“You should have a bit of a system to what you’re doing” when communicating prognoses in the subacute and long-term care settings, said Nivedita Gunturi, MD, during a session entitled “Prognostication and Goals of Care: Best Practices to Assess, Communicate a Prognosis and Conduct Family Meetings” at the 2022 Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine.
Communication about prognoses and goals of care can be more successful, comfortable, and empathetic, Dr. Gunturi advised, if one uses a framework like REMAP:
REMAP is one framework that offers a roadmap for difficult conversations, she said, about serious illness and end-of-life planning. REMAP was originally developed for oncologists but has broader applicability (J Oncol Pract 2017;13:e844–e850).
The conversation should be set up to address “the big picture [and not] the weeds,” Dr. Gunturi further advised. Clinicians should first ask families about their understanding of where their loved one is with the illness, using phrases like “‘help me understand,’ or ‘I would love to find out’ what other people have told you so I know I’m on the same page,” Dr. Gunturi said.
Clinicians should also seek families’ permission to provide their perspective and ask families how much they want to know.
Then, in keeping with the “reframe” component of REMAP, the clinician should provide some indication that bad news is coming (e.g., “things have changed”) followed by a concise, five- to seven-word “headline” of the news (e.g., “Dad’s time is short” or “the cancer has spread”).
“This is an important part, because this is where the optimism and the wish to sugarcoat [prognoses] gets in the way,” said Dr. Gunturi, referring to research that has demonstrated providers’ tendency to overestimate prognoses and then communicate further optimism.
The “expect emotion” part of REMAP requires a pause to allow the family members (and the patient, in some cases) to sit silently with their emotions. “They break the silence. They may break it with tears, with questions, with anger,” said Dr. Gunturi, “but [by waiting], you’ll then know how to respond.”
One tool that can be helpful at this point is known as NURSE statements: Naming, Understanding, Respecting, Supporting, and Exploring. “You can use ‘I wish’ and ‘I hope’ statements ... if that works for you,” she said. She added that she particularly likes NURSE statements that show respect and empathy, such as “I really admire how much you love your dad, how much support you’re giving him.”
Avoiding Burdensome End-of-Life Transitions
The “map out values” component of REMAP may involve questions about goals, hopes, and fears (e.g., “What is a good day?” and “What is important to the patient?”). When relevant, this may include questions about whether hospitalizations have been helpful.
“You can ask, ‘The last time you went to the hospital — was it helpful? Do you feel like you came back stronger?’” Dr. Gunturi said. This question is an important one, she emphasized, considering that many patients have multiple hospitalizations and intensive care admissions in the last 90 days of life.
In recommending a plan, after again asking for permission, it’s advisable to describe the plan before naming it. For instance, “describe what hospice is, and ask, ‘Does this sound like what [the patient] would want?’” advised Dr. Guntari. “Then you can say, ‘It’s called hospice.’”
Prognostication and communication are increasingly important for subacute patients, who often have unrealistic expectations of their prognosis after coming from the hospital, said Magdalena Bednarczyk, MD, during the session.
“We’re finding that patients don’t often understand the diagnosis or the prognosis,” she said. “And in the hospital, there’s a sense of hope ... It may come as a shock to them in rehab that maybe things won’t turn out as they’d hoped.”
How to Prognosticate
Attention to illness trajectories and to the progression and buildup of geriatric syndromes such as delirium, frailty, incontinence, and dysphagia is important. “The accumulation of geriatric syndromes means that, overall, prognostically, the patient is at higher risk,” Dr. Bednarczyk said. “We need to assess: are we seeing any signs or symptoms that might indicate that the patient is getting closer to the end-of-life trajectory, such as ... edema or anasarca, unexplained tachycardia, or dyspnea?”
Helpful tools, she said, include the Clinical Frailty Scale and the ePrognosis website, the latter of which includes the well-known Palliative Performance Scale as well as several validated indices/calculators that can be used to estimate the mortality risk for specific populations. (For instance, the Mitchell index estimates six-month survival for an individual with advanced dementia.)
Edward Gometz, MD, CMD, said during the session that he sometimes shares the tools he has used during family meetings. “I explain [to families] that these are tools that are oftentimes used to help us with this really hard job of prognosticating,” he said.
It is never too early to initiate goals of care conversations, he reminded session participants. “And goals of care should be revisited frequently.”
Christine Kilgore is a freelance writer based in Falls Church, VA.