Structured Communication and Interprofessional Collaboration for Goals of Care Transitions

1. Structured Communication Frameworks

Difficult conversations become more manageable when guided by structured, stepwise frameworks. These tools help clinicians prepare, assess understanding, convey information compassionately, elicit values, and co-create goal-concordant plans.

SPIKES (Set • Perception • Invitation • Knowledge • Empathy • Summary)

• Set: Choose a private space, pre‐brief with the team, and minimize interruptions.
• Perception: Ask open-ended questions to gauge patient or surrogate understanding of the clinical situation.
• Invitation: Respect autonomy by asking for permission to share information, e.g., “Would you like me to explain what to expect?”
• Knowledge: Deliver prognosis and treatment options in small, jargon-free chunks.
• Empathy: Name and validate emotions observed, such as, “I can see this is incredibly difficult.”
• Summary: Recap key decisions, outline next steps, and document the plan clearly.

REMAP (Reframe • Expect emotion • Map values • Align • Plan)

• Reframe: Shift the focus from a curative-only mindset to quality of life, e.g., “Let’s talk about what matters most to you now.”
• Expect emotion: Anticipate and create space for emotional responses like tears, silence, or anger. Pause and listen actively.
• Map values: Explore patient priorities with questions like, “What gives you strength?” or “What are you hoping for?”
• Align: Connect the patient’s stated values to medically realistic treatment options.
• Plan: Define a care pathway that is consistent with the patient’s priorities.

Serious Illness Conversation Guide (SICG)

This guide provides scripted prompts to facilitate discussions about illness understanding, information preferences, core values, fears, acceptable trade-offs, and family involvement. It is designed to be completed in one or two sessions and can be integrated into EHR templates for standardized documentation.

2. Documentation and Handoff Best Practices

Transitions of care are high-risk periods for medical errors and goal‐discordant care. Standardized documentation in the EHR, clear dashboards, and structured handoff checklists are critical to preserving patient preferences and medication decisions.

A. Essential Elements of Goals of Care Notes

• Patient’s stated values and highest priorities, ideally in their own words (using quotes).
• A clear assessment of decision-making capacity and designated surrogate.
• A summary of the prognosis discussion and the decisions made.
• The selected code status and specific choices regarding life‐sustaining interventions.
• A follow-up plan, including any referrals made (e.g., palliative care, chaplaincy).
• Clinician signature with date and time.

B. EHR Templates and Dashboards for Advance Care Planning (ACP)

Using structured fields for values, surrogates, and directives prevents this critical information from being buried in lengthy narrative notes. A dedicated ACP dashboard can flag patients with missing or outdated documentation, prompting proactive review. Smart-phrases (e.g., “.GOCSUMMARY”) can help speed documentation while maintaining narrative clarity.

C. Checklists for ICU→Step‐Down and Discharge Handoffs

A simple checklist ensures critical tasks are completed. This should include verifying that code status orders are updated and advance directives are accessible, confirming the medication plan aligns with documented goals, and ensuring pending appointments or referrals are scheduled. A brief handoff huddle involving the bedside nurse, receiving physician, and a pharmacist to review these items is best practice.

3. Interprofessional Collaboration in ACP

Advance care planning is a team sport. Each discipline contributes unique skills and perspectives that, when combined, support holistic, patient-centered, and goal-concordant care.

A. Team Roles and Responsibilities

• Nursing: Provides continuous patient contact, screens for psychosocial and spiritual distress, and reinforces discussions initiated by the team.
• Social Work: Conducts psychosocial assessments, facilitates completion of advance directives, and connects families to community resources.
• Chaplaincy: Performs spiritual assessments and addresses existential concerns, which are often central to end-of-life decision-making.
• Palliative Care: Offers expertise in complex symptom management, facilitates challenging family conferences, and provides ethics consultations.
• Pharmacy: Reviews medication regimens to identify and deprescribe non‐beneficial therapies, ensuring the drug plan aligns with care goals.

B. Facilitating Family Meetings

Schedule regular, multidisciplinary meetings with a clear, pre-stated agenda. A brief “pre-huddle” is essential to align the team on the information to be presented and the overall plan. After the meeting, document decisions, action items, and the individuals responsible for them.

C. Conflict Resolution and Ethics Consultations

Identify disagreements early, whether between family members or between the family and the care team. Use institutional triggers for rapid ethics consultations in cases involving high-stakes decisions or requests for potentially non-beneficial therapy. Mediation should be guided by institutional policies, legal standards, and, most importantly, the patient’s stated values.

4. Medication Reconciliation Aligned with Goals

At every care transition, medications must be reconciled not just for accuracy, but for appropriateness. This process is essential to honor patient preferences, stop non‐beneficial drugs, and prevent iatrogenic harm.

A. Compare Pre-Admission and Current Regimens

Systematically verify outpatient medication lists with the patient, family, and outpatient pharmacy records. This helps identify duplications, omissions, or the unintended continuation of medications that are no longer appropriate in the current clinical context.

B. Identify and Deprescribe Non-Beneficial Therapies

When care goals shift toward comfort, many chronic medications lose their benefit and may cause harm. The focus should be on discontinuing drugs intended for long-term prevention.

C. Communicate Changes to Receiving Teams

Clearly document the rationale for any medication changes, explicitly tying them to the patient’s stated values in the handoff note. The reconciled medication list and deprescribing plan must be included in the discharge summary. Verbally confirm major changes with the receiving pharmacist and physician to close the communication loop.

5. Quality Improvement and Metrics

Sustained improvements in advance care planning processes require ongoing measurement and feedback. Tracking key metrics allows teams to identify gaps and celebrate successes.

A. ACP Continuity Indicators

• Percentage of ICU discharges with a complete goals of care note and documented medication reconciliation.
• Percentage of patients with an advance directive that is scanned and easily accessible in the EHR dashboard.
• Median time from hospital admission to the first documented goals of care discussion for high-risk patients.

B. Audit and Feedback

Conduct quarterly audits of note completeness, handoff accuracy, and alignment between the medication list and documented goals. Share results via unit-level scorecards in multidisciplinary huddles to drive accountability and collaborative problem-solving.

C. Team Debriefings and Education

Implement simulation-based workshops for clinicians to practice communication skills using frameworks like SPIKES and REMAP. Hold monthly case debriefs that focus on both successes and areas for improvement. Finally, incorporate ACP communication competency into annual clinical skills assessments for physicians and nurses.