saddened to hear of the death of Dr. Andy Billings. You can find his obituary here, and you can learn more about him in this article from the New York Times on “How Doctors Die.” I learned of his death just hours before I was scheduled to present a journal club to the Internal Medicine residents I teach. As synchronicity would have it, the articles* I was presenting were the three that Dr. Billings had written on how to run family meetings in the ICU. I felt that Dr. Billings’ spirit was guiding me as I asked the residents to role play and then debrief a difficult ICU family meeting scenario.

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I would never have had the courage to try something like this had I not watched Dr. Billings lead a group of physicians through the same process back in 2010. I came away from that seminar with a clear vision of what a family meeting entails, how it’s a division of expertise. The health care team and the family meet and share what they know. The physician is the expert on the clinical circumstances, but the family is the expert on the patient, on who he was and on what he would say if he could speak for himself. It was a simple but elegant way to describe the concept of substituted judgment. Ideally, if there’s no written advance directive, the family doesn’t have to make decisions for the patient. They merely have to express the known wishes of the patient. It may seem like a subtle difference, but it takes a lot of the stress and guilt away when making life-or-death decisions.

The role play was an astonishing success. The residents playing the daughter and son-in-law were experienced second- and third-year residents, so they knew how to play family members who had unrealistic expectations and different priorities from the health care team. The resident playing the physician, a brave and caring first-year intern, floundered at first, but then had the presence of mind to call a senior resident into the scenario as the patient’s bedside nurse. At the end, the “attending” was not successful in educating the family on the dire prognosis and the futility of anything but comfort measures. That’s when the real learning began. With some input from the teaching attendings in the room, who included a cardiologist, a hospitalist, and a psychologist, the residents came up with some helpful approaches for their colleague (and for themselves) to use in the future when they felt stuck. The phrases from Dr. Billings’ articles were excellent templates. The residents talked intelligently and sensitively about hope, and how what one hopes for changes as the end of life approaches.

The level of engagement and interest in the room was palpable. This was information that was outside of clinical facts and pathophysiology, but still crucial to the residents’ formation as successful and caring physicians. In their evaluation forms, some participants noted that

• they would do more preparation before having a family meeting,
• they would try to hold them earlier in the hospital stay,
• the ten points outlined in Billings’ third article would be useful tools,
• and they would have liked a PowerPoint presentation.

That last point puzzled me at first. I strive to get away from PowerPoint whenever I can, but I’m at least 30 years older than the residents, so there’s a generational divide. Likely they have a different learning style as well. I prefer auditory learning, but I know I’m in the minority among physicians, most of whom have a visual learning style. Perhaps my feeling that Dr. Billings was present puts me in the minority, too, but if he was present in spirit, I hope he was proud to know that his seminal work is being continued in the palliative care community.

Every physician can learn how to be more skillful at interacting with patients and their families. Dr. Billings articles and my attendance at his workshop are preparing my residents to improve the quality and experience of medical care. More importantly, patient’s wishes are being acknowledged and honored.

*”The End-of-Life Family Meeting in Intensive Care-Part I: Indications, Outcomes, and Family Needs”.  Billings JA. J Palliat Med. 2011 Sep;14(9):1042-50. doi: 10.1089/jpm.2011.0038. Epub 2011 Aug 10. Review.

“Part II: Family-Centered Decision Making.  Billings JA. J Palliat Med. 2011 Sep;14(9):1051-7. doi: 10.1089/jpm.2011.0038-b. No abstract available.

“Part III: A Guide for Structured Discussions”.  Billings JA, Block SD. J Palliat Med. 2011 Sep;14(9):1058-64. doi: 10.1089/jpm.2011.0038-c. No abstract available.

What workshop or seminar have you attended that left a lasting impression on you?

Please leave a comment below and share it with me.