In this post I link to and excerpt from CoreIM’s post and podcast, Inpatient Goals of Care Conversations with COVID19
Posted: April 22, 2020
By: Dr. Amrapali Maitra, Dr. Andrew Lawton, Dr. Shunichi Nakagawa and Dr. Shreya P. Trivedi
Graphic: Kabao Vang
Audio: Harit Shah
Note to myself: This CoreIM podcast is, like all of their work, outstanding. The show notes beautifully summarize the podcast. However, the podcast and accompanying transcript, are great for reviewing in the car (podcast) or at home or office (transcript) to get all the nuances.
These are direct links to the episode’s post:
And here are excerpts:
Time Stamps
- 05:54 Laying the groundwork
- 09:00 Asking permission, eliciting values and making a recommendation
- 16:00 When a patient is dying
- 16:48 Sharing the prognosis first
- 20:35 Functional status post-CPR
- 21:54 Headline statement
- 23:57 Virtual and PPE Communication Challenges
- 25:36 Separate process from outcome
Here are excerpts:
Prior to conversation
- Identify patient’s healthcare proxy immediately upon admission
- Ask how patients wish to receive information (e.g. directly or via proxy)
- Ensure patients have means to connect with families (phone chargers, iPad, etc.)
1st Type of Conversation: Laying the groundwork – similar to breaking bad news
- Elicit patient or loved one’s understanding of illness
- “What have you been told so far about your illness?”
- “I know things have changed quickly. Tell me what you’ve heard more recently.”
- Share clinician’s hopes and concerns
- Use language of “hope” and “worry”
- “I hope our treatments will make you better and I worry that you might get sicker from this infection.”
- Expect and respond to the emotion that arises
- “I can imagine this is scary to think about. I wish things were different.”
2nd Type of Conversation: Heart of Goals of Care
- Ask permission to explore goals
- “I wonder if we could spend a little time thinking about the possibility of you getting sicker?”
- Clarify goals with specifically framed open-ended questions
- “If time were short, are there things you would be particularly worried about?”
- “If you were getting sicker, what are some of the things that would be important to you?”
- “Are there any conditions you would find unacceptable or worse than death?”
- “What would you [or your loved one] be willing to go through for the possibility of more time?” (adapted from Serious illness Conversation guide)
- Giving examples can be helpful if patients provide abstract responses:
- “Some patients tell me that if they were getting sicker, they would want to make sure they weren’t struggling to breathe, etc. Do any of these resonate with you?”
- These questions to “map” goals and values can just feel like good doctoring but they also provide key data to ultimately make a recommendation.
- Make a recommendation
- Summarize what you have heard
- First, recommend what treatment options should be continued. Then state what treatment options may not be recommended (ie. the more aggressive interventions) based on the patient’s values.
- Refrain from language of “There’s nothing more we can do,” which sounds like giving up. Instead focus on what we can do, for breathing, comfort, pain, etc.
- Use contingency planning in situations where patient or family has not yet decided or if there are rapid clinical changes: “Based on what you’ve told me, it would be reasonable, if you were to get sicker, to try a breathing tube and go to the ICU. And if it wasn’t working, if it didn’t seem like you were getting better, could we think about that?”
3rd Type of Conversation: When patient is dying
- Give clear update: “Your mom may be dying very soon”
- Expect emotion after that
- Express ongoing commitment to being there with loved one, especially as patient may be alone during COVID: “We’re going to be right here with her.”
COVID-specific Considerations
- Consider Dr. Nakagawa’s approach of sharing the prognosis first, then exploring goals, then making recommendation, especially when time is short
- There is a tension with too much autonomy and too much paternalism.
- Instead of presenting GOC as a menu for patients to choose, ideally we want shared-decision making
- Prognosis in COVID can be framed related to functional status post-CPR
- Give a “headline:” statement of the one message you want patient or family to remember later
- Communication challenges
- Virtual communication
- Validate loved one’s distance from hospital, how hard this is
- Pause frequently and check in to see how conversation is landing
- PPE communication challenges
- Maintain eye contact, consider holding hands, speak loudly through respirators
- Separate process from outcome of goals care conversation
- Easy to feel disheartened after the best conversation if the patient and family do not choose your recommendation. But our job is not to convince.
- Reflect on what went well after a conversation. Have self-compassion!
Parting thoughts
- Communication is a skill like any procedure that requires practice and reflection
- At the same time, we have to practice self-care, lean on support networks for debriefing
