In Response.

Abstract

We were encouraged by Dr Ballard’s1 response to our recent manuscript describing end-of-life care preferences among older adults presenting for elective surgery.2 In her letter, Dr Ballard1 emphasizes that anesthesiologists should elicit end-of-life preferences for high-risk patients—both young and old—before any procedure. However, she recognizes, and we agree, many anesthesiologists have not been specifically trained to address these issues. We greatly appreciate her description of the REMAP framework to help clinicians conduct these important but difficult conversations. As demonstrated so devastatingly in the last few months by the coronavirus disease 2019 (COVID-19) pandemic, there is a need for all clinicians caring for potentially critically ill patients to participate in meaningful end-of-life care discussions. We cannot solely rely on primary care clinicians, oncologists, and palliative care physicians to fulfill this role. We need to evaluate the tools, time, and education we provide to front-line clinicians—anesthesiologists, surgeons, intensivists, and emergency department physicians—that enable them to conduct these delicate conversations about life and death. REMAP provides a conversational roadmap to address goals of care: it is available as part of VitalTalk (www.vitaltalk.org), a pedagogical approach aimed at improving clinician and patient communication.3 VitalTalk is a nonprofit focused on improving communication and patient-centered care—its website has many other tools to facilitate conversations related to advanced care preferences. Other easily accessible tools like the “Best Case/Worst Case” scenario developed by Dr Schwarze and her group4 can aid clinicians in the emergent setting. Using this framework, clinicians are asked to draw out with pen and paper the range of possibilities resulting from an invasive treatment, such as intubation, against an alternative like medical management or supportive care alone. For each option, clinicians provide patients and their health care surrogates the “best case” scenario, “worst case” scenario, and “most likely” scenario along with concrete examples from clinical experience and relevant evidence. While the techniques and resources described above may help clinicians approach goals of care conversations with their patients, they are only as useful as the institutional and cultural environment supporting them.5 It is critical we recognize goals of care conversations can be the most difficult and most important aspect of a high-risk patient’s clinical care. Like placing an endotracheal tube, the skill needed to conduct end-of-life conversations must be taught, nurtured, and refined. It is the responsibility of all clinicians to ensure the delivery of goal concordant care to our sickest patients—and it is the duty of our institutions to enable this study to occur. Brooks V. Udelsman, MD, MHSDepartment of SurgeryMassachusetts General HospitalBoston, Massachusetts[email protected] Nicolas Govea, MDDepartment of AnesthesiologyNewYork-Presbyterian-Weill Cornell Medical CenterNew York, New York Zara Cooper, MD, MScDepartment of SurgeryCenter for Surgery and Public HealthBrigham and Women’s HospitalBoston, Massachusetts David C. Chang, PhD, MPH, MBADepartment of SurgeryMassachusetts General HospitalBoston, Massachusetts Angela Bader, MD, MPHDepartment of AnesthesiologyCenter for Surgery and Public HealthBrigham and Women’s HospitalBoston, Massachusetts Matthew J. Meyer, MDDepartment of AnesthesiologyUniversity of VirginiaCharlottesville, Virginia