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Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions

Cooper, Zara MD, MSc*,†,‡; Koritsanszky, Luca A. MPH*; Cauley, Christy E. MD*,§; Frydman, Julia L. BA; Bernacki, Rachelle E. MD, MS*,||; Mosenthal, Anne C. MD**; Gawande, Atul A. MD, MPH*,†; Block, Susan D. MD*,||,††,‡‡

doi: 10.1097/SLA.0000000000001491

Objective: To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies.

Summary Background Data: Improved communication is increasingly recognized as a central element in providing goal-concordant care and reducing health care utilization and costs among seriously ill older patients. Given high rates of surgery in the last weeks of life, high risk of poor outcomes after emergency operations in these patients, and barriers to quality communication in the acute setting, we sought to create a framework to support surgeons in communicating with seriously ill, older patients with surgical emergencies.

Methods: An interdisciplinary panel of 23 national leaders was convened for a 1-day conference at Harvard Medical School to provide input on concept, content, format, and usability of a communication framework. A prototype framework was created.

Results: Participants supported the concept of a structured approach to communication in these scenarios, and delineated 9 key elements of a framework: (1) formulating prognosis, (2) creating a personal connection, (3) disclosing information regarding the acute problem in the context of the underlying illness, (4) establishing a shared understanding of the patient's condition, (5) allowing silence and dealing with emotion, (6) describing surgical and palliative treatment options, (7) eliciting patient's goals and priorities, (8) making a treatment recommendation, and (9) affirming ongoing support for the patient and family.

Conclusions: Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.

*Ariadne Labs, Boston, MA

Department of Surgery, Brigham and Women's Hospital, Boston, MA

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA

§Department of Surgery, Massachusetts General Hospital, Boston, MA

Harvard Medical School, Boston, MA

||Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA

**Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ

††Department of Psychiatry, Brigham and Women's Hospital, Boston, MA

‡‡Department of Medicine, Brigham and Women's Hospital, Boston, MA.

Reprints: Zara Cooper, MD, MSc, Brigham and Women's Hospital, Department of Surgery, 75 Francis Street, Boston, MA 02115. E-mail:

Sources of support: Joint Center for Health System Innovation, Brigham and Women's Hospital.

Disclosure: The authors declare no conflict of interests.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.