For some of life’s most difficult conversations, we have scripts in place to help guide you.
The following scripts provide examples of how you might discuss a patient’s concerns and needs about advance care planning. You may want to use this or a similar script in a role-playing exercise, alone or with another person, in order to experiment with, and individualize the wording and phrasing until you are comfortable and familiar enough with the content to use it as a framework for discussions about advance care planning with your patients. Keep in mind that these conversations should be tailored to the unique and specific circumstances of each patient. Most patients will fit into three main categories for conversational purposes:
- Young and/or healthy – no known underlying health issues or concerns
- Diagnosed with a chronic condition(s) or illness(es)
- Diagnosed with a life-limiting or terminal condition
Preparing for Your Conversation with Your Patient
The overarching goal of utilizing a script is to normalize conversations around advance care planning for the young and/or healthy, so that this becomes a normal part of their health care routine and a conversation they anticipate will be brought up by the physician or health care provider at least annually.
Once a patient is diagnosed with a chronic disease or condition, conversations about advance care planning can become more targeted and specific to the likely or anticipated disease trajectory and anticipated treatments and/or medical interventions they may require. As an example, for a patient with a diagnosis of COPD, the discussion should include exploration of the patient’s preferences with regard to intubation and mechanical ventilation should they experience an acute exacerbation of their disease that requires these interventions.
For patients with a life-limiting or terminal diagnosis, conversations about advance care planning become critically important and should be person-centered and very focused on the individual’s personal values, goals and priorities. Internationally recognized expert Dr. Atul Gawande suggests using the following, or similar questions, as a dialogue framework for developing a better understanding of each patient’s values and preferences for end-of-life care:
- What is your understanding of your illness and where you are currently?
- Tell me about your fears or worries for the future?
- What are your goals and priorities?
- What outcomes are unacceptable to you? What are you willing to sacrifice and not?
- And near the end of life, what would a good day look like for you?
For purposes of this first conversation script, let’s assume the patient is healthy.
“Mrs. Smith, I’d like to talk with you about something I try to discuss with all of my patients. It’s called advance care planning. What is your understanding of advance care planning?”
“Have you given thought to the type of medical care you would want to have or not have if you ever became too ill or injured to speak for yourself? That is the purpose of advance care planning, to ensure that you are cared for the way you would want to be, even in times when you are unable to speak for yourself.”
“I don’t want you to be frightened that there is something I’m not telling you. There is no change in your health or medical condition that we haven’t already talked about. I am talking with you about this today because it is a good idea for everyone 18 years of age and older to plan for the future, and to have their care preferences communicated and documented.”
“Advance care planning will help ensure that we have a shared understanding of your values and goals for your care if you were to become seriously ill or injured. When you are ready, you should document your preferences into an advance directive that I will make part of your medical record and this will be accessible throughout the Vidant Health system. Advance Directives include the Health Care Power of Attorney and Living Will, and these would come into play only if you couldn’t make or communicate decisions on your own.”
“Would you like to talk further about the kind of care you would want or not want to have if you were no longer able to communicate these directly?”
“Is there someone that you would feel comfortable designating to act on your behalf, to represent your choices as your Health Care Power of Attorney (agent)? This person should be willing and able to act as your agent, making sure your preferences for care are shared with the health care team in situations where you are unable to. The person you identify could be a relative or a friend, but has to be 18 years of age or older. Would you like to have this person included in our discussion?
“Here’s a form – provide the patient with a toolkit – that I would like to use to structure our conversation. I would like you to take this toolkit with you. We will talk about this more the next time you come in. Please think about and consider what gives your life value, meaning and purpose. You should fill out the questions section of the toolkit, talk about this with your family, or those closest to you and then write down any questions you have. The next time you come in to see me, please bring the toolkit, your questions and anyone you’d want to include in our follow-up conversation.”
Start by asking Mrs. Smith if she has filled out the questions section of the toolkit and had a conversation with her family or loved ones about preferences for end-of-life care.
“Mrs. Smith, are you OK with me asking you some questions about specific hypothetical medical situations so I can learn about your preferences for your future care needs?”
Then ask three Advance Care Planning building block questions:
- Who would you want to make decisions for you?
- What medical care would you want if you had a severe brain injury or other serious illness and were unlikely to recover?
- How might your religious, cultural or personal values influence your decisions?
“Let’s think about some situations that your particular illness could cause. This will give me and your other providers a better roadmap for knowing how to match our care with your preferences. Everyone is different, and there are no right or wrong choices. If you were (insert hypothetical scenario here that is relevant to the patient’s diagnosis and/or condition) what would you want?”
“Mrs. Smith, have you and your Health Care Power of Attorney/agent had a chance to continue the discussion we started at your last visit? Let’s go over your preferences together.”
Revisit the three building block questions: (and be sure to document the patient’s responses)
“I am glad we went through this planning process. I have a much better idea of what matters most to you. Knowing this helps me be better equipped to honor your choices both in our routine provider/patient relationship, and also in the event of a serious illness or injury.”
“You have identified (insert name of Heath Care power of Attorney/agent here) to serve as your Health Care Power of Attorney/agent. Would you prefer to have your Health Care Power of Attorney/agent stick closely to your preferences as stated in your living will, or would you prefer to give him/her room to make changes if he/she thinks your best interests would be better served by a different decision?”
“If you are ready to, we can write down your preferences in an advance directive. You will need to have two witnesses and have your signature notarized in order for the advance directive to be official. Once this is done, we can put your advance directive into your electronic health record (EHR) and it will then be accessible throughout the Vidant system.”
“Mrs. Smith, a year has gone by since we last discussed your advance directive and your preferences for care at the end-of-life. People sometimes change their minds, so I’d like to review the choices you documented last year to make sure these are still in line with your current thinking.”
“Be sure to include a summary of each conversation you have in the patient’s electronic medical record. This may be useful in supporting reimbursement and can also help trigger your recall of the prior conversations you’ve had with your patients and provide a meaningful context for other health care providers that may be involved in the care of your patient.”