By Eric Shaban, MD, Regional Medical Director, VITAS Healthcare
Recent articles in Annals of the American Thoracic Society highlight why goals-of-care (GOC) conversations and advance care planning (ACP) sessions should be common in primary practices, specialty clinics, hospitals, and care facilities for patients facing the challenges of advanced lung disease and other advanced illnesses.
“Suggesting a goals-of-care conversation should be as commonplace in a clinician’s daily routine as taking vital signs.”
We want our healthcare colleagues to know that we are prepared at any time to step in and help facilitate these conversations on their behalf, and to follow up by providing expert end-of-life care in patients’ preferred settings so that they receive the comfort-focused modalities and support they want and deserve.
Engaging in and completing these conversations delivers measurable, high-impact results for all parties involved.
Where to Start a Goals-of-Care Conversation: 5 Questions
First, palliative care discussions identify key parameters for a patient’s care moving forward. Here are 5 questions you can ask your patient with advanced illness to help guide their care:
- “What do you understand about your disease?”
- “What are your fears and concerns about your worsening health?”
- “What is important to you?”
- “What do you want your medical care to look like moving forward?”
- “Are you ready to put your wishes and goals for care in writing so that you, your family, and your medical care team know your preferences?”
For patients, GOC conversations result in better outcomes and greater satisfaction with care. For healthcare providers, they result in goal-concordant care that delivers measurable cost savings for patients who have incurable diseases like advanced chronic obstructive pulmonary disease (COPD) or lung cancer.
Data cited in this quarter’s perspective (Ruggiero, R. and Reinke, L.), in fact, notes that the inclusion of palliative care—which is built around GOC conversations and advance care planning—saves an average of $3,237 per patient over the course of a hospital stay, compared with patients who do not receive palliative care.
Sooner Is Better
Our message to our non-hospice, non-palliative care healthcare colleagues is that the sooner these conversations take place, the better it is for everyone involved. Many patients with advanced lung disease, in fact, are eligible for hospice care long before these conversations occur.
Follow along with an example of an advance care planning conversation:
If physicians or specialists do not feel comfortable with these difficult-but-rewarding conversations, trained VITAS facilitators are always available to meet with patients and families—wherever they are and whenever they are ready to decide the course of their care as their health declines.
VITAS Can Help You Educate Your Patients
Just as we can help physicians overcome their unease or perceived lack of training to engage in goals-of-care conversations, we can help patients overcome their concerns about the transition to hospice care, by:
- reassuring patients that hospice care does not mean giving up the medications or treatments (e.g., inhalers, access to a respiratory therapist) that currently provide comfort and symptom management
- explaining the value of the interdisciplinary hospice team to address physical, emotional, and spiritual needs
- offering an individualized care plan and one of four levels of hospice care to meet their individual needs and goals
- adjusting medication delivery seamlessly as their symptoms worsen to maintain comfort (e.g., switch from inhaled medication to nebulized versions in the home)
- delivering the necessary equipment, medications, and supplies directly to them, wherever they prefer to receive care, usually at a cost saving
- easing the concerns of anxious family members and caregivers through regular team visits, training, educational materials, and 24/7 availability of VITAS clinicians to manage crises and keep their loved one comfortable
Goals-of-Care Conversations Should Be Commonplace
Our goal is to support our healthcare partners in private practices, specialty practices, hospitals, and care facilities. We want them to embrace a 360-degree view of advanced disease so that they know when it’s time to call VITAS for a goals-of-care conversation. Ideally, suggesting a GOC conversation should be as commonplace in a clinician’s daily routine as taking vital signs, interpreting laboratory findings, and exploring treatment options, particularly for those with advanced illness.
What are signs of hospice eligibility in a patient with advanced lung disease?
- A “no” answer to the “surprise question”: “Would you be surprised if this patient were to die in the next year?”
- Shortness of breath at rest or with minimal exertion
- More than 50% of waking hours spent sitting or resting (Palliative Performance Scale of about 50%)
- More dependence for activities of daily living
- Functional decline over time
We know that talking with patients about their disease and wishes is one of the hardest—and most important—activities that healthcare professionals can undertake, especially for patients with advanced illness.
Just as our hospice care teams and on-call clinicians are available 24/7/365 to provide end-of-life care, our trained physicians, nurse practitioners, and social workers are always available to start the conversation about the transition to comfort-focused care.