Communication Skills and Advance Care Planning
Breaking serious news
Know at least one structured framework. SPIKES: Set up the conversation, assess Perception, obtain an Invitation (how much detail does the patient want?), give Knowledge with a warning shot, respond to Emotions with empathy, then Summarize a Strategy. Ask-Tell-Ask and NURSE statements (Naming, Understanding, Respecting, Supporting, Exploring) are the empathy workhorses. Traps: don't ask 'Do you want us to do everything?' - it is coercive and uninformative; don't say 'there is nothing more we can do'; don't lead with statistics when the patient is asking for meaning.
Prognosis
Ask before disclosing how much information is wanted. Offer ranges rather than pinpoint estimates, pair hope with preparation, and frame uncertainty honestly.
Advance care planning
Distinguish documents. A living will records wishes; a health care power of attorney names a decision-maker; a POLST or MOLST is a signed medical order, portable across settings, intended for seriously ill or frail patients and specifying code status, intubation, antibiotics, and artificial nutrition. Advance care planning is a values-based process, not a form. For surrogates, apply substituted judgment first; fall back to best interests when wishes are unknown. Capacity is a clinical determination of four abilities (communicate a choice, understand, appreciate, reason); competence is a legal status.
Practical traps
Use professional interpreters, not family members, and never a child. Confirm understanding with teach-back. Document who was present and what was said. Truth-telling preferences vary culturally - ask the patient whether they want information or want it shared with family. Avoid the phrase 'withdrawing care'; say what will continue (comfort care) and what will stop.
Rule of thumb: whenever you deliver bad news, name the emotion in your next sentence before offering any plan.