This document discusses care conferences and goals-of-care discussions. It provides guidance on organizing and conducting care conferences, including introducing participants, explaining what is happening with the patient's condition, empathizing with family members, highlighting the patient's voice, and planning next steps. The document emphasizes listening to understand different perspectives, acknowledging emotions, and having follow-up conversations to improve outcomes for the patient.

1. 1
Care Conferences: The
Procedure of Goals-of-Care
Michael Aref MD, PhD, MBE, FACP, FHM, FAAHPM, HMDC, HEC-C
Assistant Medical Director of Palliative Medicine

2. 2
I
DISCLOSURES

3. 3
Disclosures
• I have no relevant financial disclosures

4. 4
II
OBJECTIVES

5. 5
Objectives
• Discuss opportunities and barriers for care
conferences.
• Understand the mechanisms on and skills needed
in a care conference.

6. 6
III
CARE CONFERENCES

7. 7
Stages of Organizing a Care Conference
Denial – “I have already explained
everything to the patient and they
understand it all.”
Bargaining – “Let’s hold off on the family
meeting and wait for dermatology’s input.”
Anger – “I didn’t get into medicine
to…talk…to people!!!”
Sadness – “*sob* This is going to take
forever. *sniff*”
Acceptance – “I
will be there 15
minutes early!”

8. 8
It’s not enough to hear, you must listen
“All right now, remember.
A war is mostly run. We
run whether we are
defending or attacking. If
you can’t run in a war
then it’s already over.”
—Shichiroji, Seven
Samurai
“All right now, remember.
A conversation is mostly
listening. We listen
whether we are observing
or speaking. If you can’t
listen in a conversation
then it’s already over.”
—Mike Aref

9. 9
Is the conversation necessary?
• Higher and better use.
– Will the time spent improve the situation?
• Good. Enough. Now.
– Potential versus capacity
• Stop the conversation you already had.

10. 10
Talk Early Talk Often
• Criteria for goals-of-care is a clinical change:
– New diagnosis.
– Decrease in functional status (Assisted Living, ECF).
– In/after emergency department visit.
– On admission to the floor or ICU.
– If maximizing non-invasive oxygen support or
intubation.
– Evidence of new system failure.

11. 11
Trajectories
Increased Morbidity
Increased Mortality
Hospitalizaton
Decreased Morbidity
Decreased Mortality
Increased Functional
Status
Discharge
Hospital Dependent Patients
Patients with Acute Curable Illness
Actively Dying Patients
Patients with “competing” comorbidities

12. 12
Decisional Capacity
• Ability of a patient to
understand the risks and
benefits of, and
alternatives to, a
proposed treatment or
intervention.
o Understanding
o Expressing a choice
o Appreciation
o Reasoning

13. 13
Definitions
• Care Conference
– A prearranged meeting between the patient, their surrogate, and providers that should occur when a
crucial decision for diagnosis, prognosis, and treatment is needed to direct care, but complex clinical or
psychosocial situations exist. A care conference requires the primary service, at least one specialty
provider, and should also include everyone who has valuable input or will use information directly
obtained in the meeting to further care including nursing staff, case management, social work, therapy,
and dietitian service.
• Family Meeting
– A meeting between a provider, the patient, their proxy, and additional family as appropriate to educate
and inform regarding the patient’s diagnosis, prognosis, and treatment.
• Team Meeting
– A prearranged meeting between a patients providers to discuss perspectives on diagnosis, prognosis,
and treatment to determine the optimal clinical options to offer the patient. A team meeting requires
the primary service, at least one specialty provider, and should also include every clinical team member
who has valuable input or will use information directly obtained in the meeting to further care including
nursing staff, case management, social work, therapy, and dietitian service.

14. 14
Success
• A successful care conference, family meeting, or team
meeting will show a change in clinical inertia within 36
hours of the meeting. A change in clinical inertia is
exemplified by: change in code status, additional specialist
opinions, marked changes in medication management, new
procedural or surgical interventions, and/or a clear
roadmap to disposition. The conferences also serves to
clarify clinical expectations for some patients. These
conferences often reset expectations or help determine
disposition if they are waiting for placement.

15. 15
Epic: Care Conference Request

16. 16
Physically: Care Conference Request
• Contact requested parties for the care conference
either in person, by pager, or by Voalte.

17. 17
Care Conference Talking Map
Step What you can say
Gather for a pre-meeting “Let’s decide who will talk about what.”
“Could I propose a way to structure the meeting?”
“When the meeting ends, what would be a constructive outcome?”
Introduce everyone and the agenda “Let’s start with introductions. My name is [x], and my role is [y].”
“The purpose of this meeting is to talk about [z].”
“Is there anything that you would like to cover in addition?”
Explain what’s happening “Tell me what you took away from our last conversation.”
“Could I hear from everybody?”
“Here is the most important piece of news.”
Empathize with each person “I can see you are concerned about [a].”
“I am impressed that you have been here to support [patient’s name].”
Highlight the patient’s voice “If [patient’s name] could speak, what do you think she would say?”
“How would she talk about what is important to her?”
Plan the next steps together “Based on what we’ve talked about, could I make a recommendation?”
“I’d like to hear everyone’s thoughts about the plan.”
Reflect post-meeting “What did we learn?”
vitaltalk.org

18. 18
Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

19. 19
Your Behavior
– Dan Millman

20. 20
Pre-Meeting
• If you do this right, someone is going to need a tissue.
• Where is the meeting taking place and is the patient
participating?
• Is the meeting place clear of distractions and can everyone
sit down?
• What are the desired outcomes?
• Who is going to moderate the meeting?
• What is each person’s clinical communication
responsibility?

21. 21
Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

22. 22
An AIDET Application
• Acknowledge
– “Nice to meet you.”
– “Great to see you again.”
– Not: “You look great” (the patient might not feel great!)
• Introduce
– “Let’s go around the room so everyone knows who is who. My name is [x], and my role is
[y].
• Duration
– “We have about 30 minutes to talk today as a group. I would be happy to spend more time
with you afterward if needed.”
• Explanation
– “The purpose of this meeting is to talk about [z].”
• Thank You
– “Thank you all for taking the time to meet today.”

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Sitting in the Right Setting
Actual and patient perceived time of provider at
bedside
1.04 1.28
5.14
3.44
0
1
2
3
4
5
6
Sit Stand
Actual
Time (min)
Perceived
Time (min)
Percentage of positive and negative comments by
provider posture
95%
61%
5%
39%
0%
20%
40%
60%
80%
100%
Sit (n = 20) Stand (n = 18)
K.J. Swayden et al./ Patient Education and Counseling 86 (2012) 166–171

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Impact of Physician Sitting Versus Standing
• 69 patient randomized to watch one of two videos
in which physician was standing then sitting or
sitting than standing:
– 51% preferred the sitting physician
– 23% standing
– 26% no difference
J of Pain and Symp Management 2005; Vol 29 (5). 489-497

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Agenda Setting
Step What you say
Ask about your patient’s
main concerns for the visit
“What are the important questions you wanted answered today?”
“Is there anything you wanted to ask your physicians about?”
“Do you have anything to put on our agenda?”
“Anything else?” (often the most important issue is not first)
Explain your agenda “There are two things I wanted to make sure we talked about…”
Propose an agenda that
combines the patient’s and
your concerns
“How about if we talk about your question first, then cover my two things?”
or
“Given these things, what is most important for you to cover?”
Be prepared to negotiate.
“Ok, I understand that the most important issue for you today is ___.”
“I hear that you have a number of questions. Could we prioritize them so that we cover
the most important ones if we don’t have time to get through all of them?”
Ask for feedback “Do you feel like we’ve covered the agenda? How did we do?”
vitaltalk.org/guides/first-visit/

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Cognition
– Spock

28. 28
Teach-Back
A Priori A Posteriori
• Patient has seen a specialist or
been referred from another
physician.
• Minimum: Review documentation.
Ideally speak with other physician.
• “To make sure I provide you with
the best care, it helps me to
understand if you can tell me, in
your own words, what Dr. X, the
[specialty] doctor, explained to
you.”
• You are finishing your visit and
want to assess that the patient has
increased understanding of the
clinic situation.
• “We talked about a lot today and
sometimes I can get a little
technical. For my benefit, if you
were to explain the most important
points of today’s visit to your
family, what would you tell them?”
JBI Database System Rev Implement Rep. 2016 Jan;14(1):210-47

29. 29
Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

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Emotion
– Maj General James Mattis, retired

31. 31
Your Emotion: Fear
F.E.A.R.
• False Expectations Appearing Real
F.E.A.R.
• Failure Expected Action Required

32. 32
V.A.L.U.E.
• Value family statements
• Acknowledge family emotions
• Listen to the family
• Understand the patient as a person
• Elicit family questions
Chest. 2008 Oct; 134(4): 835–843

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Expect Emotion and Empathize
Tool Example Notes
Naming (1) “It sounds/looks like
you are scared / sad /
frustrated”
Naming the emotion will
usually decrease the
intensity of emotion
Understandi
ng (<5)
“This helps me
understand what you
are thinking”
Use to convey
acknowledgement while
avoiding implications
that you understand
“everything”
Respecting
(1-2)
“I can see you have
really been trying to
follow our
instructions”
Give the patient/family
credit for what they have
done, praise is a
motivator
Supporting
(1-2)
“I will do my best to
make sure you have
what you need”
Commit 100% of what
you can commit to
without committing to
things beyond your
control
Exploring
(∞)
“Could you say more
about what you mean
when you say that…”
Open-beginning
statement with a
focused end
• Eye contact
• Muscle of facial
expression
• Posture
• Affect
• Tone of voice
• Hearing the whole patient
• Your response
www.vitaltalk.org/sites/default/files/quick-guides/NURSEforVitaltalkV1.0.pdf
Academic Medicine 2014;vol 89 (8): 1108-1112

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Four Basic Human Emotions
Happy
Sad
Scared Angry
J Exp Psychol Gen. 2016 Jun;145(6):708-30

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Silence
Type of Silence Clinician Intent
Awkward Often without clear intention (uncertainty), but also may reflect distractedness
or hostility, often masked by the clinician.
Invitational Wanting to give the patient a moment (or longer) to think about or feel what is
happening, often after an empathic response. The clinician deliberately creates
a silence meant to convey empathy, allow a patient time to think or feel, or to
invite the patient into the conversation in some way.
Compassionate Recognizing a spontaneous moment (or longer) of silence that has emerged in
the conversation, often when the clinician and patient share a feeling or the
clinician is actively generating a sense of compassion for the patient. The
clinician must:
• Give attention
• Maintain stable focus
• Have clarity of perception
J Palliat Med. 2009 Dec;12(12):1113-7.

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Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

37. 37
Identify Commonly Missed Opportunities
• Listen and respond to patient and family members.
• Acknowledge and address patient and family
emotions.
• Explore and focus on patient values and treatment
preferences.
• If not decisional, explain the principle of surrogate
decision making to the family – the goal of surrogate
decision making is to determine what the patient
would want if the patient were able to participate.
Chest. 2008 Oct; 134(4): 835–843

38. 38
Align With the Patient’s Values
Decisional Patient
• Acknowledge and address patient
and family emotions (empathy).
• Explore and focus on patient values
and treatment preferences:
– “As I listen to you, it sounds the most
important things are [x,y,z].”
Non-Decisional Patient
• Acknowledge and address family
emotions (empathy).
• Explore family’s understanding of
patient values and focus patient’s
values on treatment preferences.
• Explain the principle of surrogate
decision making to the family – the
goal of surrogate decision making is
to determine what the patient would
want if the patient were able to
participate.
Chest. 2008 Oct; 134(4): 835–843

39. 39
Substitute Decision-Making
Patient Direction
Substituted Judgement
Best Interest
•What the patient directly reports
•Patient
•The decision maker(s) reconstruct what the patient would
have wanted, in the circumstances at hand, if the patient
had decision-making capacity, using ACP paperwork and
previous conversations.
•HCPOA > Surrogate
•The decision maker(s) decide based on what, in general,
would be good for the patient.
•HCPOA > Surrogate
plato.stanford.edu/entries/advance-directives/

40. 40
Three-step Approach to Patient- and Family-
Centered Decision Making
Assess prognosis
and certainty of
prognosis
Assess family
preference for
role in decision-
making
Adapt
communication
strategy based
in patient and
family factors
and reassess
regularly
Shared
Decision
Making
Parentalism
“Doctor Decides”
“Do you want a
recommendation?”
Autonomy
“Family Decides”
“Do you want
some time to talk
with your family
about this?
Chest. 2008 Oct; 134(4): 835–843

41. 41
Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

42. 42

43. 43
Reframe Why the Status Quo Isn’t Working
Cure •“Fix it”, healed
•Treatment = cure
Delay
•Slow it down,
“palliative
treatment”
•Treatment = not
dying
Die
•There’s “nothing”
left to do
•No treatment =
quitting
You may need to discuss serious news (e.g. a scan result) first. “Given this news, it seems like a
good time to talk about what to do now.” “We’re in a different place.”
Where they
are
mentally
Where they
are clinically

44. 44
Map the Future
“Given this situation, what’s most important for you?” “When you think about the future, are there
things you want to do?” “As you think towards the future, what concerns you?”
Care to
Cure
•Probabilities
•Side effects
•Disease > Patient
Care to Slow
Progression
•Time
•Side effects
•Disease > Patient
Care to
Allow Death
•Reframing
concept of disease
care
•Patient > Disease

45. 45
Plan Medical Treatments that Match Patient Values
Parentalism
“Doctor Decides”
“Would it be helpful if I made
a recommendation?”
Autonomy
“Patient/Family Decides”
“Would it be helpful to have
some time to talk with your
family about this?”
“Here’s what I can do now that will help you do those important things. What do you think about it?”

46. 46
Plan Medical Treatments that Match Patient Values
Patient Values
• Identify what is important to and priorities for
the patient.
• Identify what they hope to achieve by receiving
care.
• Identify what they fear will happen because of
the disease.
Plan Medical Treatments
• Representation of the goals of care in the form
of
– Documentation
• Advance Directive
• Living Will
• HCPOA
– Orders
• POLST
• Code Status
– Medications
• Starting and stopping
– Services
• Social Work
• Chaplaincy
• Hospice
• Home Health
National Committee for Quality Assurance: Goals to Care

47. 47
Expect Questions About More Curative Treatment
•Testing
•Doc
Tx •Testing
•Doc
Tx •Testing
•Doc
Tx
No Tx
No Testing
No Doc
Death
“Here are the pros and cons of what you are asking about. Overall, my experience tells me that more [x] would do more harm than good
at this point. It’s hard to say that though." “The treatment has become worse than the disease.”

48. 48
Talk About Services that Would Help Before Introducing Hospice
• “We’ve talked about wanting to
conserve your energy for important
things. One thing that can help us is
having a nurse come to your house to
can help us adjust your medicines so
you don’t have to come in to clinic so
often. The best way I have to do that
is to call hospice, because they can
provide this service for us, and
more.”
 It's a service not a sentence (it's
hospice not house arrest).
 Hospice is a program, not a place.
 Patient's with an estimated life-span
of less than six months who are no
longer candidates for curative
therapy are eligible for services.
 Patient's requiring active symptom
management, who are too tenuous
to move, or are actively dying may
be eligible for in-patient hospice. In
these patients death is expected
within 5 days.

49. 49
Speaking and Translating Caring
Goals of Care
• Identify what is important to and
priorities for the patient.
• Identify what they hope to
achieve by receiving care.
• Identify what they fear will
happen because of the disease.
• Life review and legacy building
are separate, equal, but not
independent parts of care.
Plan of Care
• Representation of the goals of care in the form
of
– Documentation
• Advanced Directive
• Living Will
• HCPOA
– Orders
• POLST
• Code Status
– Medications
• Starting and stopping
– Services
• Social Work
• Chaplaincy
• Hospice
• Home Health
National Committee for Quality Assurance: Goals to Care

50. 50
Unclear Goals = Unplannable Caring
Goals of Care
• “I’m going to beat this [disease]!”
• “My family won’t let me go to a
nursing home.”
• “We’re going to fight this!”
• “I’m going to get my miracle.”
Plan of Care
• These are general, usually not agreed
upon, often unrealistic, and do not
meet a timeline consistent with life
expectancy.
• The plan of care in these case is to
explore:
– “Tell me what this means to you.”
– “Help me understand more about this
by telling me how you feel about…”
And get a family meeting with all the key
partners in the patient’s care both family
and providers.
vitaltalk.org

51. 51
S.M.A.R.T. Goal
• Specific
– What does the patient mean to accomplish with this goal?
• Measurable
– What observable shows we are meeting the stated goal?
• Agreed Upon
– Are the patient, family, and provider all on the same page?
• Realistic
– Is this possible – physiologically, clinically, financially, humanly, etc.?
• Time-Bound
– When will this be observable?
General goals cannot be translated into a plan of care
Management Review. AMA FORUM. 70 (11): 35–36
National Committee for Quality Assurance: Goals to Care

52. 52
Clear Goals Lead to a Care Plan
Goals of Care
• “I want to be able to enjoy the
holidays with my family,
particularly my grandchildren.”
Plan of Care
• This is specific, measurable, can be
agreed upon, may be realistic, and
has a set time frame.
• Perhaps a chemotherapy “holiday”
or stopping hemodialysis after the
holidays. Certainly documenting
code status and likely involving
some sort of home nursing care, be
it private duty, home health, or
hospice.

53. 53
Care Conference Talking Map
Step What you say
Gather for a pre-
meeting
Let’s decide who will talk about what.
Could I propose a way to structure the meeting?
When the meeting ends, what would be a constructive outcome?
Introduce everyone
and elicit the agenda
Let’s start with introductions. My name is [x], and my role is [y].
The purpose of this meeting is to talk about [z].
Is there anything that you would like to cover in addition?
Explain what’s
happening
Tell me what you took away from our last conversation.
Could I hear from everybody?
Here is the most important piece of news…
Empathize with each
person
I can see you are concerned about [a].
I am impressed that you have been here to support [patient’s name].
Highlight the patient’s
voice
If [patient’s name] could speak, what do you think she would say?
How would she talk about what is important to her?
Plan the next steps
together
Based on what we’ve talked about, could I make a recommendation?
I’d like to hear everyone’s thoughts about the plan.
Reflect post-meeting What did we learn?
vitaltalk.org/guides/family-conference/

54. 54
Reflect Post-Meeting
• Every care conference is an opportunity to improve
the patient-centered care for that patient.
• It is also a way for each of us to improve as
clinicians.
• If I can improve my practice with every interaction,
I am going to have a much more fulfilling career by
retaining what I do well and improving that which I
do not.

55. 55
THANK YOU!
QUESTIONS?