Points to focus upon
Advance care planning (ACP) and Goals of care (GOC) discussions are extremely important for our patients to plan for their end of life care. ACP promotes conversation amongst patients, families, and their physicians on integral topics such as substitute decision making, end of life care, financial/health decisions, code status, and estate planning.1 More importantly, it allows individuals to think and talk about what matters the most in terms of their health goals. These goals should reflect their virtues, values, and preferences on how they want their care to be at critical and vulnerable times. Additionally, it allows families to be aware of what their loved ones’ wishes are so that if the unwell patient is unable to speak for themselves, the families can act on their behalf. It is important that these conversations happen before, during, and after their visits to a doctor (hospital or clinic) on a regular basis so that patients’ wishes are well understood and documented to provide the best care that aligns with their health goals.
In the Emergency Department (ED), we are often faced with difficult scenarios where patients cannot express their care goals and their wishes are not available immediately from previous documents or from their substitute decision-makers. Unfortunately, there are many instances where these conversations never occurred previously and thus the onus of making difficult medical treatment decisions lies on the families (or loved ones) or the physicians.2 During the COVID-19 pandemic, legitimate concerns about the lack of available critical care resources have reignited this important topic and the further importance of these conversations now. Front-line physicians will need to refresh themselves on approaches to these conversations and how our message can be clear, concise, and empathetic to patients and their families if they are to present to the ED in extremis from the coronavirus. Additionally, we need to be proactive and start these conversations in the EDs (even when patients are well) so that patient’s wishes are upheld in the future.
Emergency Medicine Physicians should start goals of care conversations with our most vulnerable patients (elderly, immunocompromised, oncology, long-term care, and multiple comorbidities) to promote patients’ values and preferences when it comes to end of life care. This includes understanding what their wishes are, introducing code discussions, and making sure them and their families comprehend what these conversations mean (why they are happening and why they are extremely important now).
Additionally, all emergency physicians and front-line doctors should review helpful resources so that they are well equipped to start GOC discussions.
Target Patient population:
- All patients should be aware of advance care planning and why goals of care discussions are important. We should ideally talk about this with everyone.
- All patients who are unwell from COVID-19.
- The most vulnerable patients have a high mortality outcome if they are infected with COVID-19.3 We should discuss these topics with patients who are elderly, immunocompromised, oncology, long-term care, and multiple comorbidities.
- Families of vulnerable patients must also be in the loop to make sure these discussions are being held with loved ones.
Recommended Resources for Patients or Families
- Wency Leung. Canadians urged to plan ahead for end-of-life decisions as toll from COVID-19 builds. The Globe and Mail. March 30, 2020.
- Tom Blackwell. Some critically ill COVID-19 patients choosing to die at home rather than be treated with ventilator in ICU. National Post. April 2, 2020
- Kevin Junghwan Dong. It’s a Good Time for an Important Conversation. The Hamilton Spectator. April 16, 2020.
Here are some useful ways to approach GOC and difficult conversations with your patients.
1. SPIKES4 – Similar to Breaking bad news post
S – Setting up the interview
– Make sure to mentally rehearse the conversation in your head
– Set up a private setting with important significant others involved
– Sit down and make a connection with the patient
P – Assessing the Patient’s Perception
– Ask the patient about their understanding about their current medical condition
– Let the patient speak
I – Obtaining the Patient’s Invitation
– Ask permission to start the conversation
– Ask how they would the information to be given (how do you want me deliver your medical information to you?)
K – Giving Knowledge and Information to the Patient
– Provide knowledge that is easy to understand
– Be clear and do not lie – but do not be overly blunt
– Give information in small chunks
– Be honest
E – Addressing the Patient’s Emotions with Empathy
– Observe their reactions and provide opportunities to express their emotions
– Don’t rush this process – it may be difficult to move on without going through this step
S – Strategy and Summary
– Discuss treatment options
– Provide next steps as appropriate
– Provide emotional counselling and referrals
2. Serious Illness Conversations Guide
This has been recommended by Palliative Care physicians. Refer to the below documents for details
- BC Cancer Serious Illness Conversation Guide
- Fraser Health Serious Illness Guide
- Advanced Care Planning/Goals of Care Tool for Physicians – Code Status from JAMA
- MacEmerg Podcast. Special Episode – Gallagher, Williams & Dong | Goals of Care & Advanced Care Planning.
- CMAJ Podcasts. Palliative care during a pandemic.
Recommended reading, videos, and podcasts
- American Association of Family Physicians
- Ontario Palliative Care Network – Palliative Care Resources to Support Frontline Providers during the COVID-19 Pandemic
- Documentation Guide for physicians
This is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.
This post was edited by Dr. Teresa Chan MD FRCPC MHPE DRCPSC. This post was copyedited and uploaded by Evan Formosa.
- 1.Speak Up C. What is Advance Care Planning. Speak Up Canada. https://www.advancecareplanning.ca/what-is-advance-care-planning/. Published 2020.
- 2.What Canadians Say: The Way Forward Survey Results. Canadian Hospice Palliative Care Association; 2013:77. http://hpcintegration.ca/media/51032/The%20Way%20Forward%20-%20What%20Canadians%20Say%20-%20Survey%20Report%20Final%20Dec%202013.pdf.
- 3.Bialek S, Boundy E, et al. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. March 2020:343-346. doi:10.15585/mmwr.mm6912e2
- 4.Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A Six‐Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist. August 2000:302-311. doi:10.1634/theoncologist.5-4-302