SERIOUS ILLNESS CONVERSATIONS – HOW DO WE GET BETTER IN PRIMARY CARE?

Serious illness, whether acute or chronic in nature, are increasingly prevalent and burdensome on society as the population ages. Cancer, chronic heart disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, pulmonary hypertension, cerebrovascular insufficiency, dementia are becoming, if not already, the mainstay of primary care practice. These conditions, and many others, deserve sensitive, early, comprehensive goals of care conversations that will guide not only continued or additional medical therapies but also their subtraction as patients near the end of life.

The tragedy is that serious illness conversations don’t take place or are ineffectively done, or done at the wrong time and/or place. Primary care has been advocated as the most effective model for establishing and maintaining effective therapeutic relationships due to higher levels of continuity, trust, and ability to coordinate across settings. Yet primary care is replete with barriers to effective communication about serious illness. These include both clinical and system failures.

CLINICIAN BARRIERS
Knowledge, skills, attitudes Death is low frequency eventLack of professional training – knowledge, emotional skills etcClinician stress with conversation

Lack of confidence

Prognostication Inadequate training on how to do and convey prognosisDifficulty to prognosticate in milieu of multiple co-morbidityEmotional stress of prognosis
Timing of conversations Uncertainty as to who initiates the conversation (patient vs provider)Fear of harming patient so delayInsufficient resources and incentives

Difficulty in finding time for conversation

SYSTEM FAILURES
Lack of coordination Care fragmentationLack of clarity who lead physician might be (specialist vs PCP) 
Documentation EHRs not set up for ACP documentationLack of documentation standardsTime constraints
Feedback and Quality Improvement Lack of metricsLack of clinician performance feedbackLack of incentives for improvement

Measure overload

SOURCE: JAMA Int. Med., 2016, 176(9): 1380

BEST PRACTICE GUIDANCE (adapted from Berbnacki RE, Block SD, Communication About Serious Illness Goals: A review and Synthesis of Best Practices, JAMA Int. Med, 2014, 174(12) 1994-2003

Seven recommendations for improving serious illness conversation in your practice are being developed and tested. These seven are in the following categories:

  1. Train clinicians in serious illness conversation. Interactive, case based training is the most effective. There are multiple training resources. One of the best is VitalTalk (http://vitaltalk.org)
  1. Identify patients at risk- identify appropriate timing and content of conversation for specific sub-types of patients including cancer, end stage diseases, frail and elderly patients
  1. Trigger conversations in the outpatient setting before a crisis. – use criteria for appropriate timing (eg. cancer patients before starting second line chemotherapy)
  1. Educate patients and families- find and utilize patient information summaries on disease and disease prognosis, initiate discussion before decisions made, focus on goals before procedures
  1. Use checklist or conversation guide. Several are available. See the Conversation Project guide. Another checklist tool is the Serious Illness Conversation Guide from Ariadne Labs

http://theconversationproject.org/wp-content/uploads/2016/09/TCP_NEWStarterKit_Writable_Sept2016_FINAL.pdf

https://www.ariadnelabs.org/wp-content/uploads/sites/2/2015/08/Serious-Illness-Conversation-Guide-5.22.15.pdf

  1. Improve communication of critical information in the electronic medical record. Designate a single site within the EMR for values/goals/preferences of care as well as health proxy, POLST, and code status
  1. Measure and report performance. Identify key indicators of communication and documentation. Use indicators to provide feedback and guide improvement activities

Taking a systematic and structured approach to serious illness conversation will address fears and anxieties of patients and providers, arrive at critical decisions, and build a collaborative therapeutic relationship with your patient.

Submitted by Scott Endsley MD, Associate Medical Director, Quality

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