COMMUNICATION AND

ADVANCE CARE PLANNING

Tim Hiebert MD MSc FRCPC
Palliative Care Consultant
General Internist
WRHA
Objectives
• Acknowledge the stress of difficult conversations
• Recognise the importance of effective communication
• Recognise barriers
• Breaking Bad News
• Discussing ACP
• Semi urgently
• Urgent/emergently
• Develop an approach to decision-making that is focused on patient
values and priorities
• Become more comfortable in leading goals of care discussions
What is Advance Care Planning?
• The process of determining which treatments are most appropriate for a person in
the event that they can not speak for themselves and are facing a life-threatening
illness
• Is in force ONLY when patient is unable to speak for themselves.
• Typically covers:
• Name of Substitute Decision Maker (SDM) or proxy
• Whether to initiate BCLS/ACLS in the event of imminent death
• To indicate the focus of care.
• Should be tailored to anticipate decisions that may arise in a patient’s care:
• Resuscitation
• Intubation OR NIPPV
• Dialysis
• ICU care
• Comfort care only
Why is ACP Important?
• It is required by the WRHA and accreditation Canada for all inpatients
• It’s on the exam!
• Avoid litigation
• Avoid 4 am disasters
• Reduce inappropriate treatments/interventions
• Reduce burden on families and substitute decision-makers (SDM’s)

AND Importantly
• Patients deserve care that respects their values/priorities
• Providing Patient-centred care is highly rewarding
ACP often looks like this….
• Rushed
• Choosing from a menu:
“What would you like?”
“Do you want me to…?”
• Patient values and priorities not explored
• Stakeholders not identified (SDM)
• Patient often unable to participate (too late)
• Coercive
• Inaccurate, lack essential detail (esp in Wpg)
In Canada, ACP is done infrequently and poorly
• Most patients have not
discussed ACP prior to
hospitalization
• Hospital ACP documents at
accurate <50% of the time
• Often do not address
foreseeable issues and lack
specificity
• Studies show that Patient and
family choices do not reflect
their priorities
• Patients need guidance in ACP
decisions
• Physicians require an
understanding of patient goals
and priorities in order to guide
ACP
Why is ACP difficult?
External Factors Patient Factors
• Time • Inability to apply their values
• Timing • Inability to understand consequences
• Cumbersome forms of decisions
• Lack of continuity • False expectations
• Remuneration • Unwilling
Physician Factors
• Lack of Training/Mentoring
• Attitude
• Discomfort / emotions
• Uncertainty of prognosis
• “Not the right time”
ACP Should look like this..
• Involve the patient AND their chosen SDM (if available)
• Follow the model of shared decision-making
• Acknowledge emotions/feelings
• Explore patient’s values, beliefs, priorities
• Provide adequate information to patients/families so that they can
make informed decisions
• Treatment decisions should align with patient values/priorities in
the context of their medical circumstances.
• Be an ongoing conversation
So where do we start?
Advance care planning
• Non emergent, deliberative
• complex, sensitive discussions
• Working through the issues at the patient’s or family’s pace
• often a process rather than an event.
S Set up – suitable location, privacy, the right people

P Perceptions – Clarify understanding, answer questions

I Invitation – Get permission

K Knowledge – Provide information

E Emotion – acknowledge and respond with empathy

S Strategy / Summary – allow for questions again

https://youtu.be/FnS3K44sbu0

Taylor LJ, Nabozny MJ, Steffens NM, et al. JAMA Surg 2017;152(6):531-8.
https://www.hipxchange.org/BCWC.
ACP discussions during acute illness must be tailored to
the specific situation and address predictable events
Other Considerations
Considering Culture…
 “Don’t Tell Him He’s Dying…”
• Cultural considerations
• Don’t simply respond with “It’s their right to know”
• Patients have the right to accept or decline information – to dictate
the nature and pace of information sharing; they may indeed want to
defer to family
“Some people want to know everything they can about their illness, such
as results, prognosis, what to expect. Others don’t want to know very much
at all, perhaps having their family more involved. How involved would
you like to be regarding information and decisions about your illness?”

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Responding To Difficult Questions
• Acknowledge/Validate and Normalize
“That’s a very good question, and we should talk about it. Many people in these circumstances
wonder about…”
• Is there a reason this has come up?
“I’m wondering if something has come up that prompted you to ask this?”
• Gently explore their thoughts/understanding
• “It would help me to have a feel for what your understanding is of what is happening, and
what might be expected”
• “Sometimes when people ask questions such as this, they have an idea in their mind about
what the answer might be. Is that the case for you?”
• Give an answer if possible
• If you can’t then be honest. Offer to help find the answer
Tips in talking with SDM’s (patient can’t participate)
Decision-making with SDM’s
• For adult patients the SDM’s role is to provide insight into what the
patient would choose if they could speak for themselves
• They should not simply choose what they would want.
• An SDM should not be permitted to overrule documented ACP
discussions.
• SDM’s may not be accurate in their assessment of patient wishes.
Displacing the Decision Burden

“If he could come to the bedside as healthy as he was a month

ago, and look at the situation for himself now, what would he tell
us to do?”
Summary
• ACP discussions are extremely challenging
• They can provide peace of mind to patients and families
(and staff)
• Tools such as SPIKES and best case/worst case are very
useful
• Patient values, beliefs and priorities must be explored in
order develop an ACP that aligns with the patients needs.
Useful Resources
virtualhospice.ca
thecarenet.ca
advancecareplanning.ca