Doc, What Would You Do If This Were YOUR Father?

When families are faced with decision making at the end of life, the physician is there to provide accurate medical information, to serve as a resource, and just possibly to be a shoulder to lean on.  Is it "best care" for the physician to also share his personal opinion about what he would do...about the dialysis, the ventilator, or the vasopressors?  Or is this too intrusive or otherwise "out of bounds"?  In the December issue of the journal Pediatrics, several bioethicists opine on whether a neonatologist is acting in the best tradition of the profession...or not...when he makes a specific recommendation - against tracheostomy - in the case of a three month old neurologically devastated, former 23 week premie, emphasizing to the family that this child will never communicate meaningfully, enjoy most of what children typically experience, become independent, or live other than on life support in a perpetual state of chronic illness (1).

By and large, ethicists oppose a "directive" approach that effectively substitutes the values and preferences of the physician for those of the patient or his decision-making Agent.  The argument is that such a paternalistic approach is objectionable exactly to the degree that it infringes on the autonomy rights of the patient. In the same paper, a commentator suggests that a directive approach can be ethical if, and only if, four criteria are met.  As they apply specifically to the care of the infant in the above case, I will generalize them for our purposes: (1) how certain is the prognosis?...(2) how certain is the negative effect on the patient's and family's life if the life extending intervention is pursued?...(3) is the family adequately informed about the options?...and (4) will the physician's directive approach damage the physician-patient relationship? By this view, a directive approach will not pass muster if it fails any of the above tests.

On the other hand, there is a principle known as the "best interest standard" (BIS) that has been endorsed internationally as foundational to the ethical care of children.   The treating physician needs the permission of the child's parent to render major medical care, but he is ethically bound to refrain from seeking permission to carry out interventions that fail the BIS.  To some degree, this concept stands in opposition to unrestrained parental Autonomy and offers acknowledgement of the physician's own ethical values and responsibility.  

The pediatric case study cited above is both different from and similar to the situation in the adult ICU, where the intensivist is treating, for example, an 80 year old retired attorney with CML and multi-organ system failure.  The medical facts are different, of course.  The infant may (or may not) live for years on end after the contemplated tracheostomy, while the elder patient's lifespan is sharply demarcated.  One patient faces a potentially long but severely limited life, while for the other, the question is not whether the patient will die, but how.  In both cases, however, a "best interest" consideration arises.  Ethical distress, occurring when health professionals feel powerless to avoid inflicting unhelpful, injurious interventions on their patients, affects many nurses and physicians working in Critical Care settings and elsewhere.  Does the best interest standard, as it exists in the field of Pediatrics, have a parallel in adult Medicine?  Should it?

Arguably, this issue can be understood as a restatement of the "futility" problem. The narrowest definition of futility is applicable to interventions that will not achieve the desired biomedical goal (such as defibrillation restoring an effective cardiac rhythm).  There is strong consensus that the physician is not only entitled, but also duty bound to refrain from administering treatments that are known to be ineffective.  A "best interest" standard correlates better with a broad definition of futility that categorizes as inappropriate interventions that achieve physiological goals but fail to restore the patient to a state of health that is consistent with a "reasonable" quality of life, physical independence or, in some cases, personhood per se. On the other hand, broad definitions of futility face criticism from those who would argue that patient's values and preferences (and not the physician's) should guide decision-making when the issue is "quantity vs quality" of life.

There is also the issue of "quality of death."  When the condition is clearly terminal, and ongoing treatment is clearly burdensome to the patient, to what degree should Autonomy considerations (expressed through third parties who may or may not be capable of representing the patient) outweigh and over-rule the judgment of the healthcare team?  Shouldn't incapacitated adult patients also have the benefit of care from physicians who comply with a "best interest" standard? And if this is so, should the family not, at the very least, have the benefit of the physician's opinion?

What do YOU think?  Write to this blog.  Let's start a debate for 2017.

Ref: (1) Blumenthal-Barby J, Loftis L, Cummings CL, et al. Should Neonatologists Give Opinions Withdrawing Life-sustaining Treatment?. Pediatrics. 2016;138(6):e20162585

Thankful at Year's End...

Dear Physician,

As 2016 draws to a close, I want to take a moment to thank you for being a critical part of our ongoing growth, and our success at being the trusted source of high quality healthcare for patients and families in Suffolk County and beyond.  Because of you, Huntington Hospital was the top-rated community hospital in NY by US News in 2016, recognized also by the Joint Commission, American College of Surgeons and other quality organizations as providing exceptional care in specialties from Orthopaedics, Gynecologic Surgery, Breast Care and Bariatrics to Palliative Medicine and Oncology.  

Carrying on our medical staff's tradition of continuous improvement, a number of you made specific contributions to quality improvement initiatives.  I won’t even try, in this limited space, to list the individual physicians whose work is making this progress possible:  an Advanced Illness Collaborative is addressing the changing needs of our patients at the end of life, when curative treatment is no longer effective...the Sepsis Collaborative is continuing to make inroads in care that are decreasing mortality from this common condition, here at Huntington and across Northwell...an Anticoagulation Collaborative, now well established across our health system, started at our institution and continues its mission to reduce morbidity and mortality due to preventable venous thromboembolic events...a Critical Care initiative, known as ABCDE, is improving outcomes for ventilated patients through a “bundle” of evidence-based interventions.  This is a very incomplete list, leaving out the great work being done on our Perinatal service, in Emergency Medicine, at the Dolan Family Health Center and elsewhere.

None of this recognition and none of this improvement work would mean anything to us as physicians, if it did not reflect the reality of care at the bedside – one patient at a time receiving care that is clinically advanced, carefully coordinated and delivered by physicians who care deeply about those who come to our hospital seeking help at the darkest times of life.

I am grateful beyond words for your commitment to our shared profession, to Huntington Hospital and its mission, and to the families of our community.   Please accept my sincerest best wishes for this Holiday Season and for a New Year that brings good health, happiness and fulfillment.

Warmest regards,

Michael

Michael B Grosso, MD, FAAP

Ambiguity Tolerance and Quality

What single characteristic among practicing physicians do you think has been associated with all of the following clinical outcomes?

• increased test-ordering, 
• failure to comply with evidence-based guidelines, 
• increases in patient charges, 
• withholding negative genetic test results, 
• fear of malpractice litigation
• defensive practice, 
• increase rates of burn out, and
• discomfort in the context of death and grief

(Source: Geller G., Acad Med. 2013;88:581–584)

The answer is low "ambiguity tolerance."  I think we can add to this list two other characteristics, one of which is failure to make diagnoses (and I am referring here not to making the wrong diagnosis, but to the more subtle problem of avoiding the diagnostic process altogether).  The other involves clinical behaviors that result in harmful errors of overuse.  

Osler himself recognized that clinical life meant dealing effectively with problems of diagnosis and treatment in an environment of chronic uncertainty.  "In seeking absolute Truth" he wrote, "we aim at the unattainable."  Several factors have come together to exacerbate this problem for 21st century physicians.

One is certainly the division of labor which occurs in the hospital setting.  The contemporary Emergency physician has been trained to understand that his role is (1) to rule out a short list of life threatening conditions, and (2) to determine which patients are sick enough to require admission.  Note that neither of these activities necessarily requires that the physician make a diagnosis.  In this way the uncertainty problem is neatly sidestepped.  

Of course, this only moves the problem downstream.  (For the treat-and-release patient whose presenting problem was "headache" and whose discharge diagnosis is also "headache" the downstream physician is in the community.  Happily, such physicians still make diagnoses).  For the admitted patient, it is typically a hospitalist who is faced with the dilemma of making diagnoses.  Where the patient's complaint (say, dyspnea) could be the result of more than one disease process (say COPD, pneumonia or heart failure) there are two common strategies for avoiding diagnostic uncertainty - treat for all three, or call consultants (or both).  Unfortunately, this approach leads to overtreatment, and occasionally to contradictory imperatives.  (Do we increase the fluids, consistent with sepsis management, or restrict them as part of heart failure care?)  

A second factor is the electronic health record itself.  For a host of reasons, what was once a standard summation of the case, pulling together the key points from the history, exam and testing, ending in the same sentence with a working diagnosis ("...most consistent with community acquired pneumonia complicating the patient's chronic systolic heart failure...") is now a series of hashtag items syntactically disconnected (...#dyspnea #hypoxemia #HF #CAP...) thus leaving the reader free to interpret the writer's mental model of the case in any variety of ways.  This also relieves diagnostic uncertainty.  The less one commits to statements of diagnosis or symptom causation, the less likely it is that one can be wrong.

A third factor comes from the quality movement itself.  The PDSA model for improving "processes" took as its premise that 100% of patients with diagnosis X should receive treatment Y, where Y is an intervention supported by evidence, expert consensus or both.  So far, so good.  The problem is that as a healthcare community we came to believe that the underlying implication of this model is valid - which is that the first step of the process, i.e. making the diagnosis, is fairly trivial.  As we know, it is NOT!  All the focus has been on getting from X to Y, when getting to X is arguably the deeper problem.  

Additionally, this model of improvement tends to focus single mindedly on errors of underuse - failing to give the thrombolytic or the beta blocker or the antibiotic.  However, where diagnostic uncertainty is managed poorly, the usual error is the reverse - exposing patients to known risks of a host of interventions where the likelihood of benefit is very small. 

And so my Christmas wish list includes the following for all of us who care for patients...that we rediscover the value of the expert generalist...because there's no "dyspnea specialist," other than the internist, family physician or pediatrician...that we take seriously the issue of overtreatment (primum non nocere), and...that we rediscover the age old but still needed process of taking an incisive history, performing an accurate physical examination, and ordering tests only to confirm or rule out hypotheses, which is to say that we rediscover how to brave the blizzard of ambiguity, following the North Star of clinical reasoning to reach the all-important destination that is the diagnosis.  

Physician BURNOUT - Addressing the Epidemic

"Burnout" involves pervasive feelings of stress, anxiety, disconnection and helplessness and leads to loss of joy in work, or depression, or, for some, abandoning clinical medicine altogether.  How common is it among our colleagues?

Much too common, according to a 2015 national survey that found 46% of physicians reporting that they were "severely stressed," up from 38% in 2011.  As dramatic was that 89% acknowledged a desire to leave their current position, ranging from hopes of joining another organization to changing careers altogether. 

What Healthcare Leaders Need to Know about Burnout

Of course, practicing physicians know through lived experience why burnout is important. Relieving feelings of stress, helplessness and depression are a worthy end in themselves.  Certainly, if such was the plight of any patient we would be getting busy finding solutions.  But why else, other than sheer humanity, should healthcare leaders care?  

It turns out that this problem has too many costs to ignore, and they begin with quality of care.  Studies have found, not surprisingly, a correlation between burnout and medical errors.  Other investigations have shown that physician empathy, an early casualty of burnout,  is associated with patient experience of care, adherence to medical advice and clinical outcomes for conditions including diabetes and others.  Additionally,  burnout drives up the risk of medical malpractice claims and through attrition of the medical workforce increases costs for organizations that must accelerate expensive recruitment efforts.

What Burns Us Out

One thing that everyone studying this issue agrees about is that burnout is "multifactorial."  Work compression - having to do more with less - is a major theme.  From what I see in our hospital, this problem sits at the intersection of two related forces - the electronic health record ("version 1.0") and administrative burden.  

I would assert that every hospital in the US that migrated to an EHR without an adjustment in the number of core clinical staff effectively reduced its professional workforce by 10 - 20%. Where, you might ask, is the evidence?  This phenomenon is hard to measure.  But working and documenting in an electronic environment is so fundamentally different that one could argue the converse - that the burden of proof belongs to those who would hold that the EHR is work-neutral.  The fact is that work compression due to electronic charting is quite real.  (It is more than conceivable that a future generation of technology will close the efficiency gap, but this felicitous state is years away.)

Additionally, various quality improvement initiatives have piled on scores of things to include that physicians never thought to write about before.  Why an aspirin wasn't given, or a beta blocker, or an ACEI; why the antibiotic was selected, why the antibiotic was not selected, why the heparin was given, why it was stopped, why physical therapy was not ordered, and on and on.  Additionally, as these national projects come in and out of existence (like short-lived elementary particles), we send the memo - oh, you can stop worrying about documenting that; the federal government is no longer tracking x, y or z.  And then there is clinical documentation improvement (or CDI).  A certain kind of specificity is critically important for optimizing revenue, and certainly consistent with good practice. But it's still one more thing. 

Frustratingly, the practicing physician really can't object to any one requirement.  Documenting smoking cessation education (no longer tracked), or the number of days of overlap thromboprophylaxis, or the heart failure subtype?  Each is totally reasonable.  But when each physician spends each day crossing a minefield of such "opportunities for error" without even getting to the actual process of figuring out what the matter is with the patient or what to do about it, we have the ingredients for burnout.

But there is more.

Certain physician groups in particular - Hospitalists, Emergency physicians and Intensivists, among others - are critical to making hospitals run.  Paradoxically, rather than elevating their roles in achieving high performance in domains such as quality, safety, patient experience, efficiency and throughput, as leaders we continue to layer on mandates that may conflict directly with their professional obligation to direct their skills, experience and judgment to taking the best care possible of each and every patient.  And so, even as the profession of Nursing has systematically prioritized autonomy and the caregiver's role as patient advocate, in Medicine we have done almost the opposite, going so far as to treat these phenomena as a wrench in the system to be identified and eliminated.

How do we move forward?

I have had the opportunity to work for the past several months with a Northwell Task Force on physician wellbeing consisting of physician leaders, a psychologist, an attorney and other administrative staff.  Two kinds of action seem warranted. Easiest is to equip physicians with more resources to sustain their inner equilibrium in the face of the current, very challenging environment. Focus areas involve stress reduction, wellness and work-life balance education and support.  In the short run, this may be important, despite the fact that it fails to address the root causes of the problem.  

In the longer run, however, we will need to rethink the work of physicians fundamentally, and determine how exactly we should resource our colleagues to ensure personal satisfaction, professional growth and sustainability - for their sakes, to be sure, but most especially for sake of the patients and communities we serve. 

   

Healthcare in Revolution: The Year in Review

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness…"  

The revolution in healthcare continued unabated in 2015.  From the joy of training future physicians to the frustrations of the ubiquitous EMR…here are a few highlights of the year just past.


Resident Training. The center of gravity of the Glen Cove Family Medicine Residency program starting shifting to Huntington in 2014, and last year in-patient education for these trainees became fully integrated into our Departments of Medicine, Obstetrics, Pediatrics and Surgery.   Dr. Kraydman led the FM Medicine teaching service while Drs. Fred Diblasio, Bob Zingale, Bob Scanlon, Adriana Garrite and others provided oversight for experiences in Critical Care, Surgery, Obstetrics and Palliative Medicine respectively.  Residents achieved exceptional scores this year in the ABFM In-training exams, outperforming the national mean and, for third year residents, doing so by an impressive 77 points.   The residents and faculty are grateful to the many other members of our medical staff for all you do to make them better doctors.

The CMS Joint Replacement Bundled Payment project gained momentum with Orthopaedics Chair James Gurtowsky at the helm. This federal program seeks to encourage innovation to improve quality and efficiency across a number of conditions and treatments. Our orthopedic surgeons collaborated with their hospitalist colleagues and many other disciplines to achieve better outcomes at lower cost by standardizing care, improving care coordination, emphasizing patient engagement and reducing avoidable complications.

Emergency Medicine. To address serious staffing deficiencies in Emergency Medicine, we cross-credentialed dozens of these physicians across sites, while bringing in new Nursing leadership to ensure that our ED was staffed to meet the community's needs while creating a practice environment to attract and retain the best practitioners.  We also recruited a full time, board-certified Director of Pediatric Emergency Medicine, Adam Litroff, to support the care of almost 10,000 children who visit our facility each year.  Meanwhile, construction on a facility that will more than double the size of our current ED is on or ahead of schedule.

ICD-10. After multiple mis-fires, the federal effort to launch the 10th Edition of the International Classification of Diseases came to fruition on October 1st.  Hundreds of you complied with our Health System's mandate that you receive education to prepare you for the enhanced documentation requirements, and we thank you for that.  (More to follow, as our clinical documentation initiatives ramp up in 2016…)

Electronic Health Records. You continued functioning in the era of the EMR. Congratulations!  Dr. Robert Wachter (the individual who coined the term "hospitalist" and stands among the most articulate observers of the patient safety movement) did "a 175 degree turn about" on electronic records: previously a dewey eyed apologist for the digital revolution, Watcher catalogued the serious defects of EMRs in a Times Op-Ed piece this past year.  Rather than a being a "disruptive technology" in the trendy, positive sense of "game-changer," he acknowledged that up to now, electronic records have been just "disruptive."  Fortunately, many of you are contributing to the ongoing improvement of our EMR and will be helping with the migration to a new platform in 2017.  Together, we will achieve a state in which electronic charting is an indispensable tool and not an obstacle to practice.

School of Medicine. In May, the Hofstra - NSLIJ School of Medicine graduated its first class.  More than 60 of you serve as active faculty, mostly as community preceptors to these medical students as part of the their Introductory Clinical Experience, a "doctoring" course that not only serves as a practice space for physical diagnosis, but also as a mentoring experience, where students can learn through seeing and doing what it means to be a caring, patient-centered, and personally accountable Physician.   

Awards and recognition.  With your help, Huntington continued to be recognized by quality organizations as a leader in providing safe and effective care to our patients.  The national LeapFrog Group assigned the hospital an "A" rating for patient safety.  US News ranked Huntington in the top 10% of centers in the state. The AHA and American Stroke Association conferred "Gold Plus" recognition for quality of care for patients with stroke and cerebrovascular disease.  Other designations include Center of Excellence designation for Minimally-invasive gynecological surgery, breast surgery and Bariatrics, and the Joint Commission's Disease Specific Certification "Gold Seal" for Hip and Knee replacement and Advanced Palliative Care.

End of Life Care.  There is no aspect of medical care that requires more professionalism, skill or wisdom than decision-making at the end of life. Improvement efforts are underway, with your help, locally and System-wide.  At Huntington, we revitalized our Bioethics Committee this year, committing to a three part agenda of education, consultation and systematic policy review. Some of you are also involved with the NSLIJ Advanced Illness Collaborative project, which seeks to improve our collective ability to engage patients and families compassionately and effectively in thinking about how we die.  Based partly on the ACP "Conversation Project," the Collaborative aims to improve the quality of dialogue between caregivers and families about end-of-life options, acknowledging that supporting autonomy, promoting the patient's best interest and avoiding harm are important but sometimes conflictual aims and values. 

It remains a great source of honor and personal satisfaction for me to serve the Huntington Hospital medical staff.   I thank you for your efforts on behalf of patients, for your devotion, your intelligence and your forbearance, and I look forward to what we can achieve together in 2016.

We are all Palliative Physicians

70% of us say we prefer not to die in a hospital. Yet, 70% of us die in hospitals, too often tied to a ventilator, on vasopressors, either unconscious or in distress.  

Last week, over one hundred physicians, nurses, and other health professionals gathered at the Feinstein Institute for a day-long learning session on Advanced Illness.  Some conferences add to what you know.  Once in a while, as in this case, a conference changes the way you think. 

Some of the take-aways are obvious.  Conversations about end-of-life care need to happen long before the patient arrives in our ED or in the ICU.  So we need to engage our community partners.  These encounters are hard to have in the office (with or without federal funding) and hard to have in the hospital, because they are emotionally stressful, because they take time we don't always have, and because we need better skills.  Additionally, advance directives don’t solve the problem.  Identifying a healthcare Agent is a good idea.  But what good is it, really, if the physician and his team lack the skills to guide the individual, respectfully and empathetically, through the difficult choices to be made, honoring the patient’s autonomy while providing clear professional advice?  And Living Wills are of little help, with their boiler-plate language which rarely squares with clinical reality: “I want to forego X, Y and Z…in the event that there is no reasonable hope of my recovery…”

Here’s the real crux of the issue.  Too often we fail to grasp the essential question.  And so, with the best of intentions, we ask meaningless, or even harmful questions:  “Do you want us to do everything?”…or this variant… “If your heart were to stop, what measures would you like us to take?”  At their core, questions like these ask “which do you prefer, Mr. Smith, life or death?”  This question and its variants, often asked in a vacuum, are unhelpful, confusing and distressing to patients and families.

How, as a medical community, can we do better? First, we must listen closely, and that includes listening to ourselves.  If we were the patient, would we sound like we care? And like we were making sense?   Second, we need helpful guidelines for end-of-life discussions.  I have excerpted below a standard reference in the field of Palliative medicine.  Not every discussion will be a fully formed family meeting.  But there are steps that must precede any discussion about the plan of care when cure is no longer a realistic goal.  (A training program for practitioners is just now getting underway at our Center for Learning and Innovation.)


Ultimately, we need to learn to move beyond harmful questions -- “Do you want everything done?” -- to dialogue.  What is most important to the patient?  Is it comfort?  Is it the ability to interact with others? Is it independence? Or is it another day or week of life, until a relative arrives or an anniversary happens or just because the person’s values are such that prolonging life even a little trumps all other considerations?  Given that death is not optional, the ultimate question is “from what you know, what kind of death would mom have wanted?” The answers simply can’t be obtained from a check-the-box kind of interaction.  They require conversation. The key point is that as health professionals, we don’t advocate death, and we don’t help patients chose death.  However, as death draws nearer, we have an obligation to learn what patients and families understand about the situation, fill in the gaps, engage the family about what matters to the patient, and then make clear recommendations about how to move from curative measures that wont work to comfort measures that will.    

Ms. Smith, I have conferred with our team of physicians.  It is clear that your dad’s heart, lungs and kidneys are failing and he is not going to get better.  Basically, we have three choices.  We could admit him to the ICU.  He may need a breathing tube and then probably a feeding tube.  When his heart stops, we could do “CPR,” which means pressing very hard on his chest and shocking his heart.  Sometimes ribs break when we do this, especially in frail elderly people like your father.  The odds are less than 1/20 that CPR would work at all, and even less that he would ever be conscious after that.  Almost certainly, he would die in the ICU with the tubes.  A different option is to elect “Comfort care” at this time, which means that we would focus on pain relief and medications to keep him from the discomfort of feeling short of breath.    There is a third choice, and that is to provide medical care that will not tie him to a machine, while treating what problems we can, without invasive measures.  It is still uncomfortable to be in a hospital bed, but not as distressing as the ICU.  This care could include fluids, antibiotics and other medications, as well as pain relief and attention to his comfort.  As doctors, we aren’t perfect at predicting exactly when death will happen.  It is possible that the ICU could prolong dad’s death by a number of days, or maybe not at all.  Based on what you have told us about his wishes, our recommendation is that we avoid the most invasive care.  I suggest that as he declines we protect him from CPR and from ICU care.  I don’t think either one is in his best interest.  I know these are never easy decisions. We are here for you and for your dad. How does this plan sound to you right now? 


Once a plan of care is established, it should not be disrupted casually, because a consultant has a different point of view, or accidentally, because the care team has not communicated the family’s wishes internally, or because multiple hand-offs have thrown a wrench into our efforts to provide well-coordinated care.  As patients decline and the end draws nearer it becomes more important than ever that we function not so much as a team of experts, but as an expert team.

We know that as physicians it is our role to help - this is our motivation and our defining characteristic.  This is also the principle of beneficence, and it stands arm-in-arm with the reciprocal obligation to avoid harm ("non-maleficence").  What this means, practically speaking, is that we should never feel compelled to offer interventions that in our judgment will not help, and most especially we should avoid these when they add to suffering.  Sometimes the pursuit of these principles will put us at odds with a family.  But there are those around you who can help, including our colleagues in the Palliative Medicine program, the Bioethics consultation service, and, finally, clinical leadership.

There is tremendous opportunity here.  I look forward to working with many of you - our exceptionally committed and talented physicians -  to spread information, skills and a new culture of caring that does credit to our institution and does right by the patients and families who depend on us.
  

Communicating about Withholding or Withdrawing Therapies and 

Shifting Goals from Cure toward Comfort, Dignity and Quality of Life

1. Establish the Setting
Review relevant information.	Patient's prognosis Outcome of therapy in question in this patient
Make sure the right people are there.	Patient's or surrogate's loved ones Staff
Find a comfortable, quiet location.	Places for everyone to sit Seclusion from others Ability of everyone to see and hear each other
Introduce the topic for discussion.	“I was hoping we could talk about the next steps in your care.”
2. Review the Patient's Situation
Elicit the patient's or surrogate's understanding.	“Can you tell me your understanding of what is going on with your medical situation?” “What have the other doctors told you about your dad's medical situation?”
Educate as needed.	“That's right, the cancer has spread. What that means is that although there are treatments to control the symptoms, we can't cure the cancer.”
3. Review Overall Goals of Care
Elicit goals from the patient or surrogate.	“Did you talk with Dr. Smith about what the goal of your treatments should be?”
Summarize to confirm.	“So it sounds like the most important thing is to make sure your father is comfortable.”
4. Relate Your Recommendation for Withholding or Withdrawing Treatment
Introduce the specific treatment to be discussed.	“Today I wanted to talk about what we should do if your breathing gets worse, including whether we should use a breathing machine.”
Ask about previous experience with the intervention in question.	“Has anyone ever asked you about being on a breathing machine?”
Describe the intervention in question and its benefits and burdens for this patient.	“Based on what we’ve talked about—the fact that this cancer isn't curable—the chance of being able to come off the breathing machine would be very low.”
State your recommendation.	“I recommend that if your breathing gets worse we don't put you on a breathing machine.”
Describe how you feel your plans are consistent with the patient's overall goals.	“The reason I think we shouldn't is that you said you wouldn't want your life to be prolonged if there wasn't a good chance of recovering to where you are now.”
Describe what treatments will be provided.	“We will use medicines to improve your breathing and comfort.”
5. Respond to Patient or Surrogate Reaction
Acknowledge emotions.	“It's hard getting to this point, isn't it?”
Is the recommendation consistent with patient's values and goals?	“How does that plan sound to you?”
Answer questions.	“I’ll be around if you think of things you want to ask me later, but are there questions can  I answer now?”
6. Summarize and Establish Follow-Up
Summarize.	“Good. So we’ll keep the antibiotics going and give you medicines if the breathing gets worse, but we won't put you on a breathing machine.”
Explain the next steps in treatment.	“We’ll plan on keeping you here in the hospital for the next few days and see how things go.”
Arrange for the next meeting.	“I’ll see you tomorrow on rounds. Please have your nurse page me if you need anything before then."