Crucial Conversations With Patients in the Era of COVID-19
Authors: Caitlin Holt Siropaides, Melanie S. Sulistio, Sharon Coplen Reimold
Journal: Circulation (2020)

he coronavirus disease 2019 (COVID-19) worldwide pandemic is significantly impacting health care.Attention is drawn to the epicenters, but there are millions of patients with cardiovascular diseases and providers attempting to navigate the system across the country.In this time of uncertainty, we struggle to communicate effectively with our patients, particularly with the transition to telehealth visits.The present discussion focuses on optimizing communication to patients with cardiovascular disease during the COVID-19 pandemic, including discussing patient risk and how to communicate with symptomatic patients with varying degrees of severity of COVID infection.Addressing patients' goals of care can help guide treatment plans for COVID-19 and non-COVID-19 illnesses.Conversations regarding COVID-19 are uniquely different from routine advanced care planning in that so much is unknown about COVID-19 prognostication and management.The acute and rapid nature of clinical decline for patients with COVID-19 demands goals of care discussions much earlier than might be necessary in traditional acute cardiac complications.We recommend using frameworks such as Vital Talk's REMAP (Reframe, Expect, Map, Align, and Plan) for acute goals of care discussions or Ariadne Laboratory's Serious Illness Conversation Guide for advance care planning 1,2 to facilitate such crucial conversations.Each of these methods shares evidence-based skillsets shown to improve patient satisfaction and outcomes.First, assess patient or family understanding of their chronic and potential outcomes of an acute illness such as CO-VID-19.Providers should fill in any knowledge gaps by concisely summarizing the medical situation as it relates to a person's prognosis, quality of life, and functional outcomes.Patients with preexisting cardiovascular disease are at an increased risk of adverse outcomes and mortality, although they may not conceptualize how a COVID-19 infection could significantly impact their quality of life or cardiac disease even if they survive.This can provoke strong emotions; thus, it is crucial to address and explore the impact of this news.Both frameworks also emphasize the importance of exploring patient values regarding their goals, worries, and quality of life.Clinicians should provide a patient-specific recommendation based on their values to determine a shared medical decision.In the era of COVID-19, resource allocation may be necessary, and in such situations a care plan may not be able to fully achieve patient goals.Compassion and consideration of values specific to the options available are critical to decision making.Because COVID-19 dominates the media, patients often have concerns about their personal risk and how to manage non-COVID-19 related cardiac issues.The Table addresses the data available and how to respond in such situations using skills from the communication frameworks. 3,4s we continue to learn about COVID-19 and its trajectory, early discussion about care preferences becomes more important.Patients may quickly