Communication, Goals-of-Care Discussions, and Advance Care Planning
Core skills
The exam favors structured tools: SPIKES for breaking bad news, Ask-Tell-Ask and NURSE for responding to emotion, REMAP for goals-of-care conversations, teach-back for confirming understanding, and motivational interviewing for behavior change. Name the emotion before giving information; silence and open questions accomplish more than premature reassurance. Document who was present, what was said, what the patient or surrogate understood, and the resulting plan.
Capacity and surrogates
Decisional capacity is a clinical judgment about a specific decision, made by the treating clinician; competence is a legal status. When a patient lacks capacity, surrogates use substituted judgment (what this particular patient would have chosen) and fall back on best interests only when the patient's values are unknown. A surrogate's authority does not extend to overriding a clearly expressed prior wish.
Advance care planning documents
An advance directive is a broad category: a living will states values and desired treatments; a durable power of attorney for health care names a decision maker. POLST/MOLST is not an advance directive - it is a portable medical order for a person with serious illness or frailty, signed by a clinician, that travels across settings.
Traps
Assuming a living will designates a proxy; assuming every patient wants full prognostic disclosure; treating the surrogate's own preference as substituted judgment; treating advance care planning as a single event rather than an ongoing conversation that changes with illness.
Worked example. A son says, 'Don't tell my father he has cancer.' Ask the son what he fears his father will feel, then ask the patient how much information he wants. The patient controls information, not the family.