Death is an uncomfortable topic, even – and often especially – for clinicians, whose first priority is to improve health.
But avoiding discussions about goals and preferences in serious illness is a disservice to patients. An innovative program at BWH aims at improving the quality of care for such patients by encouraging earlier conversations about their personal goals and values, as well as fostering a better understanding of their prognosis.
“We recognized that some patients were dying without ever receiving the palliative care services they needed,” said Joshua Lakin, MD, a physician in the Division of Adult Palliative Care at Dana-Farber/Brigham and Women’s Cancer Center. He believes this was largely due to the fact that conversations between providers and patients about long-term care goals were happening too infrequently, and when they did occur, they were often very late in the illness course.
In response to a need to promote these “goals of care” conversations, an interdisciplinary leadership team representing Social Work, Palliative Care, the Hospitalist Service and Population Health Management formed the Speaking About Goals and Expectations (SAGE) program. The team used the Serious Illness Care program, originally created by Ariadne Labs – a joint initiative of BWH and Harvard Medical School – as a framework for a training program to help physicians engage hospitalized patients in discussions around their goals and values, and incorporate patients’ wishes across all aspects of care. The program earned a 2016 Success Story Award from Press Ganey last month.
“The idea is to get doctors to ask patients about their goals in a big picture view of their illnesses,” said Lakin, a member of the SAGE team.
“What are their worries? If their conditions worsen, what can they not live without? We strive to help patients receive long-term care that aligns with their values and preferences, and ensure that all providers involved with their care are part of these conversations.”
The SAGE team has trained 83 percent of the 35 hospitalists it initially identified as eligible for training. The team plans to complete more trainings within that group and expand the program to other departments.
COMMUNICATING GOALS OF CARE
The two-and-a-half-hour group training sessions cover communication skills and best practices for talking with patients about long-term goals related to their care. Participants have the opportunity to practice these discussions with medical actors who play the roles of patients. SAGE instructors provide feedback and offer ways for trainees to better promote and talk about goals of care.
Adam Schaffer, MD, a hospitalist in the Division of General Internal Medicine and Primary Care, completed the training and is now a champion for the program.
“The simulation with the actors is incredibly valuable,” Schaffer said. “Having these types of conversations can be intimidating because it’s something physicians often receive minimal training for. Practicing with an actor really helped me gain confidence.”
Physicians who complete the training continue to receive support from SAGE’s interdisciplinary leadership team, including clinical social worker Catherine Arnold, MSW, LICSW. Arnold lends her expertise to doctors who may experience difficulty in keeping these conversations moving forward. She also ensures information is shared across transitions of care so that ambulatory and post-acute providers understand patients’ goals for their treatment after discharge or upon readmission.
“Some cases can be more challenging than others, which really emphasizes the importance of an interdisciplinary approach. Our physicians know they can always come to me for support interacting with patients and their families,” Arnold said.