Communication About Serious Illness Care Goals

Abstract

ffective communication plays a major role in facilitating adaptation to illness realities, appropriate decision making, and quality of life 1,2 throughout the trajectory of a serious illness. As patients approach the end of life, communication about goals of care and planning is a key element in helping assure that patients receive the care they want, in alleviating anxiety, and in supporting families. [3][4][5] Effective communication supports, not only endof-life care, but quality of life throughout the illness trajectory, even if death is not an imminent outcome.In this review, we evaluate current practices in communication about serious illness, their effects on patients, and factors that may influence these practices; we conclude by identifying best practices in communication about goals of care in serious illness, primarily in the ambulatory setting. On the basis of this assessment, we propose a systematic approach, informed by evidence, to help assure that each seriously ill patient has a personalized serious illness treatment plan. The most common clinical conditions relevant to this discussion include cancer, congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease and/or end-stage renal disease. This work was undertaken as part of the American College of Physicians (ACP) High Value Care Initiative and subsequently endorsed by the High Value Task Force of the ACP. MethodsWe conducted a narrative review of evidence about advance care planning and end-of-life communication practices to provide clinicians with practical, evidence-based advice. Both observational and intervention studies were included, as well as indirect evidence from high-quality studies of palliative care specialist interventions that address the impact of communication about serious illness care planning on outcomes. We use the term serious illness care goals to include discussions about goals of care, advance care planning, and end-of-life discussions for patients with serious illness to emphasize the targeted population and the potential impact on these discussions, not just for the very end of life but for care throughout the course of serious illness. In citing specific studies, we use the terms (eg, end-of-life care) used by the authors (see eMethods in the Supplement for a detailed description of methodology). For a summary of the ACP High Value Care Advice, see Box 1.An understanding of patients' care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress. However, conversations about care goals are often conducted by physicians who do no...

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“…Dunlay & Strand (2016) created a framework for conducting goals of care discussions that consisted of: 1) reviewing previous discussions, 2) assessing patient willingness and preferred role, 3) discussing prognosis and anticipated outcomes, 4) asking patient values, goals, fears, 5) discussing unacceptable health states, 6) discussing life sustaining preferences, 7) summarizing and make a plan, 8) complete/updating advanced directives and document conversations in electronic medical record. This framework also highlights the use of communication strategies used to understand patient perception, allow for sharing of information, and responding in an empathetic manner.…”

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