• Agree on what medical recommendations should be made
• Agree on the team’s objective for the family meeting
• Nominate a lead spokesperson
• Decide which clinical staff should be present (try to minimise the number who attend)

It is crucial that treating teams have a discussion before meeting with the family.
This ensures there is agreement between the professionals regarding the appropriate management of the child.

These discussions can be complex, as staff from different disciplines such as medical, nursing, social work, psychology, and physiotherapy might have very different perspectives and knowledge of the family, particularly if the child’s condition has changed rapidly.

The primary objective of the pre-meeting is to reach agreement about what recommendations should be made to the family so that mixed messages are not given. It can be confusing for families to hear clinicians ‘think out loud’ about various treatments during a family meeting.

At the pre-meeting, participants should share their impressions of the child’s condition and trajectory, and their understanding of the family’s views and concerns.

It is useful for one member to offer a verbal synthesis of the information gathered, and to obtain an agreed overall view of the child’s current health status. This will often lead to an understanding of the appropriate goals of care for the child. These should be verbally summarised to ensure all team members are in agreement.

It is also useful to revisit what discussions have already taken place, and what is already known about the family’s thoughts and priorities. If an advance care planning agreement has already been reached, you may only need to reaffirm the family’s previously stated wishes.

The discussion should include what interventions are possible and what the benefits and burdens of each of these are. The teams should reach a clear consensus about what interventions should be offered to the family.

It is important not to present unrealistic or inappropriate interventions as a choice for the family to make. If for example, resuscitation would be ineffective at this point in the illness, this should be gently explained to the family, not framed as a decision.

Things you can say:

‘Given our discussion of this child’s trajectory, what would we achieve for them by inserting a vagal nerve stimulator?’

‘If we were to intubate this child, what are the likely outcomes?’

‘It seems to me that we all agree that further aggressive chemotherapy would be very unlikely to prolong this child’s life and would be highly likely to cause significant suffering. I think we should explain to the family that, for these reasons, it is not an option.’

The treating team should decide which clinician will lead the discussion with the family. Ideally, this should be the clinician with the most rapport, trust or experience with the family. It is not necessary or even helpful, for the entire treating team to be represented in the family meeting, although if there are likely to be concerns around a particular issue it can be useful to have an expert in that issue available to answer questions.

The bedside nurse is an important person to include, as the family will return to their care immediately after the meeting.

Make sure you carefully consider who needs to attend the meeting, and try to minimise the number of health professionals as this can be intimidating for the family.

The team leading the discussion should set an objective for the meeting that reflects the urgency of the situation. Advance care planning is a process not an event and frequently takes a number of discussions to complete.

Examples of objectives for family meetings include:

• introduce the concept of advance care planning in simple terms
• inform the family about the team’s increasing concerns about the child’s condition
• explore the family’s preferences around goals, fears, values and place of care
• discuss the benefits and burdens of various interventions, and the best way to care for the child given their clinical situation
• address conflict within the family
• develop a plan for care.