1. It Starts with a Conversation Damien Doyle, MD, CMD, FAAFP

2. Setting for the Conversation Quiet, private location. Make sure the patient is as comfortable as possible. Limit unnecessary interruptions. Avoid multi-tasking. Sit at the patients level and at an appropriate distance. 2

3. Discussion of Code Status and Life-sustaining Treatments If a patient has or is likely to develop a condition in the future, then that treatment should be discussed with the patient now. Despite careful advance planning, emergencies happen – these conversations may occur in the ER or ICU. 3

4. Discussion of Code Status and Life-sustaining Treatments In addition to physicians, other health care professionals have the knowledge, skills, and experience to discuss CPR and other life-sustaining treatments with patients. 4

5. Individualize the Conversation Respect personal, cultural, and religious viewpoints. Consider who should participate in the conversation. Consider the individuals level of understanding and insight. Consider the individuals current situation and likely future decisions. 5

6. What is your role in helping an individual or the authorized decision maker make an informed choice? 6

7. What is your role in helping someone make an informed choice? Active listening Frame the conversation Communicate the benefits, burdens, and risks of the intervention Give them the benefit of your knowledge and experience 7

8. How do you deal with your own biases? 8

9. Physician know thyself -- identify your own biases Understand your personal, religious, or cultural views Understand the point of view of your specialty (surgery, oncology, and hospice) 9

10. How do you help authorized decision makers make decisions for their loved one? 10

11. How do you help ADM make decisions for their loved one? Determine if the patient has expressed his or her wishes. Acknowledge the stress of the situation and the difficulty of the task. Explain the patients clinical condition and prognosis. Explain treatment options and offer recommendations based on evidence and your clinical judgment. 11

12. How do you deal with an individual who does not want to discuss code status or other life- sustaining treatments? 12

13. How do you deal with someone who does not want to discuss it? Respect the individuals right to decline to discuss it, but perhaps ask more general questions about goals of care rather than discussing code status directly. Readdress it at a future time. If possible, inform the patient that not limiting care generally means that medically indicated interventions will be provided. 13

14. For More Information marylandmolst.org MarylandMOLST@dhmh.state.md.us 14