NR 527 Week 6 Family Meeting Summary Example

Family Meeting Summary: Mrs. B.'s Goals of Care After Two Transfers in a Month, Written for the Clinician Who Missed the Meeting and Must Act at 0300

Student Name

College of Nursing, Chamberlain University

NR 527: Communication and Collaboration for Advanced Nursing Practice

Instructor Name

Month Day, Year

Family Meeting Summary: Mrs. B.'s Goals of Care After Two Transfers in a Month, Written for the Clinician Who Missed the Meeting and Must Act at 0300

Who This Summary Is For

This summary records a family meeting held at our skilled nursing facility about Mrs. B., 86, who has moderate Alzheimer dementia and has been transferred to the emergency department twice in the past month, first after a fall and then for sepsis from a urinary infection. Its main reader is not anyone who attended. It is the night nurse, the covering physician or the weekend nurse practitioner who will be called about Mrs. B. two days or two weeks from now and needs to act from the page without phoning the family or the people who were in the room. Everything a clinician needs to follow the family's decisions is in the first two sections; the discussion that led there comes after.

Decisions and What to Do

Goals of care. The family's stated priority is Mrs. B.'s comfort and her ability to recognize them and enjoy meals, over prolonging life at any cost. They want treatment that can be given at the facility and want to avoid hospital transfers where possible.

POLST updated. Do not resuscitate; selective treatment. Changed from "limited additional interventions with hospital transfer if indicated" to "treat at the facility when possible; send out only if comfort cannot be achieved here or if an injury needs surgical repair, such as a hip fracture." Signed by her son as health care power of attorney and by me. The original is in the front of the chart.

If she develops a fever or signs of infection at night: assess, notify the covering clinician, obtain a urine specimen if urinary symptoms, and start treatment at the facility per the covering clinician's orders. Do not transfer for infection alone unless she cannot swallow medications and fluids by mouth and cannot be kept comfortable.

If she falls: assess for injury. Transfer if a fracture is suspected or if she has a head injury with new confusion beyond her baseline, because she takes apixaban. Otherwise treat at the facility.

Who to call. Her son, as power of attorney, for any change in condition or any transfer, day or night; he asked to be called even at night. His sister lives out of state and asked to be updated by her brother, not by staff.

This summary will be reviewed at the weekly interdisciplinary meeting, and any change to the plan will be written in the same place, so the next reader always finds the current version first.

Who Attended

Her son (health care power of attorney), her daughter by phone, the facility nurse practitioner, the social worker, the day charge nurse and the physical therapist. The meeting lasted 50 minutes.

What Was Discussed

I summarized the past month: two transfers, a five-day admission for sepsis, a near fall on the night of her return, less walking than before the infection, and about 3 kg of weight loss. The physical therapist described her current mobility: moderate assistance to stand and a few steps with a walker. I said plainly that her dementia was progressing, that infections and falls would likely recur, and that each hospital stay had left her weaker and more confused.

Her son said the second trip to the emergency department had frightened his mother badly; she did not know where she was for two days after returning. Her daughter asked whether treating infections at the facility would be "giving up." I explained that the facility can give oral antibiotics and fluids, check blood tests and monitor closely, and that choosing to treat here means choosing a different place for treatment, not withholding it. The social worker described how residents' families often feel guilt in making these choices, and the daughter said that helped. Both children agreed on the updated goals.

What the Family Asked For

They asked to be told honestly if her condition changed in a way that suggested she was nearing the end of her life, and they asked about hospice. We agreed that I would assess her for hospice eligibility at my visit next week and discuss it with her son. They asked that her favorite hymns be played in her room in the evenings, which the charge nurse has added to her care plan.

Points Still Uncertain

Two points were left open and should not be treated as settled. First, the family did not decide about intravenous fluids if Mrs. B. becomes unable to drink; her son wanted to think about it and talk with his sister. Until they decide, a covering clinician should call him before starting or declining intravenous fluids. Second, the family has not yet decided about hospice, and nothing in this summary should be read as a hospice decision. Recording these uncertainties is part of respecting the family's values and their pace, which the national interprofessional competencies place at the center of collaborative care (Interprofessional Education Collaborative, 2023). A summary that looked more decided than the family actually was would lead a night clinician to act on choices the family had not made.

The physical therapist also raised a concern the family did not share: that limiting walking to protect Mrs. B. from falls might speed her loss of strength. The team agreed to revisit this in two weeks with the family, weighing her safety against her enjoyment of walking to the dining room.

Follow-Up

Nurse practitioner visit next week, including hospice eligibility assessment. Physical therapy to continue three times weekly with the goal of safe transfers rather than longer walks. Dietitian to review weight and food preferences. Social worker to call the son in one week. The care team will review the plan at the next weekly interdisciplinary meeting.

Why This Summary Is Structured This Way

Quality improvement programs aimed at reducing avoidable transfers from nursing homes have included tools for advance care planning and for communicating about changes in condition, alongside tools for early recognition of illness (Ouslander et al., 2011). A goals-of-care decision only reduces unwanted transfers if the clinician on call at night can find it and act on it. Focus groups with nursing home and emergency staff have described transfers in both directions without documentation of residents' wishes (Terrell & Miller, 2006). That is why the decisions and actions appear at the top, written as instructions, rather than at the end of a narrative.

References

Interprofessional Education Collaborative. (2023). IPEC core competencies for interprofessional collaborative practice: Version 3. https://www.ipecollaborative.org/ipec-core-competencies

Ouslander, J. G., Lamb, G., Tappen, R., Herndon, L., Diaz, S., Roos, B. A., Grabowski, D. C., & Bonner, A. (2011). Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project. Journal of the American Geriatrics Society, 59(4), 745-753. https://doi.org/10.1111/j.1532-5415.2011.03333.x

Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7(8), 499-505. https://doi.org/10.1016/j.jamda.2006.03.004