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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #1, #4, #7, #21, #27


Learning Objectives

  • Describe a suggested six-step process for addressing goals of care and treatment preferences with patients who are seriously ill.

  • Identify unique challenges in communicating with seriously ill older adults and strategies to address them.

  • Summarize several key communication techniques including Ask-Tell-Ask and SPIKES.

Key Clinical Points

  1. Data suggest patients and families generally desire to have open conversations with their medical providers around their goals of care, treatment preferences, and end-of-life wishes.

  2. Conversations around goals, values, and treatment preferences should be held over time, as a patient’s health status and/or perspectives evolve.

  3. Clarifying patients, and families, understanding as well as effectively addressing emotions around serious illness can help make these conversations easier.


Older adults are living longer, and with more chronic diseases, than ever before. In 2012, an estimated 43.1 million adults were over the age of 65, comprising 13.7% of the US population. About 67.3% of Medicare beneficiaries have two or more chronic conditions and 14% have six or more. In fact, the majority of hospice diagnoses are now noncancer related, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or dementia. Taken together, these data suggest effective communication around advanced illness is of ever-increasing importance for our older adults facing longer life trajectories, complex chronic illness, and debility and decline. Having achieved longevity, many older adults living with advanced illness prioritize goals such as function, comfort, and family support. Skillful communication is needed to ensure the treatments we offer align with these goals.

Effective communication with patients and families can have a number of benefits. It has been shown to improve diagnostic accuracy, health outcomes, treatment adherence, and patient satisfaction. In addition, effective end-of-life communication has been associated with decreased intensity of care, increased quality of life, and improved quality of dying for patients.

Studies consistently confirm the majority of patients facing advanced illness desire to have honest conversations about their goals, values, and end-of-life care with their providers. A recent systematic review of advance care planning in older adults found between 61% and 91% of older individuals wanted to discuss their end-of-life care with their providers. Benefits cited by patients included assurance their wishes would be respected, an opportunity to address important medical care and treatment issues before cognitive impairment or being physically unwell occurred, and to assist loved ones with decision making. They felt this responsibility to begin the discussion lies with physicians, they wanted to have the conversation in an open and honest manner, and preferred these conversations began early in their illness course.

However, despite the fact that communication around advanced illness is not only beneficial but also desired by most patients, this communication often remains inadequate. In studies, ...

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