This document discusses the importance of goals of care conversations between clinicians and seriously ill patients. Such conversations can help discover patient values and preferences to guide medical decisions. Studies found that patients who discussed end-of-life wishes with their doctors were more likely to accept their illness as terminal and want to know life expectancy. They also had less aggressive end-of-life care and their caregivers reported being better prepared and having less regret. The document emphasizes that communication is a learned skill and provides tips for clinicians to improve, such as setting intentions, pausing to reflect, and collecting lessons learned.

1. Communication in
Serious Illness:
Courageous Conversations to
Elicit Goals of Care
Anthony Back
University of Washington
Cambia Palliative Care Center of Excellence

2. start image

3. Goals of care

4. Not about selling hospice

5. Discovering values that
shape medical decisions

7. “Clinicians need to
initiate conversations…”

9. “frank…and explicit
discussion…”

10. Do ‘big picture’ conversations
matter?
• 332 patients identified prospectively
• Asked “Have you and your doctor
discussed any particular wishes about the
care you would want to receive if you were
dying?”
• Yes/no: compared re
– Distress/Depression p=NS
– Accepts illness as terminal OR 2.19
– Wants to know life expect OR 2.40
JAMA 300:1665, 2008

11. Outcomes correlated with a transition
conversation
• Medical care in last week of life
– ICU admission OR 0.35
– Ventilator use 0.26
– Resuscitation attempt 0.16
– Outpt hospice >1 wk 1.58
• Caregiver bereavement
– Better QOL p=0.001
– Felt prepared for death p=0.001
– Regret p>0.001
JAMA 300:1665, 2008

13. Close-­‐up
of
a
cri/cal
moment
• Excerpt
from
consult:
• “So
if
you
had
100
people,
the
survival
curve
drops
down
because
people
die
of
one
thing
or
another,
including
relapse.
That
tends
to
level
off
at
about
2.5
years
aGer
transplant
and
stays
level
aGer
that.
It’s
about
30%
in
your
situa/on”
• Pa/ent’s
pre-­‐visit
es/mate
of
cure:
90-­‐100%
• Pa/ent’s
post-­‐visit
es/mate
of
cure:
90-­‐100%
30

14. Strong
emo/ons
hijack
cogni/on
“AGer
he
said
the
30%,
he
just
kept
dinging
along
in
his
facts,
and
I
was
stunned.
Literally,
my
notetaking
was
completely
done.
All
I
wrote
was
30%
the
rest
of
the
/me
all
over
my
paper.
And
I
mean,
I
just
couldn’t
get
past
that
point.
I
don’t
know
how
to
describe
it”

15. Doctor
self-­‐rated
competence
Pa/ent-­‐rated
competence
Physician
self-­‐assessment:
imperfect

16. Communication is a
learned expertise

17. Our learning model
MODEL
PRACTICE
REFLECT

18. Scaffolding your learning
• Goal = what you’re trying to learn or get
better at. Set your intention every time.
• Time out = Pausing the action before too
much happens to remember.Take notes!
• Rewind & replay = Backing up to improve.
Go slow now to go fast later—
• Take home = crystallizes learning to
make it portable. Collect these!
18

19. ‘You don’t get benefits from
mechanical repetition, but by
adjusting your execution
over and over...’