Make the Serious Illness Conversation Guide easy for clinicians to use during a tough conversation
Analysis and research
Production coordination and oversight
Established a framework for considering the types of information required for guiding conversations
Over a period of years, the core design has been refined and revised to reflect lessons learned from extensive use and testing
Over 6,500 clinicians worldwide have been trained on using the Conversation Guide (Kaiser Health News, Feb 2018)
A team of palliative care experts at Dana-Farber Cancer Institute and the Harvard School of Public Health (which later became part of Ariadne Labs) were working on a project to improve communication between clinicians and people who are seriously ill.
The team had developed and validated a set of carefully worded questions that clinicians can use to uncover and understand the goals and wishes of people with serious illness, and they had developed a checklist-like framework to help clinicians have these important but difficult conversations.
We were originally asked to help optimize the Serious Illness Checklist in 2012. One year later, we refined the design of what had become known as the Serious Illness Conversation Guide, along with related program materials, based on the results of testing and feedback from clinician training. In 2016 we again worked with the Ariadne Labs team to help them evaluate lessons learned and revise the Conversation Guide to better meet clinician needs.
How we helped
Our work on the project began with an analysis and mapping of the proposed program components and a detailed analysis of the content on the draft checklist.
We also helped the team evaluate user needs (in this case, clinicians were the target users of the tool) and document the times and places in which end-of-life conversations occur and which contexts we would consider when developing the tool. The team had a number of ideas about how to support the conversation, so we used a priority mapping exercise to help them consider which possible components were most important and easiest to implement
Key to the challenge
Making a conversation guide that is easy to use is challenging, in part, because of the underlying tension between different kinds of information:
specific steps and a sequence for the clinician to follow (first do this, then do that)
themes for the clinician to address during the conversation (e.g., assess, share, explore, etc.)
and suggested words for the clinician to say to the seriously ill person ("What is your understanding now of where you are with your illness?)."
It's hard for people to navigate and process those different kinds of information in real time, especially in an emotionally charged situation. To explore what might work best, we considered a variety of options (small cards, a large shared visual like a placemat, a simple hand-held page, tablet, etc.) and created a variety of prototypes that varied in level of detail, labeling, order of elements, and visual presentation.
Elements of the solution
Although we experimented with several approaches and the tool evolved over time, the solutions we delivered:
Teased apart different types of information and labeled them clearly
Addressed the distinct needs of people just learning the approach and the needs of those who were experienced but still wanted a simple reference
Allowed individual clinicians to choose the format (from among several choices) that would best work for them
Included a Reference Guide for Clinicians that described key ideas of the approach, described the family of Serious Illness Conversation tools, explained the structure of the tool, and offered strategies for common scenarios
Included a resource for patients and their families to help people talk to loved ones and caregivers about their illness and the future
Included a user-modifiable version in Word so that facilities can make changes locally when needed
Links and resources
Learn more about this tool and related efforts to improve end-of-life care:
- Serious Illness Conversation Guide and related resources from Ariadne Labs' Serious Illness Conversation Program (free login required to download tools)
- Checklist theory used in creating end-of-life talk guide, Boston Globe article (June 2013)
- How to have a better death, The Economist article in (April 2017)
- Doctors Learn How To Talk To Patients About Dying, Kaiser Health News (Feb 2018)
- Serious Illness Communication Checklist, Virtual Mentor article from the AMA Journal of Ethics
- Development of the Serious Illness Care Program: a randomised controlled trial of a palliative care communication intervention
Facilitation and design strategy
Part of our role is to help teams reach and articulate a common understanding of their project. Here are a few excerpts from the 2016 redesign work in which we helped the team crisply define their efforts to create a revised version of the conversation guide that could be deployed widely as a stand-alone tool. (Note that it is helpful to be explicit about what the tool can't do, in addition to what you hope it will do.)
What is the Serious Illness Conversation Guide?The conversation guide is a learning tool to share good practices and proven language. It is intended to inform clinician practice, rather than serve as a procedural task list. The desired end state is for clinicians to enhance their conversations with patients.
- clinicians will use the guide only a short while and may never use the language verbatim
- the guide should be a useful tool in a clinician’s toolbox, but will not by itself transform individual or system behavior
Who is it for?Primary audience
Busy clinicians (MDs, PAs, NPs) who see seriously ill patients daily and want to improve their own practice with patients
- they will not receive training
- they are not likely to have system support; e.g., EHR prompts, triggers for the conversation, etc.
Busy clinicians (MDs, PAs, NPs) and administrators who work in an environment in which seriously ill patients are treated daily and who want to improve the system in which they work
- they may be interested in other components of the overall intervention
- they will still need the Conversation Guide as one element
This "simple" tool to shape a conversation is actually quite complicated. Our analysis of one draft showed that it included:
6 major categories of information
3 kinds of framing content (title, logo, footer)
8 labels used to identify types of content for the reader
6 parts to the conversation
9 actions and 3 instructions (across the 6-part conversation)
2 kinds of branching logic
Nearly 200 words of suggested wording made up of 2 kinds of statements and 8 questions
Testing with users
The team understood that some people struggle to use the Conversation Guide, even in the context of a program that included training and support. As they prepared to deploy the Conversation Guide as an unsupported stand-alone tool, the team had to wrestle with:
Why do some people "leave" the tool at certain times?
How much information do clinicians need, based on the team’s experience and observation?
How much information do clinicians think they need vs. how much do they actually need?
Which information makes tasks easier and which makes them more challenging?
We developed approaches to test the level of complexity and different use cases and wrote an interview protocol to help the team learn from a group of clinicians testing the new approach with patients.
Return to: Aids for Clinical Environments