- Determine the legal decision maker. If the patient is unable to make decisions, identify the appropriate proxy/surrogate. Review any completed advance directives (eg, health care proxy, POLST form).
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- Explain the prognosis. Discuss the "big picture." Be clear; avoid vague language. If the condition is incurable, say so.
- Frame the discussion as "hoping for the best while preparing for the worst."
- Answer 2 key questions: What is wrong with the patient? What will happen?
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- Elicit patient values. Engage the patient or surrogate with open-ended questions:
- "What is most important to you in your (or your loved one's) life right now?"
- "What kind of results are you hoping for?"
- "What do you hope to avoid at all costs?"
- If appropriate: "Have you been with someone who had a particularly good death or a particularly bad death? Tell me about it."
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- Use appropriate language.
- Avoid negative statements, such as: "Do you want us to withhold aggressive treatment?"
- Frame the discussion positively:
- "We want to ensure that you receive the kind of treatment you want."
- "Let us discuss how we can work towards your wish to..." (eg, stay at home).
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- Reconcile the goals of care.
Sometimes a "time-limited trial" of therapy is needed to help the patient and family cope with circumstances or reach a consensus about goals.
If so: - Outline the proposed treatment plan clearly.
- State the goals that you are hoping to achieve with the plan.
- Clarify how you will determine that these goals are being met.
- Establish a period of time for determining if the intervention works and is consistent with goals of care.
Clinicians may need to set limits on unrealistic goals without making the patient feel abandoned: "I understand your goal is not to be a burden to your family and you want an assisted death. Unfortunately, I cannot do that. However, I can help you manage distressing symptoms, and I can find ways to help you not be a burden." |
- Recommend a care plan based on the patient's goals.
- Summarize the patient goal (eg, "From what I understand, your goal is to...")
- Outline the plan (eg, "In order to meet this goal, we can...")
- Be specific whenever possible ("I would/would not recommend...")
- Discuss discontinuing interventions and therapies that will not help meet the patient's goals.
- Diagnostic, treatment, and disposition plans are best formulated and discussed with the patient's goals of care in mind.
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