Table 3.

Approach to delivering bad news in a family meeting: setting, perception, invitation, knowledge, emotions, summarize, and strategize

Step	Action	Benefits
Setting	Arrange for a private, quite room with all pagers and cell phones on silent. Tissues should be available. Each participant should have a place to sit and be able to make eye contact with the patient and family. The leader of the meeting should have all participants introduce themselves and explain their relation to the patient, including family members	A comfortable and nonchaotic setting allows for a connection to be made between providers and patients. Allows for patient/family to focus on the information as much as possible
Perception	Begin by asking the patient or family what their understanding is of the medical situation. Example: “What is your understanding of your medical situation thus far?”	Allows for providers to assess where the patient or family is in their comprehension of the medical events. Allows for assessment of any coping mechanisms, such as denial
Invitation	Ask the patient or family for invitations about sharing medical information. Example: “How would you like to hear information? Are you the type of person who likes to know all of the details or just an overview with more emphasis on our next steps?”; “Would it be ok if I shared an update on his kidney function?”	Allows the patient to have control over the meeting and may lessen anxiety
Knowledge	Share medical information in short chunks without use of medical jargon or many numbers. Provide warning shots before delivering bad news. Use silence. Check in with the patient or family frequently to ensure comprehension. Example: “Unfortunately, your (or your loved one’s) kidneys have not recovered the way we would have hoped, and it’s quite serious now. [pause] At this time, your kidneys have stopped working all together. If it’s ok with you, I would like to share some of the options we have to support you going forward.” Check-in statement: “I know this is a lot of information and often, doctors speak quite quickly; does everything make sense so far?”	Allows for the patient or family to absorb as much information as possible in a tempo controlled by them
Emotions	Respond to patient’s or family’s emotions with empathic support statements. Explore the emotion and validate its presence. Example: “I can see how upsetting this is to you.” “Would you be able to share what your biggest worry is at this time?” “I can assure you, many patients experience what you are going through.”	Aligns you with the patient or family and allows for pause points during the meetings to respond to emotions
Summarize and strategize	Provide a short summary statement at the end that describes the content of the meeting and presents the next steps. Example: “To summarize, we have just gone over the events related to your dad’s kidney function, and at this time, we have decided to initiate a TLT of CRRT on the basis of the goals we have discussed. We expect that we will have a good idea of response to therapy in about a week. We will update you daily and together, look for the clinical markers we spoke about. We will arrange for another meeting with as many of your providers as possible in a few days.”	Allows for a short summary of the meeting and increases the ability for the patient or family to absorb the decisions given the emotional nature of the events

TLT, time–limited trial; CRRT, continuous RRT.