Thrilled to announce that our paper is just out in @BMJ_SPCare!!

Common pitfalls in exploring values.

"What would he say?" --> "I don't know" --> freeze
"What is important?" --> "Getting better" --> freeze

What should you do?

spcare.bmj.com/content/early/…

1/ Among opening Qs, start with general ones, then proceed with more specific ones.

Many start with "What would they say?"
But this Q is too negative. Many cannot answer.

Instead, start with more general/positive ones.
Very few cannot answer "What makes you happy?"

2/

I don't care too much about how we call it (ACP, SIC, GOC, etc).

We just need 3 steps, 1)prognosis--> 2)goals/values --> 3)treatment preferences.

2) depends on 1), 3) depends on 2).

If you are healthy, don't worry about 1) and 3), but still you need to talk about 2).

1/

https://twitter.com/GeriPalBlog/status/1496907959838064644

When you get older, or you have some disease (like cancer or HF), 1) starts to become not forever, then 2) might change (that's ok).

Still, you don't need 3). Just keep talking about 2) regularly, make sure your family knows it.

2/

It is better to sit down when you talk to a patient/family, even for a few min.

By standing, you give the impression that you are busy and you can leave at any moment, which makes pt uncomfortable.

Let me share my anecdote.

1/ Several years ago, I got a consult in the ICU.

Pt was in his 70s, intubated for a week, was at end of life.

A sister was sitting at the bedside, looked anxious.

I went into the room, introduced myself, grabbed a chair,and sat down next to her.

2/

One of my favorite consults is goals of care BEFORE high-risk CT surgery.

Why palliative care/GOC before surgery?

It is because we need to have a high-quality conversation, in very challenging cases.

In my opinion, there must be 2 phases of conversations.

1/ First of all, we need to decide whether or not to do surgery.

The best tool for this is BC/WC model by @GretchenSchwa10

The beauty in this model is, by giving the WC of surgery and the BC of no surgery, you can create the story for both options.

2/

jamanetwork.com/journals/jamas…

The reason for palliative care consult is GOC.

Yes, you have to start GOC by asking "What did doctors tell you?"

But this question should NOT come right after you introduce yourself.

If I were a patient, I would think "Who are you?"

It won't make a good impression.

1/ First, you have to explain what is palliative care and why you are here.

Then, you have to ask about symptoms. Pain? SOB? nausea?

Then, ask about the patient and family.
- Where do you live?
- With who?
- Any family?
- Where do they live?
- Do they come see you?

2/

In a family meeting, after you explained the situation is worse, I see many doctors ask,

"What would he WANT?"

I think this is a BAD question, although I'm aware it is well-intentioned.

I will tell you why...(thread)

1/ What you should do at this point is exploring goals/values of the patient.

But if you use "want", that q is (automatically) asking about treatment options, not goals/values.
(I want chemo, I want dialysis, etc).

2/

I see trainees give prognosis ("days to weeks") immediately after "how much time I have left?"

It is crucial (and awful) information, and has to be delivered carefully (and as best as possible).

Things I pay attention to (mini thread)

When they ask "how much time?"

1/ - Make sure they are ready to hear. "Is it ok to share that info?"

- Emphasize uncertainty. "we cannot give you the exact number (bcz we don't know), but we can give you our best guess"

2/

Out latest paper is just published in @PalliativeMed_j
62 cases for LVAD withdrawal in @nyphospital

When LVAD withdrawal is requested, how did we handle it?

Major findings follow.
liebertpub.com/doi/10.1089/jp… 14 patient joined the decision of WD (requested to stop LVAD by themselves).
The median days between a req and deactivation was 5.5
Significant difference between in and out the ICU (1 d vs 46d, p=0.013)