Family meetings: an essential component of comprehensive palliative care.

Mrs S. is an 83-year-old woman with advanced dementia who lives with her daughter. At baseline, Mrs S. is communicative but confused, requires assistance for her activities of daily living, and has little interest in food. Her daughter tries to feed her a puréed diet that she has been following since her discharge from hospital 3 months ago after aspiration pneumonia. Over the past several weeks the daughter has noticed Mrs S. coughing after her meals. She has tried to keep her mother upright during meals and afterward, but the coughing persists and continues to worsen. Mrs S. has now developed a fever and increasing congestion, prompting her daughter to take her to the hospital. Mrs S. is again admitted with a diagnosis of aspiration pneumonia. She is instructed to ingest nothing by mouth, given intravenous hydration, and started on dual antibiotic therapy. After several days her fever resolves but she remains congested. Although she is more alert, she is still drowsier than her usual state. Repeat assessments by the speech-language pathologist (SLP) deem her to be at high risk of recurrent aspiration pneumonia. Her daughter is concerned about Mrs S.’s lack of oral intake and is asking about feeding options. Mrs S. is fairly new to your family practice. You first met her after her last admission 3 months ago for aspiration pneumonia. You recall the challenges you had in communicating with Mrs S.’s son and daughter during your first meeting when you attempted to discuss her advanced dementia and goals of care. You sensed that her children believed you were being overly pessimistic about the natural progression of her advanced dementia and that they were not ready to make any decisions about goals of care if their mother required readmission.