Goals-of-Care Conversation at Discharge
Mrs. Chen, 82, has stage IV heart failure (EF 25%) and stage 3 chronic kidney disease. She has been admitted three times in four months. Today she is stable and medically ready for discharge to home, where she lives alone. Her daughter, who lives two hours away, wants "everything done" and asks that her mother not be told the prognosis. Mrs. Chen has asked the nurse twice, "Am I dying?" She has no advance directive. The discharge planner wants to send her home with a follow-up in two weeks.
1. How do you respond to Mrs. Chen's question and to the daughter's request?
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Answer Mrs. Chen honestly and at her pace: acknowledge her question, explore what she is worried about, and share what is known about her illness without imposing a timeline. Do not deceive her at a family member's request; the patient has the right to information about her own care.
Tell the daughter gently that you cannot withhold information from her mother, but you can involve the daughter in a family meeting and support her. Explain that the goal is to align care with her mother's values.
Rationale: truth-telling and patient autonomy are foundational; family preferences cannot override the patient's right to know.
2. What discharge plan changes would you advocate, and why is two-week follow-up inadequate?
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Advocate for: a goals-of-care and advance directive discussion before discharge; a palliative care referral; a heart failure clinic or home health visit within 3–7 days; a medication reconciliation with a teach-back; and a plan for who to call. Two weeks is too long given three admissions in four months, high readmission risk, living alone, and advanced disease.
Rationale: early follow-up and palliative involvement reduce readmissions and align treatment with the patient's goals.
3. How do you document and coordinate this conversation?
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Document the patient's questions and words, the information provided, the daughter's request and your response, the plan for a family meeting, referrals made, and the follow-up plan. Use a structured handoff to home health and the primary care provider, including code status and goals-of-care status. Record that no advance directive exists and that one is being pursued.
Rationale: clear documentation ensures continuity and protects all parties when goals evolve.