1. GOALS of CARE DISCUSSIONS
Pearls and Pitfalls
You are covering for the weekend in QC as a locum, and the nurse asks you to assess one of the LTC patients who has developed a fever, low BP and seems confused. You quickly review his chart and note the following:

2. 75 year old man, Long Term Care resident.
1. advanced Parkinson’s disease, communication difficult
2. severe COPD, with recurrent LRTI (aspiration)
3. chronic pain from radiculopathies aggravated by his stooped posture
Lewy Body dementia + paranoia make optimizing care often challenging
Slow decline in function over the past year.
His current MOST > 1 yr old = CPR for a witnessed arrest + M3
(would consider transfer to a higher level of care, but no ICU/intubation)
How would you approach this situation?

3. The 3 C’s
CONTEXT
COUNCIL
CONCERNS

4. THE SETTING OF THIS CONVERSATION
CONTEXT 
THE SETTING OF THIS CONVERSATION
Right time and place?
Private setting, minimize interruptions
“Do you prefer to make healthcare decisions on your own or
are there family or friends who you wish to be involved?”
@gracefarris
Information needs
“Tell me what you understand about your (your loved one’s) illness?”
“Are you the type of person who likes all the information and details about your condition including details about what will happen in the future?”
Physical Context
timing, place, who should be present
Cognitive & Emotional & Spiritual Context
what does the patient/family know (perceptions) – measure the gap between your perception and that of the patient and their family
What do they need and want to know?
Decision making
“If you become too sick to speak for yourself who would make decisions for you?”

5. Patient-Centered approach
CONcerns 
Patient-Centered approach
“We are not very good at predicting how things will evolve for people with [illness] so while we hope for the best, we must also have a plan for when things get worse.”
“Can we take some time right now* to discuss a plan for that time?”
Concerns:
- our concerns as HCP (clarifying a code status, avoiding futile treatments) may sometimes trump patient concerns
- Try to see the situation from the patient & family’s perspective
- why now? Routine paperwork or life-threatening situation? Make space of emotions
*Why now?
Routine admission paperwork or end-stage/life threatening illness?
Be clear and be prepared to make space of strong emotions.

6. Pitfalls
Has any one here ever had an awkward GOC discussion, either as a provider or as a patient/concerned family member?

7. The Menu:
This approach leaves patients to pick from an overwhelming array of interventions (pressors, shocks, tubes), some of which may be appropriate and some of which may not.

8. The Horrors: 
This approach uses scare tactics and horror stories about CPR to try to talk people into avoiding resuscitation. This may work in the short term, but feels emotionally manipulative or coercive. Often providers are describing their own fears about what CPR will feel like for them, rather than what the patient will experience. 

9. The Numbers: 
This strategy involves bombarding patients with statistics, which are unlikely to be heard in the midst of a terrifying and emotionally charged decision.

10. The Transcendent: 
This method presumes an understanding of a patient’s beliefs regarding something that may be deeply personal or metaphysical. It may sometimes be appropriate to reference deeper conceptions of dying, but only when patients have already shared their own views on death and what lies (or does not lie) beyond.

11. Patient-centered goals of care
“As your illness gets worse, what is most important to you?”
“What do you fear most about the future?”
“Is there anything that would be worse than death for you?”
“Does the treatment you are receiving feel right to you?”

12. COunsel Medical recommendations based on
medical condition and patient preferences
“I’m worried that, with the severity of your lung disease, CPR would be unlikely to help you recover.
I would recommend that when your condition worsens to the point of dying, we should do everything possible to relieve your symptoms and support you, but we should not attempt CPR or artificial breathing.”
COUNSEL: 
Use plain language and avoid jargon. Simplify statistical information into straightforward background for your recommendation. Provide a clear recommendation, remembering that even despite your best efforts to approach this conversation thoughtfully, patients and providers may disagree about the best way forward.

13. CREDITS iPall – Heart Failure – Palliative Care Assessment Tool
Dr Nathan Gray
Palliative Care, Duke University, Durham, NC
@NathanAGray
Dr Grace Farris
Chief of the Division of Hospital Medicine, Mount Sinai West, New York, NY
@gracefarris