Goals-of-care conversations are often a gateway to hospice for many patients and families, and health care providers need to develop the skills necessary for effective discussions.

Effective goals-of-care conversations should be timely, compassionate, clear and patient-centered, helping families make a graceful transition and develop trust, according to Margot Allen, Division Director of Psychosocial Support for BAYADA Hospice.

Hospice News spoke with Allen about the key ingredients to a successful goals-of-care conversation, how providers can develop those skills and help communicate them throughout the health care continuum.

What does an effective kind of goals of care conversation look like?

When talking about an effective goals-of-care conversation, make sure that you’re involving everybody necessary. So we want to make sure that we’re prioritizing patient autonomy. So if the patient has the ability to make their decisions or make their needs known, we should be listening to them. The second is to let the patient and family lead that conversation.

If we go in with an agenda, it’s not going to go well. If we let the patient and family lead that conversation, it goes a lot smoother. We can certainly guide questions and discussion points, but letting them lead that and really have that control builds a lot of trust with the family. 

And then one of the things that I always stress is that we don’t go in and talk about the hard topics right away. We go and we build that rapport with patients and families. We want to get to know them, ask them if they have any needs in hospice. We always ask about symptom management, so making sure that they don’t have any active symptoms that we can chat with a nurse about or call the doctor about, and then we slowly work in to integrate those difficult conversations.

If I can sense that the family has some hesitations about entering certain conversations, I will always say to them: “Do I have your permission to be honest with you?” And getting that permission to be honest and tell them my interpretation, my understanding of their situation, goes a long way. I’m not telling them how it is, but I’m telling them my interpretation of what I’ve been told.

The biggest thing that I will get on a giant soap box about is making sure that we’re not framing hospice in a way that means that they’re giving up. Hospice is an extra layer of support. It doesn’t mean that we’re surrendering all care. It doesn’t mean that if a patient needs IVs, that we wouldn’t make an exception for certain cases. It’s not about giving up. It’s about making sure that they are comfortable and living out the remainder of their days.

What are some strategies that hospices can employ to foster better goals-of-care conversations?

One of the big ones is interdisciplinary team participation. Hospice is one of those unique industries where interdisciplinary teams are required. It’s not just multiple individuals or multiple disciplines seeing that patient. It’s multiple disciplines coming together to discuss that patient’s care and collaborate to make sure that we’re not missing anything.

 Another strategy that I always use is continuing education, so making sure that we’re providing our staff with the education and the tools and the resources that they need to care for their patients. Just because you go through school, it doesn’t mean that you’re set for the rest of your life to practice medicine, and so making sure that we’re continually improving their skills and allowing them that time to grow. 

If I have an important or difficult conversation that I need to have with a patient or family, I often rehearse that in my car, practicing how to deliver that conversation.

How can hospices help providers in other areas of the continuum recognize the importance of these skills?

So one of the greatest tools that we can offer are in-services to other community resources. It provides education to different communities, whether they be independent living, skilled nursing, but it also fosters that referral source relationship. Giving them that education is really helpful and really beneficial.

The other is just leading by example. If we provide excellent care, they’re going to want to provide excellent care as well. Excellence inspires excellence.

How can hospices reach patients in need when it comes time to have one of these conversations?

Building rapport is the biggest thing. If we don’t have rapport, and we don’t have the trust of the patient and family, we’re not going to get anywhere. It’s about building relationships. As health care professionals, we know what the typical disease trajectory looks like for patients, but that doesn’t mean that they understand it. So we have an obligation to ensure that they fully understand everything that’s going on and every possible outcome so they can make a true informed decision.