Advance Care Planning Among Patients with Heart Failure: A Review of Challenges and Approaches to Better Communication

What Do I Say? Structuring the Conversation

Heart failure patients and their caregivers may vary in their preferences for hearing information about their disease; therefore, it is critical to open any conversation about planning for future in the context of their illness by asking what and how much information is desired. This includes evaluating how involved in decision-making the patient wants to be. Previously suggested language includes [69,70]:

• Would you like to consider all the options, or my opinion about the options that fit best with what I know about you?
• Some people like to know everything about their disease and be involved in all decision making. Others do not want all the news and would rather the doctor talk to __________. Which kind of person are you? How involved do you want to be in these decisions?
• Would you like me to tell you the full details of your condition?
• If you prefer not to hear the details, is there someone in your family who you trust to receive this information?

After establishing the patient’s preferences for hearing different types of information and level of involvement in decision-making about their care, the ask-tell-ask model [69,71] provides a useful approach to communicating with patients and their families. The conversation generally begins by asking patients what he or she understands about their illness (eg, “What do you understand about your heart failure?”; “I want to make sure we’re on the same page; what have other doctors told you?”). Building on what the patient already knows, the clinician can then disclose new information, correct misunderstandings, or confirm impressions and expectations the patient might have. In this way, information is tailored to the patient’s understanding and aimed at addressing potential knowledge gaps, all within the context of their preferences. Finally, the clinician asks the patient to describe their new understanding and whether or not they have questions or concerns (eg, “To make sure I did a good job of explaining to you, can you tell me what you now know about your condition from our conversation?”; “I know I’ve covered a lot and I want to make sure I was clear. When you get home, how are you going to explain what I’ve told you to your spouse?”). This approach encourages communication and exchange between patient and physician. Additionally, expressions of concern promote relationship building and bonding between physician and patient.

Keeping the Conversation Going

ACP communication can cover a wide range of topics beyond disease and prognostic disclosure by the provider to the patient. A critical aspect of ACP conversations is an exploration of the patient’s values and preferences, which can be used to help contextualize treatment choices and subsequently guide in-the-moment decision-making [72]. Using open-ended questions throughout the conversation gives the patient an opportunity to reflect on and communicate their wishes and values and allows them to engage in the conversation on their own terms. Examples of discussion-stimulating questions include [69,73]:

• What concerns you most about your illness?
• How is treatment going for you (your family)?
• As you think about your illness, what is the best and worst that might happen?
• What are your greatest hopes about your health?
• What has been most difficult about this illness for you?
• Looking back at your life, what has been important to you?
• At this point, what is most important for you to do?