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Special Communication
December 2014

Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices

Rachelle E. Bernacki, MD, MS1,2,3,4; Susan D. Block, MD1,2,4,5; for the American College of Physicians High Value Care Task Force
Author Affiliations
  • 1Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 2Ariadne Labs, Brigham and Women's Hospital & Harvard School of Public Health, Boston, Massachusetts
  • 3Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
  • 4Center for Palliative Care, Harvard Medical School, Boston, Massachusetts
  • 5Departments of Psychiatry and Medicine, Brigham and Women's Hospital, Boston, Massachusetts
JAMA Intern Med. 2014;174(12):1994-2003. doi:10.1001/jamainternmed.2014.5271

An understanding of patients’ care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress. However, conversations about care goals are often conducted by physicians who do not know the patient, do not routinely address patients’ nonmedical goals, and often fail to provide patients with sufficient information about prognosis to allow appropriate decisions; in addition, they tend to occur so late in the patient’s illness that their impact on care processes is reduced. This article (1) reviews the evidence and describes best practices in conversations about serious illness care goals and (2) offers practical advice for clinicians and health care systems about developing a systematic approach to quality and timing of such communication to assure that each patient has a personalized serious illness care plan. Best practices in discussing goals of care include the following: sharing prognostic information, eliciting decision-making preferences, understanding fears and goals, exploring views on trade-offs and impaired function, and wishes for family involvement. Several interventions hold promise in systematizing conversations with patients about serious illness care goals: better education of physicians; systems to identify and trigger early discussions for appropriate patients; patient and family education; structured formats to guide discussions; dedicated, structured sections in the electronic health record for recording information; and continuous measurement. We conclude that communication about serious illness care goals is an intervention that should be systematically integrated into our clinical care structures and processes.

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1 Comment for this article
Cultural Variations in Serious Illness Care Goals
Esha Ray Chaudhuri | N/A
Rachelle E. Bernacki and Susan D. Block (1) provide an eminently valuable, state of the art synopsis of Best Practices for Communication as an important intervention in Advance Care Planning (ACP) discussions. Intended as a High Value Care Initiative for clinicians and the Health Care systems, the Review provides important knowledge for stakeholders including patients , families and Caregivers on interfaces of health care allocation, systemic priorities and clinical premises about care choices and treatment preferences of seriously ill patients. The Review and Synthesis of Best Practices is particularly notable for its recognition of communication as a valuable care intervention and systematizing its integration into clinical care structure and processes.Conceptually, Best Practices tend to emphasize efficiency of techniques in communications than effectiveness of their intent especially in dealing with diversity of patient population, Thus, analysis of the key elements in Serious Illness Conversation Guide in the Review (Figure E7) especially engaging issues of prognostic disclosure, patient goals, fears and family involvement, albeit an efficient portrayal of a selective sample, may not be universally applicable for all patients (2) (3) (4) without verifiable evidence about (a) universality of assumptions of the Practices evaluated and (b) reliability of its measures among diverse patient population.Effective knowledge needs an interpretive framework which transcends objective empathy and compassion to include a critical sensitization about all conceptual assumptions being based on some form of subjective beliefs and values and how both technical knowledge and interpretive insights equally contribute to a true dialogue process. While efficiency of communication skills are enriched by pursuing psychological axioms of behavioural principles, effectiveness of communication is achieved through recognition, understanding and interpretation of the multifaceted context of diverse patient perspectives which warrant multidisciplinary insights.Patients are not generic entities. Even for the “Seriously ill”, choices for End of Life (EOL) Care would essentially reflect his/her total life experience , intricately woven in multiple complexities including age and gender, family structure and tradition, ethnicity, and faith, education levels ,work or professional experience and socio-economic status. Recognition and systematic integration of this cultural context into clinical care process would help make serious illness care equitable and fair for all patients. Interpretation of cultural variations in ethical norms is important for enriching cultural insights (5) of communicative competence. In diverse patient perspectives , the cultural constructs of sanctity of life, more than clinical prognosis of its diminished utility, would frame the choice of care. References1.Bernacki, RE, Block, SD. Communication About Serious Illness Care Goals : A Review and Synthesis of Best Practices . JAMA Intern.Med. 2014: 174(12):1-112. Blackhall, LJ, Frank, G et al. Bioethics in a different tongue : The case of truth-telling. J Urban Health.2001:78(1):59-713. Kagawa-Singer M, Blackhall LJ. Negotiating cross-cultural issues at the end of life: \"You got to go where he lives\". JAMA. 2001: 286(23):2993–3001.4. Blackhall, LJ, Murphy, ST et al .Ethnicity and attitudes toward patient autonomy. JAMA. 1995 : 274 (10) : 820-55. Betancourt, JR. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches . The Commonwealth Fund : Field Report October 2002Esha Ray Chaudhuri PhDStakeholder/ Patient Family MemberCalgary, Alberta, Canada