5 - Planning for the Future: Discussing What’s Important, Well Before a Crisis

Summary

Most clinicians prefer that patients plan for their future illness care before things become urgent or they lose the ability to make decisions. Completing an advance directive form by itself does not always impact future care decisions. Rather than focusing on hypothetical specific treatment decisions in the future or the completion of forms, conversations early in serious illness focusing on what matters most to patients may help guide care decisions over time and prepare patients and families for future conversations about specifics in real time when things do progress. The key is to plan on multiple small conversations over time. A roadmap for having these early goals of care discussion is PAUSE (Pause to make time for the conversation, Ask permission to discuss the topic and explain why, Uncover values first (don’t lead with code status), Suggest selecting a surrogate, Expect emotion/End). Some patients shy away from considering a future state when their disease has worsened, and are not interested in talking about what matters to them. Exploring why using a motivational approach and focusing on your relationship may help plant the seed and make future conversations easier.