Serious Illness Communication (Sanders, 6/2/2021)

Many thanks to Dr. Justin Sanders for a really important Grand Rounds presentation this week on Serious Illness Communication. Dr. Sanders is a family physician, a palliative care specialist and a researcher in Dr. Atul Gawande's think tank, Ariadne Labs. He has a particular interest in disparities and inequities in end of life care.

A recording of his Grand Rounds can be found HERE.

What is serious illness communication, you ask? 

Serious Illness Communication is a framework for how health care providers can engage with patients with advanced illness to elicit their goals and values, share their prognosis, and explore key topics for their end of life care-- all essential components of advanced care planning as well as the physician-patient relationship. 

Dr. Sanders (and the serious illness care model) ask us to proactively identify patients with severe illness so that we can prioritize and systematize important conversations. The goal?  Improved communication with our patients and "goal-concordant care"-- that is, to be sure that the care a patient receives at the end of their life is concordant with the life they want to live.

Take a moment to consider your patient panel, or if that feels overwhelming, take a look at your patient schedule for today and ask yourself this question: which of my patients would I not be surprised if they died in the next year? 

This is called "the surprise question" and has been validated in palliative care studies. Maybe you are thinking about a patient with chronic heart disease, lung disease, cancer, or  maybe one who has been hospitalized several times in the last year; perhaps it's someone with decreasing mobility, or even one that you hear a lot from their caretaker. It may be helpful to extend that time to 1-2 years so you capture as many patients is possible.

Now, the next question: is there a way your system can help plan the time, space, and opportunity to have these important conversations? Maybe an EHR prompt? An extended visit? A dedicated visit?

Once the space is set, the serious illness communication can begin-- guided by the serious illness communication guide (SICG) cut and paste below. 

The work is big: Have you asked them who their surrogate decision-maker should be in their stead? Do they have an Advanced Care Plan? Do they have a POLST? But perhaps more importantly:

 Here are the key SICG questions:

• What are YOUR goals?
• What are YOUR fears and worries if your health deteriorates or your illness progresses?
• What are your strengths?
• What abilities are important for you in your life?
• What might you be willing to go through for the sake of more time?

These are such a powerful set of questions-- of course, the very questions I would want someone to ask me if my time was short-- and turns out the very questions patients want to be asked. 

He also spent some time talking about framing prognosis and encouraged us to use a framework for how we present this information. An original viewpoint co-authored in JAMA by Dr. Sanders and colleagues is linked here for your own reading.

The short take is this: prognosis communication is super challenging, many of us struggle with how to provide this type of information in a useful way that doesn't allow for hope. The article argues that prognosis may be communicated in three different approaches: time-based, function-based, and reasonable-uncertainty based. Exploring with a patient for his/her preferences to guide the discussion will help providers give the patient the most useful information.

Time: how much time do you think I Have

Function: what will my function look like

Reasonable uncertainty: remember our goal is not to be right; it's to help patients have the information they need to reach their goals.

And then, finally Dr. Sanders said, you (the provider) should take the information gleaned from this rich conversation with your patient, apply the prognosis information you have, and make a recommendation (patients want a recommendation from you!), using language like this: "I have heard you say_________________and based on what you said, I am going to recommend ________________________."

Voila. Hard stuff. Thanks for the work you do.