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RPACE - Conversation


Conversations about a person's values and beliefs can be started at any time; ideally before a diagnosis of serious illness, in the form of Advance Care Planning.  Conversations about a person’s wishes for care can be initiated at any stage of their illness journey -- from the time of diagnosis until end of life. Using identification tools, those who are at high risk of health deterioration can be prioritized to have a conversation as soon as possible. These conversations can assist clinicians in framing future recommendations for care and treatment in a way that is meaningfully aligned with the patient's wishes and values. Based on the conversation outcome, we can integrate a palliative approach if the person's values are aligned with the philosophy of palliative care.  It is important to realize that a person’s wishes and priorities can change over time as their health changes, and that these conversations need to be revisited over time and may lead to changes in a person’s Advance Care Plan.


Conversation frameworks

Serious illness conversation

The Serious Illness Conversation Guide is an evidence based tool that uses patient-tested language to assess a person's wishes and goals in the context of their serious illness. It was developed by Ariadne Labs in collaboration with the Harvard T.H. Chan School of Public Health. The Guide features 9 different questions and includes guidance on how to start and end the discussion. It utilizes "hope… worry" and "wish… worry" statements to support honest but senstive communication about the reality of the illness.

Download the Serious illness conversation guide:

Watch the VCH video of Serious Illness Conversation demonstration.

For conversation guides in multiple different languages, see the translation page.

The four questions framework

The 4 questions framework was developed by Coastal Community of Care in VCH. These questions help teams learn about a person's understanding of their illness, priorities, hopes and fears.

Download the Coastal four questions to guide goals of care conversations:


The four questions framework

The 4 questions framework was developed by Coastal Community of Care in VCH. These questions help teams learn about a person's understanding of their illness, priorities, hopes and fears.

Download the Long-Term care four-question framework: 


The AFIRM framework

This framework assists clinicians navigate conversations with family members who voice a concern or notice a change in a resident's health.

Download the AFIRM framework: 

 

Conversation tips

Conversation Don'ts: Things to avoid

Conversation Dos: Instead...try these

Do not provide facts in response to emotions. Do not assume that you know the reason for their emotions.

  • Allow for silence.

  • Explore their emotions. Ask them "Tell me more..."

Do not make the conversation more about what you have to share.

  • Clinican should talk < 50% of the time.

  • Listen and empathize.

  • Gather information about them so that you can make recommendations that resonate with their situation and their wishes.

Do not user formal medical terminiology.

  • Use vocabulary appropriate to the patient's level of education and understanding of their condition. (E.g. breathing machine with a tube down your throat rather than intubation and mechanical ventilation).

  • Check that you have understood their responses correctly by paraphrasing what you've heard them say.

Do not give false hope or make premature promises.

  • Be open and honest. Use "I wish/hope...but I worry...and I wonder..." statements.

  • Your "wish/hope" should align with what you've heard them say. This allows them to feel heard.

Do not provide patient with a list of menu options.

  • Make a recommednation that alighs with what matters to them and what is likely to assist them in achieving their wishes.

Do not make the conversation about life or death.

  • Recognize that there is more to life than quantity/time. This is about quality of life and the circumstances that patients find acceptable and unacceptable for their unique future.

Do not talk down to patients or convey closed body language.

  • Sit down at their level.

  • User open body language (e.g. uncross arms, lean into conversation, nod your head in affirmation).


SOURCE: RPACE - Conversation ( )
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