Jim’s Notebook: Improving Goals-of-Care Conversations with Tips from a VITAS Pro
Greetings! I am now far away from my desk in northern Michigan, camping my heart out. But I wrote this before leaving, so I wouldn’t be leaving my readers hanging for a week. Thanks again to all of you for tuning into Inside Hospice.
Today I want to talk about goals-of-care conversations. Many patients miss out on the benefits of hospice care – or come on service too late – because they lacked timely access to these discussions. Many health care providers are not training clinicians to facilitate such conversations, and for some people, these conversations can seem antithetical to their perceived mission of curing disease and staving off death.
I recently had the pleasure of speaking with Dr. Ileana Leyva, regional medical director for the large hospice provider VITAS Healthcare, for a Hospice News article on improving access to the benefit for cancer patients. But we also talked about goals-of-care conversations. Dr. Leyva gave me some tips for conducting them effectively that I thought I would share with you here.
Dr. Leyva told me this:
You have to do some prep work. I tell my docs, “You can’t wing it.” You have to do a record review. You have to know what you’re walking into. Many times, I describe it as I feel like I’m a referee with a whistle in my mouth, because I’m referencing five different physician specialties during these conversations. So, rule number one is you have to be prepared for it.
Two, you have to set the stage. You can’t just walk in and decide that we’re going to do this right now. You have to invite that conversation, plan it with the patient and whoever is most important to be present. At times patients have certain people they don’t want present, because they’re not going to be as open with you if there’s a particular person in the room.
We have to leave all our biases and judgments at the door, because it’s not our journey. It’s the patient’s journey. That can be very, very hard, because we know what that trajectory will look like for the patient and they don’t. So it’s really a conversation about helping me understand what you’ve been told and what you’ve understood of where things are, and then the conversation of what you think is happening and [based on that], guiding them to better understand their disease.
At the same time, asking the key question: What’s most important to you with regard to where you’re going to live your life? How do you want to live your life? I have patients who say, “I want to be home. I don’t want to go back to the hospital. I’m done with the tests and anything that’s invasive.” And I have had other patients who’ve told me, “If you can prop me up in the corner, and I can watch my grandkids, that to me is a good quality of life.”
So, it’s getting what’s most important for the patient and trying to then be able to implement the plan of care around what’s important to the patient and what’s feasible and viable as well. So, that’s why I say it’s also refereeing five or six other sub-specialties into not undermining what a good plan of care may look like.
It’s a long conversation, and it’s never a one and done. It’s a fluid conversation that takes place over time, and it’s important to do more listening during the goals-of-care conversation than it is to do speaking.
I really appreciated Dr. Leyva’s insights.
Hospice and palliative care providers know how to have these conversations, perhaps better than many clinicians in other settings. What are your best tips for holding them? Let me know in the comments.