Integrating serious illness conversations for person‐centred clinical care

Michel et al. wrote a highly insightful piece embedded with real-world clinical narratives to highlight the pressing need for a structural goals-of-care (GOC) framework within clinical practice to identify patients at high risk of clinical deterioration, hold and document timely GOC discussions with them and promote person-centred, goal-concordant care.1 We echo the authors' views and suggest that serious illness conversations (SICs) should be formally taught in undergraduate and postgraduate medical training and adopted for use in routine clinical practice for this purpose. In the past, GOC discussions have traditionally been limited to one or more of the following forms: advanced medical directives that are legally binding documentations that narrowly pertain to extraordinary life-sustaining interventions in the case of terminal illness with medical futility, advanced care planning documentations of generic conversations to explore values and care preferences in adult persons of any health status or inpatient ‘code status’ discussions to document resuscitation status in the event of sudden cardiopulmonary arrest.2 More recently, the advent of SICs developed by Ariadne Labs has drastically transformed the landscape of GOC discussions, where various members of the healthcare team hold intentional, ‘in-the-moment’ discussions with specific patients deemed to have a severe, life-limiting medical condition.3 While initially designed for use in oncological patients,3 its application has quickly broadened to other patient populations including those with advanced heart,4 lung4 or renal disease.5 To improve the understanding of what constitutes a ‘serious illness’, a recent consensus guideline defines it as any ‘health condition that carries a high risk of mortality and either negatively impacts a person's daily function or quality of life, or excessively strains their caregivers’.6 In practical terms, patients who have incurable diseases, advanced organ impairment, repeated hospitalisations with functional decline and/or who fulfill the 'surprise question' should be included for such discussions.7 Electronic health records-generated user prompts or institutional workflows can be implemented to trigger the process of SICs based on pre-defined criteria. In addition, a SIC-based conversational framework for GOC discussions has the added benefits of strong psychological grounding with the use of patient-tested language as well as the possibility of creating local or culturally adapted formats.8, 9 Importantly, once the suitable patients are identified, SICs can and should ideally be performed by various members of the primary healthcare team (doctors, nurses, allied health professionals) in bite-sized conversations at different time points, where the full picture of the patient's personhood and care goals is gradually put together as a team effort to deliver person-centred, goal-concordant care for our patients.