Five years ago, Dr. Susan Block had a series of conversations with surgeon-author Dr. Atul Gawande, who later wrote the book Being Mortal: Medicine and What Matters in the End. They explored how to talk to seriously ill patients and their families about end-of-life concerns when there are no more curative treatments available and the patient is at high risk of dying within a year.
“He told me he would like to learn how to do better in having these types of conversations with his own patients,” said Block, founding chair of the department of psycho-social oncology and palliative care at the Dana-Farber Cancer Institute in Boston. “He asked if I had a checklist of questions that I ask.” Gawande is also the author of The Checklist Manifesto, a book about using checklists to reduce medical and surgical errors.
Block said she initially was skeptical about applying a checklist to a situation as sensitive as talking with patients and their families about end-of-life care. But helping doctors improve their ability to begin conversations about advance planning was appealing. So she began developing a standardized approach physicians could use to initiate and improve those discussions.
The result was the Serious Illness Conversation Guide, which Block developed as part of a collaboration between Brigham and Women's Hospital and the Harvard School of Public Health called Ariadne Labs, of which Gawande is executive director. Its Serious Illness Care Program is based on seven questions doctors should ask patients that will give them a better understanding of what kind of care will help ensure their best quality of life.
Questions focus on helping patients understand the reality of their medical situation without crushing their spirit. Doctors are trained to ask patients about their concerns and fears, their ideas about what's important to their quality of life, and to help them set realistic health goals.
The program was developed as part of a systemwide approach to palliative care. It has been used for more than two years at Dana-Farber in a four-year randomized clinical trial to evaluate its efficacy. Physicians receive training, using patient-actors, on asking the questions.