Podcast: COVID-19: Advance care directives

During the COVID-19 pandemic, physicians may be deployed to unfamiliar clinical units and may need to have difficult discussions around goals of care that they are not used to having, perhaps even with patients they don’t know. In this podcast, Dr. Yolanda Madarnas, CMPA Physician Advisor, and Dr. Steven Bellemare, CMPA Director of Practice Improvement, discuss the CMPA’s experience with cases involving end of life care.

Listen to them discuss key messages that may help you effectively support patients and families who need to make plan of care choices as a result of a COVID-19-related critical illness.


Dr. Yolanda Madarnas: Hi Steven. Hello everyone.

Dr. Steven Bellemare: Hi Yolanda. Welcome back to our third edition of our special COVID-19 related podcasts.

Yolanda: Yes. So Steven, in the evolving COVID-19 health care setting, I know that physicians are finding themselves having more and more discussion, possibly with patients they don't know at all about goals of care.

Steven: That's right and you know in addition we may end up by virtue of the fact that we are being deployed in some incidences to units where we don't usually work, find ourselves actually needing to have such discussions that we're actually not used to having at all.

Yolanda: While we know it may be difficult and intimidating.

Steven: These conversations for sure are tough at the best of times.

Yolanda: Not having these conversations early before they become necessary actually robs our individual patients of control and choice and might result in medical care that isn't reflective of what is most important to them.

Steven: That's right. So, in this podcast everyone we want to provide you with an overview of some of the issues we see arising out of our medical legal cases, especially around end of life care, critical illness care and hopefully we will be able to help you identify how you might be most effective in having those critical illness discussions about goals of care, especially if this is not something you are used to doing.

Yolanda: For sure. So, following the principle of a person centered approach that aims to include the patient's loved ones and the care team when feasible can help physicians feel that they've assisted their patient in making the most appropriate decisions possible.

Steven: So we have three take home messages for you today. The first one being that it's important to communicate with families and the care team about goals of care early effectively, routinely and repeatedly.

Yolanda: Our second point would be that it is important to have an approach to ask patients about goals of care. Having this approach is going to make you more likely to do so and might save you time.

Steven: Finally, we want to impress the importance of normalizing the discussion. Normalizing the discussion is going to actually help reduce the patient misunderstandings, fear and discomfort and result in overall improved satisfaction with the care that's being received.

Yolanda: So, in essence these end of life discussions are actually part of the job of every physician but end of life and critical illness communication is still challenging even for the most experienced physicians who have these discussions every day.

Steven: Right. So preparing tools to start or structure or even trouble shoot these difficult conversations can actually make it less scary for everyone and actually help us be more likely to have these conversations especially when time may be short in the COVID settings.

Yolanda: So, planning to have these conversations in a timely patient centered setting can help the process move along and make it easier for patients and may reduce our medical legal risk.

Steven: You know Yolanda, patients and families are more likely to be more satisfied with the care they receive when they feel heard and involved in the decisions.

Yolanda: Yes, for sure. So take for example Steven a situation that's not uncommon in many of our college complaints. We had a patient who is admitted to an acute care hospital with a straightforward potentially reversible life threatening illness.

Steven: Okay.

Yolanda: That rapidly deteriorates.

Steven: Alright.

Yolanda: Our patient has previously told us they do not want to pursue supportive care and heroic measures if survival is unlikely and their family had agreed. So patient is provided with comfort care measures and passes away comfortably. After the family files a college complaint alleging the care was poor. The college had no criticism of the care per say, saying that it was consistent with the patient's wishes but there was some criticism of the physician in having fallen short of having had optimal communication with that patient's family especially when their condition worsened.

Steven: Right. So essentially you are highlighting a common theme in critical illness or end of life care issues. Is that the issues are often not about the medicine they are about the communication, right? This highlights the importance of keeping all the players apprised of the situation and making it clear actually how the care is aligned with the patient's advanced directive and sometimes we may take for granted that it is clear and apparent when it's not.

Yolanda: And it's not. Complaints like this do highlight that for us. So, a reminder that because the changes in clinical status can occur quite rapidly it's so important to plan for frequent updates on how things are going. Particularly now in the COVID context which may well mean having to discuss what will and won't be possible depending on the availability of resources and how this might diverge from a patient or family expectations.

Steven: Right. We know that it is not an easy thing to do. It's not an easy thing to address but one of those most frequent issues we hear from families and patients in our college complaints or even in our lawsuits, is the lack of availability of the MRP, the most responsible physician, to discuss the patient's situation, to hear their concerns and explain to them how it is that things are going.

Yolanda: So while we know that the care is delivered many times in teaching hospitals or even in nonteaching institutions by a team where a number of individuals participant in the care. There is an MRP who may delegate a number of things but these discussions are particularly important to be held by the MRP and providing that opportunity to review the state of affairs how things are going and how the care aligns with the patient's advanced directives is critically important issue.

Steven: Right.

Yolanda: Making the time for this can make all the difference.

Steven: You know it's made all the more important in the context of potentially limited access to resources such as medications like Propofol for instance. It's been in the news recently. Equipment like ventilators and palliative care physicians or even facilities. The appropriate rooms for looking after the patients. So, we've all see how fluid the situation around COVID has been evolved and how one region is completely different from another and how very difficult it is to predict where things are going.

Yolanda: Yeah. It may be that you'll never have to address resource issues as part of the goals of care discussions that you have but keeping your eye on that ball will be important to help you feel prepared to do so if and when the time comes and patients and families are likely going to be aware and understand the limitations through the media, news reports and so on but that communication and adaptability on our part are key especially when deviations from a previously agreed to or expected care plan have to take place because of resource shortages.

Steven: Well, look Yolanda we are already quite far into this broadcast and we haven't even got to take home point one. So, perhaps this is a good place to do that and that message was that we should keep in mind the importance of communicating with families and patients and other caregivers about goals of care early and I don't mean early in the morning here, I mean early in the illness or in the situation effectively and repeatedly even.

Yolanda: While we've used the term end of life at several points here in the podcast, it may be somewhat of a misnomer, it doesn't imply that we should wait until a patient is clearly at the end of their life to have these discussions. Critical illnesses in practice or in theory are an optimal time to bring out and highlight these care goals, as any new serious illness or diagnosis and in the setting of COVID this might ideally mean discussing it with any high risk patient in the event they contract the illness.

Steven: Right, before they get it, right. Having these discussions when the threat is theoretical and not imminent is likely to be easier on everyone including us, right, as the physicians.

Yolanda: That's been my experience with my cancer patients, having that discussion long before it's really on the radar.

Steven: Right. Don't get us wrong though, we are not suggesting you start calling patients in your practice out of the blue to find out what their wishes out should they get COVID-19. That will be a bit startling.

Yolanda: Not at all. But that said, it may be wise to raise the issue with them during visits for other issues, especially if they have a comorbity that does put them at higher risk for serious COVID-19 related complications.

Steven: And in that sense you know, even though you may not end up being the one looking after them, should they get COVID and require admission, your efforts to actually raise the issue ahead of team may at least have primed them to consider the implications of the diagnosis for their care.

Yolanda: Absolutely. We recognize that many frail or older patients may not actually want aggressive life prolonging measures and they may prioritize quality of life and actually being able to say goodbye to their families.

Steven: Frank communication is so important.

Yolanda: Absolutely. So explaining the impact of their comorbity on the likelihood of surviving a COVID-19 or other critical illness can actually allow them to make an informed choice as to their level of care and whatever their decision is many will at least understand the process better and hopefully feel included and heard.

Steven: Right. You know patients listen to the news. They know that COVID-19 has a high likelihood of poor outcomes in patients with comorbities. So, looking at it not as something awkward to raise but rather as an opportunity to provide guidance on the proverbial elephant in the room so to speak, may actual help you to be more comfortable in raising the issue.

Yolanda: It's already there. You are not really raising anything new. You are allowing permission to talk about it and explain it because people may actually have a misconception of what their risk and their comorbities are. But it's important to raise it and allow our patients and their families to participate in that shared decision making.

Steven: Right. It's important to point out here Yolanda that the purpose of an early conversation is not to convince anyone to seek a particular kind of care over another, a least invasive care for instance. Quite to the contrary. It's about setting the context for making the decision that is right for them, isn't it?

Yolanda: Yeah.

Steven: We shouldn't avoid the conversation assuming we will have to convince patients to do something or anything. That would be very adversarial approaching it that way.

Yolanda: Absolutely. So starting with goals of care, raising potential resource issues as an additional consideration as well as the impact of any comorbidities they shoulder, doing so early may actually help us and help our patients align their values with the reality of what might and might not be possible during the COVID-19 crisis.

Steven: Yeah. So, that's part one, right. That's addressing with the patient and getting them to think about what they would like to do if they were to contract COVID-19 but before they get ill.

Yolanda: If those stars align then you are also able to continue being the primary physician tasked with looking after them when they are actually ill, then part two comes into play.

Steven: That's about having the discussions about what is and what is not possible at that particular time.

Yolanda: That's quite difficult to plan for as we've seen over the first eight weeks of this pandemic. Information, situations change at an incredibly fast pace and what was available yesterday may no longer be available today and what you thought wouldn't be available has actually not been as scarce as we anticipated.

Steven: That's right. So, getting back to our case example Yolanda, the issue at play there if you'll recall, right, the family didn't have a line of sight into why decisions were being made for their loved ones and how they actually were consistent with previously expressed wishes.

Yolanda: Yeah. So the take away or learnable point here is that frank frequent routine and repeated, not one off meetings and discussions with patients and their loved ones to explain the situation, the options as they are on that day can make the whole difference between perception of excellent versus negligent care.

Steven: Right. It's all in the relationships you build, right. It's the feeling of control and choice and being heard that will help the patient and their family feel valued.

Yolanda: And hopefully reduce the medical legal issues for the physician.

Steven: Provided those conversations you have are also documented.

Yolanda: Absolutely. While we recognize this can be a difficult time with time constraints that we are all subject to and the fact that it's unlikely that families are actually going to be present there in person to meet with you.

Steven: Right. In the context of the pandemic, the family most likely won't be there because of the limitations on visiting.

Yolanda: Yeah. So trying to plan ahead for that gets into our take home message number two. Having an approach to ask about your patient's goal of care values, their fears, their expectations. May make you more likely to do it and might save time in the long run.

Steven: Right. You know, that makes me think of a lot of the resources available. You are talking about fears and expectations.

Yolanda: Yeah.

Steven: That gets back to the FIFE model of exploring people's feelings, people's ideas about their illness, their function as well as their expectations for the care.

Yolanda: While the association doesn't endorse any particular approach per say, there is a Canadian website, www.planwellguide.com that may be worth a look to get some ideas on how to build an approach to these situations that suits your values.

Steven: Yeah. There are a lot of good resources out there Yolanda. Some of them have videos that you can watch to get a little bit of coaching. Some of them even have talking maps, like road maps. They are essentially scripts if you will.

Yolanda: For these difficult conversations.

Steven: Right, and these are all designed to actually help you be more comfortable and better care for patients and families.

Yolanda: This is well within the context of shared care, shared decision making and we can find this just googling it.

Steven: Yeah. Yeah. That's right. There really is quite a wealth of resources out there.

Yolanda: Out there.

Steven: Finally our third take home point was that using normalizing language can help put patients at ease and facilitate the sharing of opinions.

Yolanda: For example using the third person. So when people with COVID get worse they have to make decisions about their care. They tell me that it's less stressful when those discussions happen earlier.

Steven: Right. Or even things like most people tell me they don't want to burden their families by requiring them to make those decisions without knowing their wishes.

Yolanda: So we recognize that people are likely to want to be reassured that they or their loved ones aren't being singled out. I'm having this discussion with all my patients right now.

Steven: Right. So normalizing family feelings, like many family members feel helpless in these situations. How do you feel? Can be helpful.

Yolanda: Absolutely. So, in the end these goal of care discussions are not really made all that different by COVID. They are just happening more often out of necessity and they might be influenced by resource issues. So, in fact COVID might present us with the opportunity to preemptively have these discussions.

Steven: Right. Indeed. What may be different is that you as the physician may not be used to having those discussions with your patients by virtue of your usual scope of practice or by the fact that COVID is forcing you into those kind of situations that you normally wouldn't be taking part in.

Yolanda: So we hope that these few tips today might help you feel more comfortable having these discussions, knowing a bit more about the issues at play in the typical end of life cases that are likely to impact patient and family satisfaction with care and thus your medical legal risk.

Steven: Right. You know Yolanda, if there is one key message that we could share it would the power to just sit in silence. Allowing patients and families time to process and think of questions. It's okay not to fill that space. It actually will feel longer than it actually will be.

Yolanda: While that space is long face to face, recognizing that the family is not likely to be in the room during COVID related care, you're likely to be having some of these conversations on the telephone.

Steven: Yeah.

Yolanda: Which will probably be extra awkward. So you might want to acknowledge that silence explicitly on the phone, validate it and attempt to ease the family's comfort with it and allow them permission and time to think and process what's just been discussed.

Steven: Right. Well, Yolanda, I think if we don't want to be interrupted by the end of the podcast music we are going to have to start wrapping this up here.

Yolanda: Okay.

Steven: Thank you so much for joining me today to talk about this important issue.

Yolanda: Thank you Steven. Thank you everyone for joining us. Just a reminder to visit the COVID-19 hub on the CMP website and as well please call us anytime to discuss specific issues to your day to day. Our podcasts are not meant to be all encompassing but rather touch on highlights that are meant as food for thought.

Steven: Hopefully these highlights are going to be helpful to you.

Yolanda: We hope so.

Steven: Thanks for joining us.

Yolanda: Thanks again. Bye bye.

Steven: Bye.

Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a "standard of care" for Canadian health care providers.