Talking With Patients - Talking With Patients & Families

IN SHORT: Goals of care discussions should occur early and often with clear, objective predictions of prognosis and definitive care recommendations offered. End-of-life care should focus on promoting family connections as able and managing dyspnea.

VitalTalk site & app for discussions with families, including a targeted guide for discussions with patients and families about COVID (Back et al) and COVID-specific family discussion videos

San Francisco VA Advanced Care Planning Communication Guidelines

NHS Scotland poster on Difficult Conversations

• Early & repeated goals of care discussion, trying to focus first on patient’s goals and then their code status (Curtis et al)
  • Consider early Palliative Care consults (even in ER) to help with discussions
  • Be clear about poor prognosis in pre-existing terminal conditions such as dementia as families may not have heard this information before (as one Palliative Care provider put it, “to be clear is to be kind” even if it feels blunt or cruel to deliver bad news)
• Consider working on informed assent instead of informed consent - making a recommendation regarding code status based on goals and likely outcomes to which a patient/family may agree or disagree rather than asking them what they would like (Curtis et al)
• Provide specific, objective outcome predictions -- thus far, COVID-19 CPR data indicates extremely poor outcomes with only 13.2% ROSC, 2.9% 30-day survival, and 0.7% 30-day survival with good neurologic outcome (Shao et al)
  • NHPCO’s COVID-specific guide for mortality rates and outcomes, UW Medicine COVID Prognostication Tool (Gibbon et al), and GO-FAR calculator for probability of post-hospital CPR survival to discharge with good neurologic status can provide additional data specific to your patient
• The goals of care discussion process may differ depending on level of emergency/standards of care (see Ethics above) -- in general, we should adhere to traditional norms of patient autonomy in determining code status and allow for disagreement with our recommendations
  • Medical futility exists in some patients regardless of care conditions, iIf medically appropriate and legal in your region, may still declare a treatment medically futile
  • If entering crisis standards of care, families may face triage team decisions they do not understand and may hate; triage re-consideration should be based on objective medical information as per crisis guidelines and not on family discomfort with decision

• Help patients and families connect via visitation (if permitted) or video or audio calls (Etkind et al); if unable to arrange a call consider helping a patient to record a last message to loved ones
• Dyspnea/air hunger control appears to be one of the greatest challenges with this disease and may require admission for symptom management (Etkind et al)
• O2 supplementation should still be via non-aerosolizing means (NC, NRB) if possible and should focus on dyspnea, not hypoxemia (Fausto, Ting et al)
• Consider early use of opiate & benzodiazepine infusions for end-of-life symptom management as may be able to control symptoms while minimizing PPE use esp. if IV poles are placed outside rooms (Fausto, Ting et al)