Communication, Goals of Care, and Advance Care Planning
Core skills
Serious-illness communication is a procedure: prepare, elicit the patient's understanding and information preference, deliver news in small chunks, respond to emotion before giving more information, and summarize a plan. SPIKES and Ask–Tell–Ask provide scaffolds. Naming emotion ('It sounds as though this has been frightening') is more therapeutic than premature reassurance.
Goals of care
Goals-of-care discussions explore values, what matters most, and acceptable functional outcomes before discussing specific treatments. Ask about understanding, hopes, worries, and what the patient would trade for time. Avoid framing the choice as 'treatment versus nothing'; reframe around what we hope to achieve. Code status is a treatment decision, not a checkbox, and should be revisited whenever the clinical situation changes.
Advance care planning
ACP is an iterative process, not a form. Identify a health care proxy, discuss substituted judgment, and complete state-specific documents such as a living will or POLST/MOLST where available. POLST applies to seriously ill patients and travels across care settings; a living will does not direct EMS.
Capacity and collusion
Decision-making capacity requires understanding, appreciation, reasoning, and expressing a choice. It is decision-specific, and disagreement is not incapacity. If capacity is absent, follow the statutory hierarchy of guardian and surrogate decision-makers.
Worked example
A daughter says, 'Don't tell Dad he has cancer.' Explore her fear ('What worries you about telling him?'), then ask the patient how much he wants to know. Most patients want information, and collusion often reflects family distress rather than patient preference.
Trap: quoting survival statistics before checking whether the patient wants numbers.