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Real-Time MedFT Case Consultation: What Would You Do Next Week?

Posted By Randall Reitz, Tuesday, January 3, 2012

Fall 2011

Natalia and Norberto* attended my clinic's diabetes group medical appointment for the first time. They are both immigrants from a Spanish-speaking country who reside in a small town in western Colorado. Natalia has very limited English ability and Norberto knows just enough English to speak for her and to correct the interpreter. Both of them are 5'3” tall. His BMI is 41; hers is 55. Both have diabetes, chronic pain, and numerous other chronic conditions that are caused by or exacerbated by their weights

The topic for the group appointment was "sexual health with diabetes” and the patients were asked to submit anonymous questions to a panel that included a family physician, a family therapist (me), and a resident physician. Despite the promises of confidentiality, few patients submitted questions. We received a question about Viagra, a question about female Viagra alternatives, and a question about how diabetes can affect sexual performance. Natalia submitted a very detailed question which roughly translated to "My husband is now unable to ever have sex with me. He cannot maintain an erection. I am sexually unfulfilled and am not sure what I can do. What do you recommend?”

The panel attempted to maintain confidentiality with this question, but about 1 minute into the discussion Natalia interjected to clarify her question. Norberto then provided a rejoinder, and the couple started a sexual repartee in front of the group. The panelists redirected the discussion, but failed to fully respond to the question.

At the end of the group all participants set a self-management goal for themselves, which they report out to everyone. When it was Natalia's turn, Norberto stated that she needed to drink less soda. Natalia clarified that she only drinks 1-2 diet sodas per day. Norberto stated that it was at least 3-4. Their dialogue continued for about 5 minutes at which point Natalia stated "Why aren't you more worried about your 4-5 beers per night and less worried about my diet soda?” Norberto didn't respond and a silence fell over the room.

Four Months Later

I was precepting residents as they come out of exam rooms and report on their cases. A first year resident was seeing Natalia (and Norberto) so I joined the presentation along with the attending physician. The resident informed us that Natalia has end-stage renal failure and has been referred to hospice. As I knew the couple and have reasonably good medical Spanish I was asked to interpret for the last portion of the visit. The goal was to clarify what the couple understood and to answer any questions they might have.

After greeting the patients and explaining my role, I assumed my customary interpreter's position, slightly behind and to one side of the patient. The resident asked Natalia if she understood why she had received a visit from a hospice social worker. Natalia stated that when the person first came she didn't know she was going to die. She was in her home with Norberto and their adult children when she was told that she would probably only live for 6 to 12 months. At first she was shocked and everyone started crying. In the 2-3 weeks since then she has come to greatly appreciate hospice's home-based care. She credits them with helping to manager her pain and for being very responsive to her calls. She is very pleased to be receiving her care in-home and hopes not to leave.

During our visit Natalia and Norberto reprised their previous interaction of speaking over and contradicting each other. At one point he called her a "masoquista” and she often struggled to speak with the resident, as her husband continued over her. She reported that she has been sleepwalking and he has installed an alarm on their bedroom door so he will know if she is at-risk during a sleepwalking spell.

The resident seeing the patient that day was due to invite a patient or family to "Psych Day”. So, I suggested that she invite Natalia, Norberto, and their children to come. I will attend this visit along with a 2nd resident. I will assist with the patient's care and the 2nd resident will observe and provide feedback.

Now

If you had 45 minutes to work with a family in this setting, what would you want to accomplish? How would you focus the discussion?

Have you ever provided a family conference such as this? If so, what was the outcome?

 

*The patients' names and identifying information have been changed. Additionally, the content of this blog post was approved by my hospital's risk management department and the patients provided verbal consent to have it published online.

 


Randall Reitz is the Director of Social Media for CFHA and the Behavioral Science Faculty at the St Mary's Family Medicine Residency in Grand Junction, Colorado. He studied family therapy at Brigham Young University and Indiana State University.

He is the author of CFHA's
CollaboBlog.



 

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Comments on this post...

Barry J. Jacobs says...
Posted Tuesday, January 3, 2012
Two old family therapy sources that I've found helpful in this type of situation are Families Facing Death--Family Dynamics of Terminal Illness by Elliott J. Rosen (1990, Lexington, Books) and the "Helping Families with Anticipatory Loss" chapter by John Rolland in the book Living Beyond Loss (1991, Norton). In his chapter, Rolland focuses a great deal on family beliefs. That's where I'd start with this family. I'd ask them all again at the outset of the session, starting with Natalia, what their understanding of the medical prognosis is. If they are clear in their common understanding that her condition is terminal and that the purpose of hospice is palliative, then I'd inquire about the conversations that they have had and the changes that they have noted in the family since the advent of this terrible news. I would point out matter-of-factly that, given a terminal prognosis, some families pull together while others fall apart with family members turning on one another in anger rather dealing with the sadness. I'd ask if either description applies to them. I'd also ask about how terminal situations are typically handled in their home culture, especially how spiritual beliefs come into play. Finally, I'd ask each of them, starting with Natalia, how they would like the family members to interact with one another during this last period of time together. You could also ask about possible impediments to achieving those wishes and how best to overcome those impediments.

I think that kind of discussion in and of itself will allow the family members to gain some observing distance on their reactions during this crisis and to begin to consciously think through how they would like Natalia's last few months to unfold. Offering them the opportunity to have similar discussions on a regular basis over the next few months will help family members feel that you will continue to care for them as they deal with this life passage and that you will continue to set a supportive frame for them that will help them endure as best as possible through this difficult time, as well as afterwards.
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Jennifer Hodgson says...
Posted Tuesday, January 3, 2012
First of all, what an opportunity and a privilege to work with clients who are showing you who they are...walls down. Sometimes I find it helpful to teach couples presenting as you illustrated first with a communication technique (i.e., Speaker-Listener by Markman). This often helps to slow down the conversation enough so everyone feels heard. The goal as you may know is not so someone can "win" but for both to feel heard. It would be great to have their adult children a part of the session too. I also like a technique common to the Milan Systemic Approach to Family Therapy (an oldie but goodie) called "circular questioning." Using this approach you really help the family to foster new awareness and information in the system by having them think through the lens of another member (good resource - http://www.anzjft.com/pages/articles/940.pdf). Oftentimes providers will get a family together and instead of helping them to communicate as a family they treat them as a room of individuals. This NOT family therapy. Family therapy is about the interconnectedness and dynamics of the members of a system. It is critical to get them talking to one another in a different way. My thought is that with 45 minutes helping them to learn a few communication tools to use outside of therapy is more helpful than being the tool they use to communicate. Of course though I also work together with the client to create an agenda that is mindful of where they are at and what they want to discuss...using that as part of the communication enhancement work. One of the best gifts to be given to a family who is facing a loss of a loved one is the opportunity to say all they need to say and increase intimacy.
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Randall Reitz says...
Posted Friday, January 13, 2012
REPORT BACK: The family conference was a great success, but not in ways I had anticipated. As described in the initial post, I co-facilitated the session as a training episode for a 1st-year resident who was involved in Natalia’s care and a second resident who observed and provided feedback.

The conference was very well attended, including Natalia, Norbert, 4 of their adult children, Natalia’s sister, and the sister’s daughter (Natalia’s niece.) The family entered the large counseling room ANGRY and wanting to get the attention of the healthcare system. They were especially upset that no one had told them that Natalia’s condition had deteriorated quickly and that they were informed that she would be a good candidate for hospice when a hospice counselor (previously unknown to them) visited them at the house.
It is still unclear to me exactly how this happened, but the contributing factors seem to be the acuity of her recent hospitalization, the fact that her primary care provider was a resident on an away rotation, the language barrier, and the lack of clarity regarding her prognosis. It is still unclear to us who instigated the hospice referral or if it was appropriate. It was clear, however, that the family felt like we dropped the ball. Their concern was that our care was provider-centric, not patient-centric. It was episodic (based on Natalia’s episodes of poor health), and not coordinated.
Fortunately, our 1st-year resident demonstrated systemic awareness beyond her years. She did a great job of eliciting multiple voices, drawing in the silent family members. She didn’t grasp the nuances of the circular questioning, so that wasn’t apparent, but her direct 1-to-1 interviewing skills were right on. She apologized for the failings of the healthcare system (without taking the blame for herself since she was only a smaller player).
Another approach that was successful was drawing upon the wisdom of the family to make sense of what had happened. Two of the daughters work in healthcare and had considerable interface with hospice. Rather than having the doctor explain the ins-and-outs of prognosis (through an interpreter), the daughters were able to explain to their parents that mom could still live for many years. Rather than the physician mandating next steps, the family was able to make recommendations.

(Un)fortunately, as is often the case when healthcare is patient-centered and systemically-oriented, the family ended the session very pleased, with their issues addressed, and with a query as to whether they could transfer their mother’s primary care to the 1st-year resident.
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