Communication and Advance Care Planning
Communication and Advance Care Planning
Goals-of-care communication is a core hospice and palliative skill. Know the difference between shared decision-making, informed consent, and advance care planning. Explore what the patient understands, what they want to know, and what matters most before discussing treatments. Use frameworks such as ask-tell-ask, NURSE for emotions, and SPIKES for serious news. Advance directives include living wills and durable power of attorney for health care; POLST or MOLST is a portable medical order for seriously ill patients and must be completed with the patient or proxy according to state rules. Document code status and the specific treatments discussed, not just DNR.
Traps: assuming a DNR order means no treatment; saying there is nothing more we can do; allowing family to override a capable patient's wishes; treating a proxy as a substitute for the patient's known values; and holding only one advance care planning conversation. Do not use jargon or give prognostic numbers without context. Use a qualified interpreter, not a family child, and document cultural preferences.
Worked example/rule of thumb: a daughter says, do not tell Dad he is dying. Ask the patient whether he wants information and how much; explore the daughter's fear; negotiate a plan that preserves trust. Rule: ask before telling, respond to emotion before facts, and document the goal, not only the order.