Communication and Shared Decision Making
Core frameworks
Use structured tools such as SPIKES for breaking bad news, NURSE for responding to emotion, and Ask-Tell-Ask to check understanding before and after information. Shared decision making requires eliciting the patient's goals and values, explaining options and tradeoffs, and confirming a plan. Decision-making capacity is decision-specific: the patient must understand, appreciate, reason, and express a choice. Capacity differs from legal competence.
Goals of care
Ask what the patient understands before giving news, then ask what is most important. Avoid yes-or-no questions such as Do you want us to do everything? Instead explore what treatments can and cannot achieve. Family meetings should identify the surrogate, review the illness, elicit values, and summarize a plan. Use professional interpreters, not family members, and confirm understanding with teach-back. Document goals and code status clearly.
Traps
Saying there is nothing more we can do is inaccurate and harmful; say that the focus is shifting. Avoid the phrase withdrawing care when treatment is being redirected to comfort. Do not assume a family member speaks for the patient without confirming the surrogate. Do not collude with family requests to hide the diagnosis without exploring the reasons. Cultural norms about truth-telling and family involvement vary, so ask rather than stereotype.
Worked example
A 68-year-old with advanced COPD and recurrent hospitalizations says she wants to avoid another ICU stay. Ask what she understands about her lungs, then reflect that her breathing is worsening despite maximal therapy. Explore what a good day looks like and what she would be willing to trade for it. Summarize that the team will focus on breathing comfort at home and will not use a breathing machine. Rule of thumb: ask before telling, and always connect the plan to the patient's stated values.