Family Meetings Research Articles

Focused on the Family: Development of a Family-Based Intervention Promoting the Transition to Adult Health Care for Adolescents with Type 1 Diabetes

Background/Objectives: There is minimal evidence for current interventions promoting the transition to adult healthcare for youth with type 1 diabetes (T1D). Few interventions exclusively target modifiable individual and family-based factors that contribute to transition readiness. The purpose of this paper is to describe the development of Behavioral Family Systems Therapy for Diabetes Transition (BFST-DT), a virtual family-based transition readiness intervention for adolescents with T1D. Methods: The development of BFST-DT occurred in three phases. In phase 1, focus groups with adolescents and young adults with T1D, their caregivers, and pediatric and adult diabetes providers were conducted to assess perspectives on common family challenges surrounding diabetes management and the transition to adult healthcare. In phase 2, focus group data were used to create video vignettes to be used as part of the intervention. In phase 3, BFST-DT was created through the adaptation of a previous evidence-based family intervention for families of adolescents with T1D. Results: BFST-DT is a virtual, 6-month family-based intervention involving four multi-family group meetings and six individual family meetings. It targets the modifiable and reciprocal interactions among individual and family transition readiness factors. Conclusions: BFST-DT is the first family-focused intervention promoting transition readiness in adolescents with T1D and is currently being tested. Intervention development benefits from prioritization of engagement with patients, caregivers, and providers, as their perspectives are invaluable for creating interventions that are relevant and acceptable to communities.

Investigating stress, social support, and decisional conflict dynamics in surrogates of intensive care unit patients with cancer.

The purpose of this study is to examine fluctuations in stress, social support, and decisional conflict among surrogates during the admission and discharge phases of intensive care unit (ICU) patients with cancer. Additionally, this study seeks to identify the factors that influence changes in decisional conflict experienced by these surrogates. This study involved surrogates of ICU patients with cancer. Data were collected within three days of ICU admission and during the discharge phase. The study included 115 surrogates of ICU patients with cancer. Following ICU discharge, the surrogates experienced a significant reduction in mean stress levels (t = - 7.205; p < .001), improved family support (t = 3.748; p < .001), and decreased support from healthcare professionals (t = - 3.286; p = .001). Younger surrogates, high-stress levels in surrogates, and low social support from healthcare professionals were associated with high decisional conflict. Stepwise multiple regression analysis indicated that surrogates' age, changes in stress, and changes in healthcare professionals' support explained 5%, 8%, and 16% of the variation in changes in decisional conflict, respectively. To effectively reduce decisional conflict, particularly during the transition of patients with cancer from the ICU, a robust support system and comprehensive information on the treatment and prognosis of diseases in patients with cancer should be provided to younger surrogates. Healthcare professionals can facilitate family meetings and ensure comprehensive communication of the treatment plan. Practical guidance, social work assistance, timely clarification, and thorough information healthcare professionals provide can effectively mitigate decisional conflicts and enhance decision-making processes.

Shared Decision-Making Communication and Prognostic Misunderstanding in the ICU

Surrogate misunderstanding of patient survival prognosis in the intensive care unit (ICU) is associated with poor patient and surrogate outcomes. Shared decision-making (SDM) may reduce misunderstanding. To evaluate the association between SDM-aligned communication and prognostic misunderstanding. This retrospective cohort study was conducted at 13 medical and surgical ICUs at 5 hospitals in North Carolina, Pennsylvania, and Washington between December 2012 and January 2017. Participants were surrogates of adult patients receiving prolonged mechanical ventilation and ICU physicians. Analysis was performed May to November 2023. SDM-aligned communication during ICU family meetings, defined as the presence of high-quality serious illness communication behaviors aligned with SDM principles. The primary outcome was postmeeting surrogate prognostic misunderstanding, defined as the absolute difference between the physician's estimate of survival prognosis and the surrogate's perception of that estimate (range, 0-100 percentage points). The secondary outcome was postmeeting physician misunderstanding, defined as the absolute difference between a surrogate's estimate of survival prognosis and the physician's perception of that estimate (range, 0-100 percentage points). Prognostic misunderstanding of 20 percentage points or greater was considered clinically significant as in prior work. Of 137 surrogates, most were female (102 [74.5%]), and there were 22 (16.1%) Black surrogates, 107 (78.1%) White surrogates, and 8 surrogates (5.8%) with other race and ethnicity. Of 100 physicians, most were male (64 [64.0%]), with 11 (11.0%) Asian physicians, 4 (4.0%) Black physicians, and 75 (75.0%) White physicians. Median (IQR) surrogate prognostic misunderstanding declined significantly after family meetings (before: 22.0 [10.0 to 40.0] percentage points; after: 15.0 [5.0 to 34.0] percentage points; P = .002), but there was no significant change in median (IQR) physician prognostic misunderstanding (before: 12.0 [5.0 to 30.0] percentage points; after: 15.0 [5.0 to 29.0] percentage points; P = .99). In adjusted analyses, SDM-aligned communication was not associated with prognostic misunderstanding among surrogates or physicians (surrogates: β = -0.74; 95% CI, -1.81 to 0.32; P = .17; physicians: β = -0.51; 95% CI, -1.63 to 0.62; P = .38). In a prespecified subgroup analysis of 78 surrogates (56.9%) with clinically significant premeeting prognostic misunderstanding, SDM-aligned communication was associated with reduced surrogate postmeeting prognostic misunderstanding (β = -1.71; 95% CI, -3.09 to -0.34; P = .01). In this retrospective cohort study, SDM-aligned communication was not associated with changes in prognostic misunderstanding for all surrogates or physicians, but it was associated with reduced prognostic misunderstanding among surrogates with clinically significant misunderstanding at baseline.

A Quality Improvement Initiative to Implement Focused Family Meetings in the Surgical Intensive Care Unit: Does It Matter?

A Quality Improvement Initiative to Implement Focused Family Meetings in the Surgical Intensive Care Unit: Does It Matter?

An Authentic Learning Experience for Medical Students on Conducting a Family Meeting

An Authentic Learning Experience for Medical Students on Conducting a Family Meeting

Talking About Suffering in the Intensive Care Unit

Background Some have hypothesized that talk about suffering can be used by clinicians to motivate difficult decisions, especially to argue for reducing treatment at the end of life. We examined how talk about suffering is related to decision-making for critically ill patients, by evaluating transcripts of conversations between clinicians and patients’ families. Methods We conducted a secondary qualitative content analysis of audio-recorded family meetings from a multicenter trial conducted in the adult intensive care units of five hospitals from 2012–2017 to look at how the term “suffering” and its variants were used. A coding guide was developed by consensus-oriented discussion by four members of the research team. Two coders independently evaluated each transcript. We followed an inductive approach to data analysis in reviewing transcripts; findings were iteratively discussed among study authors until consensus on key themes was reached. Results Of 146 available transcripts, 34 (23%) contained the word “suffer” or “suffering” at least once, with 58 distinct uses. Clinicians contributed 62% of first uses. Among uses describing the suffering of persons, 57% (n = 24) were related to a decision, but only 42% (n = 10) of decision-relevant uses accompanied a proposal to limit treatment, and only half of treatment-limiting uses (n = 5) were initiated by clinicians. The target terms had a variety of implicit meanings, including poor prognosis, reduced functioning, pain, discomfort, low quality of life, and emotional distress. Suffering was frequently attributed to persons who were unconscious. Conclusions Our results did not support the claim that the term “suffering” and its variants are used primarily by clinicians to justify limiting treatment, and the terms were not commonly used in our sample when decisions were requested. Still, when these terms were used, they were often used in a decision-relevant fashion.

The Role of Structured Goals of Care Discussions in Critically Ill Thoracic Surgery Patients.

Objective: The American College of Surgeons recommends structured family meetings (FM) for high-risk surgical patients. We hypothesized that goals of care discussions (GOCD) in the form of an FM, multidisciplinary family meeting (MDFM), or palliative care consult (PCC) would be underutilized in imminently dying thoracic surgery patients. Methods: A retrospective chart review at a tertiary academic medical center was performed on all inpatient mortalities and discharges to hospice after any thoracic surgery operation. The utilization of GOCDs was compared between the 2 groups. Secondary outcomes were length-of-stay, comatose status and ventilator dependence during initial GOCD, and timing of code status change. Results: In total, 56 patients met inclusion criteria: 44 of 56 (78.6%) died and 12 of 56 (21.4%) were discharged to hospice. Most patients had a FM (79.5% mortality vs 100% hospice, P = .29) and few had an MDFM (25.0% mortality vs 25.0% hospice, P = 1.00). Patients discharged to hospice were more likely to have a PCC (66.7% vs 31.2%, P = .03) and less likely to be comatose (16.7% vs 59.1%, P = .009) or ventilator dependent during initial GOCD (16.7% vs 70.5%, P = .001). Among patients who died and were DNR-CC (do not resuscitate-comfort care; 37 of 44), 75.7% died the same day of code status change and 67.6% died within 48 h of initial GOCD. Discussion: Although FMs were common, MDFMs were infrequent. Patients discharged to hospice were more likely to have a PCC. Most deaths occurred shortly after initial GOCD and most code status changes occurred on day-of-death. This data suggest an opportunity to improve GOCDs in critically ill thoracic surgery patients.

Optimizing outcomes: Impact of palliative care consultation timing in the cardiovascular intensive care unit

BackgroundICU patients and their families experience significant stress due to illness severity and prognostic uncertainty, making palliative care (PC) integral for symptom management, family support, and end-of-life care goals. The impact of PC in the Cardiac Intensive Care Unit (CICU) remains unstudied. ObjectiveWe explore the impact of early palliative care consultation (PCC) on patient outcomes in the CICU, including mortality, length of stay, and family meeting frequency. MethodsThis retrospective study at MedStar Washington Hospital Center included 209 adult patients admitted to the CICU between December 2021 and June 2022 receiving PCC. We compared outcomes between those receiving early (<72 h) and late (>72 h) PCC, including mortality, length of stay, and family meeting frequency. Statistical analysis included Wilcoxon rank sum tests, Chi-squared tests, Fisher's exact test, and Poisson regression models. ResultsThe study included 209 patients admitted to the (M age = 68 years, SD = 14; 45 % female; 62 % Black, 30 % White) who received PCC, most (79 %) within 72 h. Early PCC was associated with shorter CICU stays (median, 3 vs. 5.5 days; p = 0.005). Early PCC patients had higher odds of family meetings (IRR=3.59; p < 0.001) and experienced a change in code status sooner (median 1 day vs. 3 days, p < 0.001). Late PCC patients were more likely to undergo tracheostomy (13.6% vs. 2.4 %; p = 0.007), cardioversion (9.1% vs. 1.8 %; p = 0.037), and have PEG tubes placed (13.6% vs. 2.4 %; p = 0.007). ConclusionsEarly PCC in the CICU is associated with shorter CICU stays, fewer procedures, and more frequent family meetings.

Caring for Families of Patients With Acquired Brain Injury Early During Hospitalization: A Feasibility Study of the SAFIR© Intervention.

This study aimed to assess the feasibility of a complex family nursing intervention (SAFIR©) designed to support families of patients with acquired brain injuries during the early phase of hospitalization, using a one-group pre- and post-test design with a one-month follow-up. Family members participated in four family meetings. Quantitative data were collected using an intervention protocol checklist and questionnaires. Qualitative data were gathered through semi-structured interviews, written open-ended questions, and note-taking. Feasibility outcomes revealed a family recruitment rate of 15.4% and a retention rate of 100%. Protocol adherence ranged from 94% in Phase 1 to 78% in Phase 3. Our results indicated that the intervention was meaningful and suitable for family members (n=7), healthcare provider (n=1), and nursing managers (n=6). From a sustainability perspective, our findings suggest the need to formally involve the entire inter-professional team in the intervention. Further evaluation of the intervention is warranted through a large-scale experimental.

Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study.

There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved. To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement. A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases. National recruitment (study phases 1 and 3); three English maternity services (study phase 2). We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families. The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced. Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups. We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research. This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (NIHR award ref: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.

Fast Facts and Concepts #485 Developing a Shared "Headline" before a Family Meeting.

Fast Facts and Concepts #485 Developing a Shared "Headline" before a Family Meeting.

Pilot Implementation of Guiando Buenas Decisiones, an Evidence-Based Parenting Program for Spanish-Speaking Families, in Pediatric Primary Care in a Large, U.S. Health System: A Qualitative Interview Study.

Adolescent substance use is a significant public health problem in the United States and Hispanic youth engage in substance use services at lower rates than other groups. For this under-served group, prevention services delivered in non-stigmatized, non-specialty care settings may increase access to the services. We describe findings from a feasibility pilot of the implementation of a virtual version of Guiando Buenas Decisiones (GBD), a universal, group-based substance use prevention program for parents. It was conducted with Spanish-speaking families and delivered, virtually, in pediatric primary care in a large healthcare system in the U.S. Through qualitative interviews with pediatricians (n =7) and parents (n = 26), we explored potential barriers and facilitators of GBD enrollment and engagement. Parents and pediatricians alike noted the dearth of universal prevention programming in Spanish and that GBD could help address the need for linguistically appropriate programming. Parents liked the curriculum content, materials and videos; they felt the focus on strengthening family bonds, setting clear expectations and guidelines, the use of family meetings, and the positive tools provided for navigating family conflict were well-aligned with their cultural and family values. Feedback from parents was helpful for informing more personalized and attentive approaches to program outreach and recruitment methods, and for adaptation of recruitment fliers and letters. In this pediatric primary care context serving an underserved population, we found virtual GBD feasible to implement, acceptable and appealing to parents, and judged by pediatricians as a promising, much-needed addition to their prevention armamentarium.

Factors Associated With Quality-of-Dying-and-Death Classes Among Critically Ill Patients

Improving end-of-life care in the intensive care unit (ICU) is a priority, but clinically modifiable factors of quality of dying and death (QODD) are seldom identified. To comprehensively identify factors associated with QODD classes of dying ICU patients, emphasizing clinically modifiable factors based on the integrative framework of factors associated with for bereavement outcomes. This observational cohort study was conducted at medical ICUs of 2 Taiwanese medical centers from January 2018 to March 2020 with follow-up through December 2022. Eligible participants included primary family surrogates responsible for decision making for critically ill ICU patients at high risk of death (Acute Physiology and Chronic Health Evaluation II score >20) but who survived more than 3 days after ICU admission. Data analysis was conducted from July to September 2023. QODD was measured by the 23-item ICU-QODD questionnaire. Factors associated with patient membership in 4 previously determined QODD classes (high, moderate, poor to uncertain, and worst) were examined using a 3-step approach for latent class modeling with the high QODD class as the reference category. A total of 309 family surrogates (mean [SD] age, 49.83 [12.55] years; 184 women [59.5%] and 125 men [40.5%]) were included in the study. Of all surrogates, 91 (29.4%) were the patients' spouse and 66 (53.7%) were the patients' adult child. Patient demographics were not associated with QODD class. Two family demographics (age and gender), relationship with the patient (spousal or adult-child), and length of ICU stay were associated with QODD classes. Patients of surrogates perceiving greater social support were less likely to be in the poor to uncertain (adjusted odds ratio [aOR], 0.89; 95% CI, 0.83-0.94) and worst (aOR, 0.92; 95% CI, 0.87-0.96) QODD classes. Family meetings were associated with the poor to uncertain QODD class (aOR, 8.61; 95% CI, 2.49-29.74) and worst QODD class (aOR, 7.28; 95% CI, 1.37-38.71). Death with cardiopulmonary resuscitation was associated with the worst QODD class (aOR, 7.51; 95% CI, 1.12-50.25). Family presence at patient death was uniformly negatively associated with the moderate QODD class (aOR, 0.16; 95% CI, 0.05-0.54), poor to uncertain QODD class (aOR, 0.21; 95% CI, 0.05-0.82), and worst QODD class (aOR, 0.08; 95% CI, 0.02-0.38). Higher family satisfaction with ICU care was negatively associated with the poor to uncertain QODD class (aOR, 0.93; 95% CI, 0.87-0.98) and worst QODD class (aOR, 0.86; 95% CI, 0.81-0.92). In this cohort study of critically ill patients and their family surrogates, modifiable end-of-life ICU-care characteristics played a more significant role in associations with patient QODD class than did immutable family demographics, preexisting family health conditions, patient demographics, and patient clinical characteristics, thereby illuminating actionable opportunities to improve end-of-life ICU care.

Dostoevsky in a Free Application: the Publishing Project of Adolf Marx in the Notebooks of Anna Dostoevskaya

The publication of the Complete Works of F. M. Dostoevsky became the main deed of his widow. Over the course of 10 years, book publication has been stable and profitable for the writer’s family. In 1893, the publisher of the weekly “Niva,” A. F. Marx, offered Anna Grigoryevna to sell him the literary rights to Dostoevsky’s works for printing them as a free supplement to his magazine. Dostoevskaya devoted a chapter of published memoirs to this transaction, but her unpublished notebooks contain additional information about both the external side of the agreement with Marx (lists, dates, notes) and the inner world of the publisher during this period (memories, experiences, doubts, comments). This article introduces into scientific circulation the materials of A. G. Dostoevskaya’s notebooks about family meetings about the sale of literary rights, details and curious stories related to the signing of an agreement with Marx. Ultimately, the deal with Marx was not as profitable as it seemed at first. It divided the publishing activities of the writer’s widow into “before” and “after” the contract: the time after the return of copyright was marked by a sharp decline in demand for Dostoevsky’s works due to the surplus of the Complete works of the Marx publishing house on the book market. The contract with “Niva’s” publisher turned out to be one of the essential circumstances in the process of termination of A. G. Dostoevskaya’s publishing activities in 1910. Despite the adverse consequences of the deal with Marx for the Dostoevsky family's book business, the writer’s widow remained friendly with “Niva’s” publisher, as evidenced by the documents provided in the article: her letter to him about the donation and publication of three letters from Dostoevsky to his brother Mikhail, as well as the mentions of the name of Marx and his publications in notebooks.

Enhancing Educational Quality through Principals' Human Resources Management Strategies

This article investigates the principal's strategies for enhancing the quality of education through human resource management at MTs Al Anwar Sarang. The school faces several challenges, including teacher discipline, the mismatch between academic qualifications and teaching assignments, and the mastery of learning methods and media. A qualitative research method was employed, involving in-depth interviews to gather data on the strategies used by the school principal to improve education quality. Interviewees included principals, educators, education personnel, and other relevant parties. The data were analyzed using data condensation techniques as described by Miles and Huberman, followed by presentation and conclusion drawing. The study revealed that the principal implemented several effective strategies. These included granting educators the freedom to develop professionally, providing motivation and support, delegating training responsibilities, and involving resource persons. Additional support was given through adequate facilities, sufficient time, family meetings, and rewards. These strategies led to improvements in individual skills and fostered a dynamic, collaborative, and reward-focused school environment. Specifically, they enhanced educator discipline, improved the quality of teaching, and bolstered mastery of learning methods and media. The findings suggest that the principal’s policies, which promote autonomy and professional development, significantly contribute to educational improvements. Furthermore, the strategies created a positive atmosphere and a solid community of educators, supporting sustainable growth for the entire educational team. This study provides valuable insights for educators, policymakers, and researchers into how strategic human resource management can enhance education quality. The pragmatic framework introduced here demonstrates how school principals can effectively guide human resource management to achieve significant educational improvements.

Clinicians' Use of Choice Framing in ICU Family Meetings.

To quantify the frequency and patterns of clinicians' use of choice frames when discussing preference-sensitive care with surrogate decision-makers in the ICU. Secondary sequential content analysis. One hundred one audio-recorded and transcribed conferences between surrogates and clinicians of incapacitated, critically ill adults from a prospective, multicenter cohort study. Surrogate decision-makers and clinicians. None. Four coders identified preference-sensitive decision episodes addressed in the meetings, including topics such as mechanical ventilation, renal replacement, and overall goals of care. Prior critical care literature provided specific topics identified as preference-sensitive specific to the critical care context. Coders then examined each decision episode for the types of choice frames used by clinicians. The choice frames were selected a priori based on decision science literature. In total, there were 202 decision episodes across the 101 transcripts, with 20.3% of the decision episodes discussing mechanical ventilation, 19.3% overall goals of care, 14.4% renal replacement therapy, 14.4% post-discharge care (i.e., discharge location such as a skilled nursing facility), and the remaining 32.1% other topics. Clinicians used default framing, in which an option is presented that will be carried out if another option is not actively chosen, more frequently than any other choice frame (127 or 62.9% of decision episodes). Clinicians presented a polar interrogative, or a "yes or no question" to accept or reject a specific care choice, in 43 (21.3%) decision episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation. Clinicians frequently use default framing and polar questions when discussing preference-sensitive choices with surrogate decision-makers, which are known to be powerful nudges. Future work should focus on designing interventions promoting the informed use of these and the other most common choice frames used by practicing clinicians.

Pre-post-evaluation of a dementia-specific advance care planning toolkit for Japanese primary care clinicians.

The population of people living with dementia (PLwD) continues to grow in Japan where advance care planning (ACP) for PLwD is relatively new. Our aim was to evaluate the feasibility and cultural acceptability of a dementia-specific ACP communication skills toolkit for Japanese primary care clinicians. We delivered 13 training sessions in primary care clinics across central Japan and conducted a post-training survey to assess whether the toolkit increased confidence in dementia-specific ACP communication skills and the acceptability of the toolkit with the following four statements: (1) The language in the sessions was clear, (2) The sessions took an appropriate amount of time to complete, (3) The design of the sessions was an effective educational method, and (4) The sessions were culturally appropriate for communication with Japanese patients with dementia and their family members. We asked participants to respond using a 5-point Likert scale from strongly agree to strongly disagree. All participants were Japanese and included 80 physicians (mean age 39.8 years), 33 nurses (mean age 45.7 years), and 58 other participants (mean age 42.9 years), who were 30.0%, 87.9%, and 55.2% female, respectively. Most participants practiced in rural settings. In pre- post-comparisons, participant confidence increased in determining capacity, understanding dementia prognosis, goals of care, eliciting surrogates, recommending self-care practices to families, and leading family meetings (all p < 0.001). Most participants strongly agreed or agreed that the toolkit was an effective method (96.9%), took an appropriate amount of time (94.5%), contained clear language (89.8%), and was culturally appropriate (73.6%). Dementia-specific ACP communication skills toolkit can be delivered in Japan. Japanese primary care clinicians generally felt the dementia-specific ACP toolkit increased their confidence in ACP communication skills and was acceptable. The language, time, and design were well received, though further work is needed to improve the cultural appropriateness of the toolkit.

Multiple Goals Theory and Communication Quality Analysis for Fellows Communication Training.

End-of-life communication skills are vital to high-quality critical care. Patients and families often report deficiencies in end-of-life communication by providers. However, formalized training is difficult to implement and study on a large scale. Furthermore, curricula are often designed with early-stage clinical trainees in mind and are not tailored to advanced clinician learners. The goal of this pilot study was to explore educational and practical implications of using Multiple Goals Theory (MGT), Communication Quality Analysis (CQA), and communication logs as a three-pronged, reflective communication curriculum for advanced trainees. We describe design and qualitative evaluation of a novel, pilot, longitudinal curricular intervention for pulmonary and critical care fellows and program directors at a tertiary academic medical center. The 2-year longitudinal communication curriculum incorporates 1) a theoretical framework from communication science (MGT), with 2) a novel training modality of analyzing audio-recorded intensive care unit family meetings (CQA), and 3) written communication logs after an intensive care unit family meeting. The sample included 13 pulmonary and critical care medicine fellows and two program directors. Qualitative thematic analysis was conducted on seven fellow interviews and on 23 communication logs completed. Four themes emerged from interviews: 1) fellows incorporated the skills into real-life practice and found the curriculum useful and valuable; 2) a key takeaway from MGT was the deemphasis of task goals; 3) CQA was an engaging opportunity for self-reflection and learning; and 4) written communication logs were perceived as helpful in theory but too burdensome in practice. Findings from analyses of the communication logs included that most fellows' writing was brief and without substantial reflection. Many scholars have argued that communication theory can impact practice, but few have recognized the potential of theory and methods, such as MGT and CQA, as educational tools. Our findings demonstrate that MGT is a feasible and useful theoretical framework for improving communication skills among advanced trainees, and CQA fosters meaningful self-reflection about practice. Communication logs were not feasible or useful training tools in this context, but CQA workshops helped fulfill the goals of narrative reflection. Next steps are to implement this curriculum in more programs and measure changes in behavior acquisition and clinical care.

A Pediatric Interprofessional Cardiac Intensive Care Unit Intervention: CICU Teams and Loved Ones Communicating (CICU TALC) is Feasible, Acceptable, and Improves Clinician Communication Behaviors in Family Meetings.

Parents of children in the pediatric cardiac intensive care unit (CICU) are often unprepared for family meetings (FM). Clinicians often do not follow best practices for communicating with families, adding to distress. An interprofessional team intervention for FM is feasible, acceptable, and positively impacts family preparation and conduct of FM in the CICU. We implemented a family- and team-support intervention for conducting FM and conducted a pretest-posttest study with parents of patients selected for a FM and clinicians. We measured feasibility, fidelity to intervention protocol, and parent acceptability via questionnaire and semi-structured interviews. Clinician behavior in meetings was assessed through semantic content analyses of meeting transcripts tracking elicitation of parental concerns, questions asked of parents, and responses to parental empathic opportunities. Logistic and ordinal logistic regression assessed intervention impact on clinician communication behaviors in meetings comparing pre- and post-intervention data. Sixty parents (95% of approached) were enrolled, with collection of 97% FM and 98% questionnaire data. We accomplished > 85% fidelity to intervention protocol. Most parents (80%) said the preparation worksheet had the right amount of information and felt positive about families receiving this worksheet. Clinicians were more likely to elicit parental concerns (adjusted odds ratio = 3.42; 95%CI [1.13, 11.0]) in post-intervention FM. There were no significant differences in remaining measures. Implementing an interprofessional team intervention to improve family preparation and conduct of FM is locally feasible, acceptable, and changes clinician behaviors. Future research should assess broader impact of training on clinicians, patients, and families.

Effects of Family Culture and Marital Decisions of the Business Owners on Access to Financing of Very Small Businesses

Purpose: This study seeks to examine the effects of family culture (presence during family meetings, assistance in important family events, and strong family bonds) as well as marital decisions (mutual participation, joint savings decisions, and joint ventures) on access to financing of very small businesses in the North West Region of Cameroon. Methods: The study used a series of exogenous and control variables adapted from the model of Gikonyo, Agwata, &amp; Anyango (2011) who proposed a strategic model for quantitative research. Primary data were collected through convenient sampling from 293 very small business owners in each divisional headquarters of the North West Region of Cameroon. We used the multiple correspondence analysis to construct indexes for family culture, marital decisions as well as access to financing of very small businesses. The hypotheses of the study were then tested using the ordinary least square estimation technique. Results: The results obtained showed in aggregate, a positive and significant effect of family culture and marital decisions on access to financing. More precisely, the coefficients of presence during family meetings, assistance in important family events as well as strong family bonds are positive. These results were statistically significant at 1% level. Implications: This study has significant practical implications on the financial health of very small businesses in the context of developing countries like Cameroon in general and the North West Region of Cameroon in particular plagued by the crisis and COVID-19. The study therefore concluded that if very small business owners can improve on the respect of family cultures and can jointly decide on their financial actions with their spouses, they will have better access to financing, especially in developing countries like Cameroon and more particularly in the North West Region of the country.