Dr. Anna Stecher presented a novel take on noon report today as she led us through 3 separate clinical stories she has encountered that involve complex goals of care and end of life conversations.
With these stories as a starting point, participants reflected on past difficult conversations they have had, with a focus on complex “Family Conferences” which can be particularly stressful for a primary team resident to lead with multiple subspecialists, strong emotions, and family dynamics.
We discussed the “Vital Talks” Framework for such conversations, which is a helpful (but not all-encompassing) guideline for approaching these moments.
The framework can be described as follows:
- Meet with other members of the team (subspecialists, nurses, etc.) and share key points of agreement, update on clinical status and potential family dynamics
- Decide on whom is leading the meeting
- Ensure private location
- Clearly delineate purpose of meeting (“get to understand patient’s wishes better”, or “hear concerns, provide an update, and plan together”, as opposed to “decide on a code status”).
- Elicit the family’s understanding and perspective of situation as it stands
- Provide broken-down pieces of information (not as a monologue or lecture)
- Ensure ample time understanding and questions
- Summarize succinctly
- Wait and acknowledge emotion. OK to provide time to process/allow for silence if appropriate
- Elicit patient’s values: have family provide information about the patient as a person sans illness- what were their priorities, what would the patient want?
- Stress that family’s role is not to make a decision on behalf of the patient, simply to act as a translator for what the patient would want or learn about what options are most consistent with the patient’s values
- Demonstrate how a potential plan of action or several options might align with the stated values of the patient
- Consider making a recommendation based on what you know of the patient’s values and medical situation if necessary
- Give all family members opportunity to express different views without taking sides
Dr. Stecher presented some data about palliative care consultations for terminally ill patients in the ICU. While data is somewhat sparse, introduction of early palliative care may possibly reduce mortality rates and likely shorten length of stay within this patient subset.
There is also some literature describing the most commonly cited barriers to goals of care discussions for hospitalized patients and their families, including factors such as perceived difficulty by family members to accept a loved one’s poor prognosis, and difficulty understanding limitations/ complications of life sustaining therapies. The most evidence-based interventions to address these and other concerns include: printed info, structured communication by the ICU team, and ethics and/or palliative care consultation.