In medical school, physicians learn to use the power of medicine to treat disease and restore health. But when a cure might not be possible, many of us outside of palliative care lack training on how to initiate difficult conversations about serious illness with patients and families.
To improve the care of seriously ill patients at Baylor Scott & White Health, we sought an approach that would equip family physicians, internists, cardiologists, oncologists, geriatricians and others with the skills to have more frequent, better, and earlier conversations with patients about what’s most important to them. This approach allows us to take a patient-centered, population health approach to supportive and palliative care that also improves job quality for healthcare providers.
Palliative care is sometimes confused with hospice or considered to be a hospital service only for patients in their final days. In fact, palliative care is specialized medical care that seeks to provide relief from the symptoms and stress of a serious illness with the goal of improving quality of life for both the patient and the family.
Our philosophy is that supportive and palliative care is appropriate at any age and any stage of a serious illness and should be available in the outpatient and home settings. By training more non-palliative care clinicians to communicate effectively, we enable more patients and families facing serious illness to make earlier, more informed choices that reflect their values, reduce suffering, enhance family well-being, and improve quality of life. Research shows that discussing these issues eases patient stress and leads to better clinical outcomes and improved patient experiences.
An Evidence-Based Approach
We chose to adopt the Serious Illness Conversation and Care Planning Program developed by Ariadne Labs, a joint center of Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, because it is closely aligned with our own vision of supportive and palliative care. It is evidence-based and addresses clinician-behavior and system changes, such as making serious-illness conversations part of daily workflows, documentation, and follow-up. The program helps overcome barriers that non-palliative care physicians face by providing patient selection guidance, systems for conducting and revisiting conversations, and a process for measurement, feedback, and continuous improvement.
As part of the program, teams of our palliative care physicians based in North and Central Texas trained at Ariadne Labs in Boston to learn how to mentor other clinicians on using the program tools. Scott & White Medical Center-Temple began the program in October 2016, starting with oncologists, cardiologists, and geriatricians, and our North Texas hospitals are beginning this spring.
Clinician learners role-play with patient actors using the program’s conversation guide, which helps clinicians apply the tools and have more impactful conversations. The guide allows clinicians to get to what matters most to patients by asking often-overlooked questions, such as:
- What do you understand about your illness?
- What are your biggest worries?
- What gives you strength?
Physicians using the guide are pleasantly surprised by how effectively it draws out information about a patient’s priorities, values, and goals.
Easy to Implement
Almost any health system can implement key components of the program. An important first step is to identify who would benefit from these conversations. In our organization, we start with patients who we think could die within the next 12 months. We schedule time for the patient, family members, and care team to discuss their goals of care, including what trade-offs the patient might want to make—or is unwilling to make—to extend life. Then we create a document that reflects these desires and make the document available to the broader care team, including the hospital care team, through the patient’s electronic health record.
We are already finding that, in addition to creating a standardized document recording the patient’s answers to key questions, this process is prompting patients to prepare or modify advance directives.
The program is about asking people what’s most important to them, and the answer is not always living longer. Understanding priorities early supports the quadruple aim—better outcomes, better patient experience, lower costs, and improved job quality for healthcare providers—and ultimately leads to what’s best for patients.
Clifford Fullerton, MD, MSc, is president, Baylor Scott & White Quality Alliance, Dallas.