1. Introduce yourself and your role. I would like to discuss the next steps in taking care of X.
2. Setting up the scene. Determine what the pt / family already knows.* Determine pt’s functional status prior to illness.
3. Deliver bad news. I would like to provide you with an update on X’s medical condition
- don’t focus on the medical, but rather on what is pt-centered: function, quality, and time of remaining life
- summarize condition with a bottom-line: ‘getting worse,’ ‘not going to improve,’ ‘dying and time is likely very short.’
4. Listen. Whether or not you use the word dying, when you have presented bad news (such as information about disease progression), the next step is for you to allow silence, and let the family/patient respond.
5. Respond to the questions as well as the emotions. Name and validate.
If the emergency physician recognizes that the patient is likely to die during this hospitalization, regardless of critical interventions, it would be reasonable to express to the surrogate “worry” about how dire the situation appears. It is also reasonable in such a situation to ask the surrogate about whether the patient had expressed, or if the surrogate has an understanding of, the patient’s goals, values, and perspective on medical priorities near the end of life. Had the patient talked about whether “dying on machines” was acceptable or unacceptable? Does “being comfortable in a peaceful situation if I am dying” sound more consistent? – from ACEPnow
- Determine the legal decision maker if available and review any completed advance directives.
- Complete a rapid goals of care discussion (see Fast Facts #223-227).
- Make recommendations. For example, ‘According to what you want for [the patient], I would/would not recommend….’
If comfort is the priority, then hospice involvement or a palliative care consultation might be the most important intervention.
* if you do not know the patient or family well, take a moment to build relationship. Ask a non-medical question such as I am just getting to know you. I had a chance to look at your chart and learn about your medical condition but it does not say much about your life before you got sick. Can you tell us about the things you liked to do before you got sick? Similarly, if the patient is not able to participate in the meeting, ask family to describe the patient prior to his becoming ill: As we get started, can you describe what Mr. Jones was like before he became ill?
-Could you please share with me what is important to you (to him/her) regarding what quality of life you would want for the rest of your life? I want to make sure I understand so I can what I can to help you get there.
-Thank you for sharing this. Knowing that  would want X, …
-It’s really hard not knowing whether or not you’re going to survive. Can I offer to contact a patient rep if you would like help contacting your loved ones during this difficult time?
This “resuscitation menu,” or asking “should we do everything if your heart stops?” is an ineffective way to have goals of care conversations. From the patient perspective, our medical expertise and knowledge mean that when we offer a treatment or a menu of options, they are reasonable and realistic options – when in reality, they may not be appropriate or in keeping with the patient’s values around the quality of life. Studies show that patients often have a poor understanding of CPR, intubation, and unrealistically optimistic expectations.
-for renal pts: hydromorphone (dilaudid) is the longer lasting choice compared to fentanyl