Discussing Goals of Care With Families Using the Four Steps

To the Editor,

Communication in medicine is a lost art. It can be difficult due to time constraints, emotional reactions, and learning curves patients must overcome. It is particularly difficult when families are faced with decisions that affect the future of a loved one. Having to deliver bad news is inevitable for physicians of all specialties, and the need for quality communication is magnified in end-of-life care. However, many clinicians lack the skills needed to provide this aspect of care (Amiel et al., 2006). Delivering bad news is especially poor in the intensive care unit (Rosenbaum, Ferguson, & Lobas, 2004).

Illness presents difficulties not only for patients and their families but is also a source of internal conflict for the clinician. Doctors fear upsetting patients, especially when issues involve mortality (Bor, Miller, Goldman, & Scher, 1993; Fallowfield et al., 2002). Stress related to these incidents can contribute to burnout and anxiety (Ramirez et al., 1995). Physicians may have perceptions of failure, unresolved feelings about death and dying, and concerns about the patient’s response to news (Rosenbaum et al., 2004). Oftentimes, doctors have limited training regarding how to properly carry family meetings. Less than 5% of medical school curriculum time is spent on training in communication skills (Sandvik et al., 2002).

How communication is delivered can affect perspectives on illness (Ptacek, 1996). Poor communication can result in increased stress and anxiety, poor adjustment, and poorer health outcomes (Amiel et al., 2006). This is most evident in the intensive care unit, where aggressive management is a combination of poor physician communication, poor patient understanding, and an inability to properly convey diagnosis, prognosis, goals of care, and expected outcomes.

Poor communication leading to aggressive medical care is supported by data in oncology. Studies suggest that oncologists without communication skills training are more likely to prescribe third- and fourth-line chemotherapy (Back, Arnold, Baile, Tulsky, & Fryer-Edwards, 2005). Oftentimes, aggressive medical decision making is not aligned with the goal of medical care (Zimmermann, Riechelmann, Krzyzanowska, Rodin, & Tannock, 2008).

Effective communication is an essential part of medical care. Physicians more aware of emotions are more likely to identify psychosocial deterioration, an important contributing factor to medical decision making. The need for an improved forum is needed in all specialties. How to carry such conversations gracefully is likely to improve outcomes for both patients and providers. We suggest a four-step approach to effectively deliver news between patient and provider. Each step is patient-centered, a key requirement for effective communication.

• Step 1: Establish a diagnosis: Unless there is a clear diagnosis to discuss, the goals of the interview may not be met.

• Step 2: Discuss prognosis and assess for understanding and expectations. Proper medical decision making is hardly “informed” if both patients and families are unaware of best outcomes or how life will be affected by both their medical illness and their decision to forego or continue with treatment.

• Step 3: What are the goals of care? Realistic and achievable goals can be set when discussed in the context of prognosis. Although establishing clear goals may be difficult, physicians can assist decision makers by soliciting advice, or recommending them to reach out to family, friends, chaplains, or spiritual advisors.

• Step 4: Decision regarding treatment. Only after discussing the first three steps can medical decisions appropriately be considered. Once goals of care are established, the medical team can review all the available treatment modalities and discuss which can help achieve personal goals. Unfortunately, oftentimes, the goal is to die a peaceful death at home, and hospice may be appropriate. By not discussing prognosis and goals of care, medical decisions may be inappropriately made.

Where to Next

Conducting a family meeting has come a long way. Currently, we reside in a time when many practices of the past have outright been eliminated, but a strategic evidence-based approach has yet to be established. The science behind doctor patient communication has come a long way but still has room to grow.

Surveys conducted from 1950 to 1970, when treatment prospects for cancer were weak, revealed that most physicians considered it inhumane and damaging to the patient to disclose the bad news about diagnosis (Baile, 2000). That feeling changed during the 1970s-1980s as patients wanted to take part in the decision-making process. In a survey published in 1982, 96% wished to be told if they had a diagnosis with cancer and 85% wished, in cases of a grave prognosis, to be given a realistic estimate of how long they had to live (Baile, 2000).

Communication is complex and often an intangible subject to describe; bringing a standardized approach to sensitive conversations will improve health care outcomes and medical decision making.