Reach consensus

• If outpatient, may require calls/email

• Aim for prognostic alignment

Set the goal for the meeting

Identify a speaker

Discern whether this is a loser's or winner's game

🏠 Missing family

🥼 Missing clinicians

⚖ Misalignment in clinical / prognostic understanding

🎙 Multiple speakers

⏳ Forcing a non-urgent meeting

🚧 Ignoring limits

• Do you or anyone else need food, caffeine, the restroom?

The relevant clinicians

The relevant family

The news

Chairs (please sit!)

Assess illness understanding

• "What's the last update you received?"

• "What have the doctors said?"

• "I just want to make sure we're on the same page..."

Bottom line up front (1-3 sentences)

Next phase of the conversation (exploring GOC)

or

Identify next steps (e.g., cool off period)

🚨 Family unprepared to receive news

• Ask permission! "Is it okay if I share what we've found?"

🚦 Assuming knowledge

• Don't skip assessment of illness understanding

📜 Retelling the whole clinical course

• Illness understanding may allow to jump right to GOC without a prolonged summary

😵 Jargon

• Avoid specialized medical language

🌊 Jabber

• Be succinct

🤢 Toxic knowledge

• Avoid giving unactionable info that impairs decision-making

🧨 Ignoring emotion

• Acknowledge, empathize, validate

• Address an emotionally charged question at the emotional level before the cognitive level

• Ask permission before moving through emotion

• Beware the uncanny valley 🤖

😩 Family distrust

• Anticipate and manage conflict

• Acknowledge reality

• Move slowly; listen to stories

• Don't argue about claims that are impossible to refute (and even if they are, weigh burdens/benefits of arguing)

• Apologize if necessary

  • Concrete, brief, avoid qualifications, outline steps to avoid issue in the future

✨ Belief in miracles

• Acknowledge divine presence while also acknowledging human-level need for decision-making

• Confer with chaplain

🎉Toxic positivity

• Shift focus from losses to needs

Telephonic visit (if avoidable)

💀 Failure to diagnose + discuss dying

The relevant clinicians

The relevant family

Shared understanding of illness (agree on the news)

Chairs (please sit!)

Discuss medicine's goals of care

• Longevity, function, comfort

• Identify interventions that may be needed to clarify GOC (e.g., biopsy)

Explore expectations, hopes, worries

• Assess disparity between clinician and family expectations

• Assess and broaden hope portfolio

• Look for stories, roles, metaphors, affect

For surrogate decision-makers

• Substituted judgment if possible

• Substituted interests often necessary

• Best interests sometimes necessary

Next phase of the conversation (prognosis & planning)

or

Identify next steps (e.g., cool off period)

🔮 Assuming GOC

🚩 Naïve allocation

• Addressing "everything"

• Highlighting trade-offs

• Attend to ambivalence

🔥 Answering hopes with "but"

• Align with hopes

• Share your worries with "and" (e.g., "I'm hoping this works, and I'm worried that...")

🧭 Preference-goal substitution

• Discuss goals before preferences

• Avoid preference entrenchment among clinicians

🔒 Inflexible goals

• Promote flexibility (e.g., goal A in the short-term to facilitate a discussion about goal B)

The relevant clinicians

The relevant family

Shared understanding of illness (agree on the news)

Share understanding of GOC + hopes + worries

Chairs (please sit!)

Scenario planning

• Best, worst, and most likely case scenarios

• Holistic prognosis (time, function, symptoms)

• Iterative (e.g., ICU) vs. one-time (e.g., surgery)

• What does it look like to live well given everything we know?

Review previously discussed GOC/plans

Back-up and emergency planning

• Who's the surrogate decision-maker? (ideally would have been known from initial eval/H&P)

• Advance directive

• Code status

• Functional milestones

  • Retirement, driving, home safety, continence, diet

• (Re)Hospitalization

• Hospice

• Disease-specific plans

For surrogate decision-makers

• Broadening the role to include not just advocating for treatments, but protecting from harmful interventions

• Substituted judgment if possible

• Substituted interests often necessary

• Best interests sometimes necessary

Execute plans

Follow-up

Plan may feedback into another conversation

Unprepared to plan

• Ask permission

Pressure to decide (if not urgent)

Myopic procrastination

• Focus on needs instead of losses ("Can I talk about what you might need in the coming months?")

• Highlight trade-offs

Number avalanche

• Focus on narrative-based scenarios (with numbers in back pocket if needed)

Unmoored preferences

• Explore GOC first

• Use preferences to clarify GOC ("Based on that choice, it seems like you might prioritize this the most?")

Sunk costs

• Clarify holistic prognosis early, including expected milestones

• Clarify limits early

Stalled decision-making

• Diagnose mental state (e.g., ambivalence, depression, delirium, etc)

• Bolster decision-making supports

• Time-limited trial

Lack of recommendation

Requests for potentially inappropriate treatment

• Clarify GOC - will the intervention serve the goal?

• Acknowledge, empathize, validate emotions

• Identify distrust and build rapport

• If truly physiologically futile, can decline to provide based on clinical judgment (rare)

• If irresolvable, may need ethics consult

Offering 3+ options

• Sometimes necessary, but can often be avoided by simplifying to two

• e.g., surveillance vs. ablation vs. or surgery can be simplified to surveillance vs. intervention

  • If they opt for intervention, exploring ablation vs. surgery