INTRODUCTION — The clinical interview in palliative care is central to the information-gathering process and to understanding and being able to address patient and family suffering. It is also a fundamental therapeutic method. Good communication skills, while always important in clinical medicine, are especially indispensable in the context of a life-threatening illness, where fear, anxiety, existential terror, and terrible sadness can make for a challenging clinician-patient relationship. A key task for the palliative care consultant is to establish a personal connection with the patient that can not only tolerate but also integrate the affect that is typically associated with profound worries about the future and with repeatedly receiving bad news. The palliative care interview aims to collect both routine medical data and, as described below, additional personal information not regularly included in a medical history that is relevant to both diagnosis and treatment. (See "Overview of comprehensive patient assessment in palliative care".)

This topic will focus on the initial interview conducted during a subspecialty palliative care consultation for an adult, which includes identifying specialized aspects of information gathering and developing an intimate, trusting clinician-patient relationship that can address a broad range of biopsychosocial and existential/spiritual issues. An overview of the domains of a comprehensive palliative care assessment and a number of related topics in medical consultation and palliative care are covered elsewhere. (See "Overview of comprehensive patient assessment in palliative care" and "Overview of the principles of medical consultation and perioperative medicine" and "Benefits, services, and models of subspecialty palliative care" and "Primary palliative care" and "Communication of prognosis in palliative care" and "Survival estimates in advanced terminal cancer" and "Communication in the ICU: Holding a meeting with families and caregivers" and "Discussing serious news" and "Overview of spirituality in palliative care" and "Approach to symptom assessment in palliative care" and "Pediatric palliative care" and "Ethical issues in palliative care" and "Assessment of decision-making capacity in adults".)

GOALS OF BOTH PATIENTS AND CLINICIANS — When patients and families facing a serious and/or life-threatening illness are asked what matters most to them, comfort is often a foremost concern. However, issues that extend beyond the usual biomedical goals of clinical care are also cited [1-4]:

●Ensuring that all medical options are considered in treating the disease

●Avoiding inappropriate prolongation of dying

●Relieving the burden on the family

●Achieving a sense of control

●Strengthening relationships with loved ones

Other studies of patient preferences additionally note the importance of clinician-patient communication [5] and having an opportunity to achieve a sense of completion of life [2]. (See "Psychosocial issues in advanced illness", section on 'Common issues for patients with advanced illness'.)

The clinician requesting a palliative care consultation as well as the palliative care consultant may also have additional goals for the encounter, including:

●Pain and symptom assessment and management

●Clarification of disease prognosis and goals of care

●Providing guidance in decision-making (focusing on balancing quality and quantity of life)

●Provision of added psychosocial and spiritual support for the patient and family facing an uncertain future

●Assistance with disposition, including possible rehabilitation, nursing home, or hospice referral

One of the challenges of the palliative care consultation is clarifying (and sometimes negotiating between) differing goals among patients, families, other medical providers, and the palliative care team.

PROBLEMS COMMUNICATING WITH PATIENTS WHO HAVE A SERIOUS ILLNESS — At least in the setting of cancer, patients and their oncologists tend to collude in avoiding upsetting topics, such as bad news, worsening prognosis, decisions about cardiopulmonary resuscitation (CPR), and worries about dying [6]. While some patients and families would prefer to leave psychologically threatening domains untouched, especially death and dying, others want more attention to end-of-life issues, including such concerns as funerals, the likely timing of death [7], and hospice [8]. The variation in patient and family preferences around these matters is quite large, but interviewers regularly fail to accurately estimate patients’ desires for the amount and kind of information they want to receive (underestimation is most prevalent) or their preferred role in decision-making; furthermore, clinicians also tend not to review, corroborate, or correct patients’ understanding of the information delivered [9,10]. (See "Overview of comprehensive patient assessment in palliative care", section on 'Illness understanding and care preferences' and "Discussing serious news", section on 'Patients’ preferences when receiving serious news'.)

Seriously ill patients and their families report considerable unhappiness with the quality of communication with clinicians [11,12]. Clinicians cut off patients’ stories within a few minutes of beginning the interview, and they tend to dominate the agenda [13]. Cancer patients express a wide range of emotions in their outpatient visits [14], but many opportunities for empathy and trust building are missed [15,16].

Studies of clinician-patient communication in palliative care demonstrate poor patient knowledge after encounters with clinicians [17] and surprising brevity of discussions around therapeutic plans, even when the discussion concerns major decisions about CPR [18]. Clinicians believe they have explained more to patients than audiotape recordings demonstrate [19], while patients report that they have many questions that are unaddressed [20]. For many clinicians, the phase of the interview devoted to explaining treatment options is more of a monologue, with little checking of understanding or solicitation of questions. Such monologues are both inefficient and ineffective. Better strategies are outlined below. (See 'Patient and family education' below.)

Discussions about such matters as CPR occur very late in the course of a terminal illness [21] or not at all [22-25]. In a 2006 study of seriously ill hospitalized patients and their family members, only one-third had discussed CPR with their clinicians and only 2 percent knew that their chance of survival following CPR was less than 10 percent [26]. Lack of understanding about prognosis is associated with preferences for more aggressive treatment at the end of life [27], while patients who receive more accurate information about the lack of efficacy of CPR choose less aggressive treatment [28]. Advance care planning discussions, if they occur at all, lack attention to such basic issues as patient values or prognosis [25]. (See "Advance care planning and advance directives".)

At the same time, enhanced communication, especially through family meetings, has been shown to have a positive impact on family satisfaction as well as subsequent resource utilization [29-34]. (See "Communication in the ICU: Holding a meeting with families and caregivers".)

Essential proficiency in communication for palliative care practice can be learned [35-39] and objectively evaluated [40].

PREPARING FOR THE CONSULTATION — A consultation ideally begins with a referral request and a conversation with the referring clinician. What is the reason for the consultation, and how does the referring clinician hope you can be helpful? Should you primarily provide one-time consultative advice to the referring clinician, or is it hoped that you will begin an ongoing role in the patient’s care?

Data gathering at this stage begins with a thorough review of the chart and a discussion with the clinical team or teams. The primary nurse, attending physician, specialty physician(s), house officers, and social worker can all potentially share their view of the clinical situation and what kind of help is needed. It is always important to understand and address the fundamental question(s) being posed by the primary referring clinician. If there is conflict among the treating teams or between the team and the patient or family, this should be understood and considered up front. Such basic questions can help to determine which members of the palliative care team should be present for the initial interview and what they should mainly focus on.

Getting started — The initial interview is not only aimed at eliciting the information required to answer the consultative question, which may include diagnosis and management of a specific condition/problem/complication but also may include some or all of the following tasks (see "Overview of comprehensive patient assessment in palliative care", section on 'Domains of palliative assessment'):

●Developing a trusting, personal connection with the patient and family

●Establishing a relationship that is defined by attention to both biomedical and psychosocial/spiritual issues, including the emotional experience of being ill

●Educating the patient about the disease and its prognosis and management

●Understanding the needs of the family

●Conveying non-abandonment, particularly when limits are being set on treatment [41]

In addition to providing an overview of the medical history from the patient’s perspective, the opening phase of the interview should also be directed towards “aligning with” the patient and family, letting them know through your behaviors that you respect their perspectives, hope to understand their situation both in biomedical and psychosocial arenas, acknowledge their emotions, and seek to make a personal connection. The following scheme helps to identify central tasks and also suggests an interview structure and a format for documentation.

Greeting — Greet the patient and family members, introduce yourself and the palliative care service, explain the concept of palliative care, and jointly set the agenda.

●“I am a palliative care specialist and was asked by Dr. Smith to help you with your pain management. Could we talk now? Are you comfortable right now?”

●“I work with a group of clinicians, nurses, social workers, and chaplains as part of our palliative care team. Did your doctors say we were coming? Do you know what palliative care is? Our job is to help you live as well as you can with your (heart failure).”

●“I would like to begin by hearing from you about the story of your illness. Is that okay?”

Patients are often unfamiliar with palliative care. Clinicians may experience awkwardness in explaining the role of the palliative care consultant. A brief, clear statement is recommended:

●“Palliative care is a medical specialty that aims to help people and their families facing a serious illness live as well as possible. Our goal in working with you and your clinicians is to understand how you are feeling physically and emotionally, and to provide you with the care that helps you function at your best.”

●“Palliative care is a team approach to helping patients and their families when they face a serious illness. We focus on managing uncomfortable symptoms such as pain, providing emotional and practical support, helping with decisions about the kind of medical treatments you want, and arranging for good care when you leave the hospital.”

Patient-centered interview: Process — A key skill for most palliative care interviews is to let the patient and family talk while providing nonverbal cues that encourage them to tell the story of their illness. An expert interview is initially guided by issues that are raised by the patient and family and flows seamlessly into key topics of concern to the consultant [42].

The interview begins with broad open-ended questions and active listening. As an example, “Tell me the story of your illness.” The clinician’s facilitating behaviors can encourage the patient to elaborate on his or her story:

●Nonverbal encouragement, such as that conveyed by attentive posture and head nodding

●Verbal encouragement to elaborate (“OK… Uh huh… Yes… Tell me more…”)

●Clarification (“Say more about that… I am not sure I understand that…”)

●Not interrupting

●Use of silence to encourage the patient to elaborate

Patient-centered interview: Content — Patients typically want to tell the story of their illness from the beginning through to the present. Listening carefully to this account with little interruption and encouraging the patient to elaborate on critical parts of the story provides the interviewer with a broad picture of the illness and an understanding of the patient’s perspective, while conveying interest in the patient’s experience. Clinicians are often quick to interrupt, establish their own agenda for the interview, and ask directed questions [43], but doing this prematurely undermines learning about the overall illness from the patient’s perspective and also interferes with the establishment of a relationship in which the patient feels that they are heard and attended to. During this phase of the interview, obtain a clear picture of the origin, course, and current state of the illness from the patient/family perspective, with special attention paid to the following issues (see "Overview of comprehensive patient assessment in palliative care", section on 'Illness understanding and care preferences' and "Overview of spirituality in palliative care" and "Psychosocial issues in advanced illness", section on 'Mediators of coping' and "Psychosocial issues in advanced illness", section on 'Common issues for patients with advanced illness'):

●Patient and family understanding about the nature of the illness and its trajectory

●Preferences for information giving (eg, “Do you like to get all the details about your condition, even the disturbing information, or would you rather get just the ‘broad strokes’ or even leave these matters to your family or clinician?”) (see "Discussing serious news", section on 'Patients’ preferences when receiving serious news')

●Preferences about decision-making (eg, “How do you like to make major decisions about your ongoing care? Do you want to make them mostly by yourself with the help of your clinician or family, or even leave the decisions to your family or clinician?”)

●Important hopes

●Biggest concerns

●Personal coping strategies and difficulties coping

●Existential and spiritual issues (see "Overview of comprehensive patient assessment in palliative care", section on 'Religious, spiritual, and existential (transcendent) issues')

●“Unfinished business,” closure, and reconciliation [44]

Some sample questions to use in exploring each of these areas are provided (table 1). These questions will be tailored depending on the main purpose of the consultation as well as patient and family preferences.

Patient-centered interview: Responding to emotions — Throughout the palliative care interview, particular attention should be directed towards recognizing and exploring emotions through elicitation, acknowledgment, and legitimization, and the provision of empathic responses (table 2). A separate topic review that discusses models for delivery of serious news is available (see "Discussing serious news") as well as a table of popular mnemonics for carrying out the process (table 3).

CLINICIAN-CENTERED INTERVIEW — After the patient-centered part of the interview, the clinician can then fill in the details of the history using more active closed-ended questioning. The clinician should explicitly “sign-post” the change in the interview process by stating something like, “Now I would like to fill in some of the medical details of your story so I can make sure I understand key elements that we have not yet covered.”

The interview needs to cover a variety of facts about the patient and family as well as the specific illness (table 4):

●Medically important details about the symptom history, disease trajectory, and treatment history

●Review of the common symptoms of advanced serious illness (see "Approach to symptom assessment in palliative care")

●A detailed social history (see "Overview of comprehensive patient assessment in palliative care", section on 'Social and economic needs of patients and caregivers')

●A spiritual and religious history (see "Overview of comprehensive patient assessment in palliative care", section on 'Religious, spiritual, and existential (transcendent) issues' and "Overview of spirituality in palliative care", section on 'Integrating spirituality into palliative care')

●Family history

●Performance status (table 5)

●Patient’s illness understanding and goals, values, and preferences for future care (table 6)

●Advance care planning (see 'Care planning: Establishing goals of care and making a recommendation' below)

Some tools and examples for data collection and documentation are available in separate topic reviews on symptom assessment in palliative care, spirituality, and advance directives (see "Overview of comprehensive patient assessment in palliative care" and "Approach to symptom assessment in palliative care" and "Ethical issues in palliative care" and "Overview of spirituality in palliative care", section on 'Integrating spirituality into palliative care'). These tools can be embedded in a standardized palliative care consultation note to ensure systematic collection of data on specific symptoms (standardized consultation notes are especially important if one works in a teaching hospital where trainees with variable experience collect the initial database). There is growing evidence that a comprehensive palliative care evaluation lessens symptoms and improves quality of life [45].

Patient and family education — During the interview, but especially after the interviewer completes the data collection process, including the physical examination and review of laboratory values, the clinician may want to ensure a common understanding with the patient and family (if desired by the patient) about the illness, treatment options, and prognosis. Information sharing should be clear, simple, and jargon-free, and it should build as much as possible on the patient and family’s current understanding. It should also allow for and encourage further patient and family questions. (See "Discussing serious news".)

Clinicians tend to give explanations that are overly long monologues loaded with technical details and difficult concepts that can be lost on patients, especially when they are anxious and easily overwhelmed. In many clinical encounters, clinicians take over the treatment phase of the interview almost entirely, without checking for understanding or continued patient engagement. A better strategy for this phase of the encounter is to provide succinct, clear, jargon-free explanations in small amounts at a time, letting the patient guide you to areas that they feel deserve elaboration. Repetition of key information and checking on the patient’s understanding are often necessary. As an example, “So now that we have talked this over, can you let me know what your understanding is about this new medication: how you take it, what it should do, and common side effects?”

“Ask-tell-ask” is a mnemonic for “asking” patients about their current understanding of an issue, then crafting an explanation (“tell”) that is keyed to their level of knowledge and information preferences, and finally, “asking” the patient if he or she understands. This might be followed by asking the patient to repeat the key points you communicated (“What is your understanding now about your condition?”) or answer a few basic queries about what they need to know (“So, what do you understand now would be the value of a feeding tube?”) (table 7) [46]. Ask–tell-ask can be repeatedly used in the treatment phase of the interview to prevent it from becoming a monologue and to ensure continued patient and family engagement in the discussion and understanding of the information [47]. If the patient says something that the clinician doesn’t fully understand, the clinician should say “tell me more about…” and then listen carefully and clarify until understanding is achieved. If the new information is emotionally unsettling to the patient, the clinician may need to shift the interview back and forth between emotional management skills (table 2) and information giving.

A key task in educating the patient and family is often also providing prognostic information [48] (see "Communication of prognosis in palliative care" and "Survival estimates in advanced terminal cancer"). Without at least a rough understanding of their prognosis with and without further medical treatment, seriously ill patients cannot make good choices about goals and methods for their care.

Patient and family education about prognosis may be difficult and requires a difficult balance between truthfulness and maintaining hope. A useful mantra that can help patients and families explore both sides of this equation is: “Hope for the best, but simultaneously plan for the worst” [49]. Serious or difficult news may be optimally delivered in the context of a family meeting, or at least with trusted family members present for an added “set of ears” as well as for added emotional support. Models for discussing serious news are provided in the table and discussed elsewhere (table 3). (See "Discussing serious news", section on 'Approaches to breaking serious news: existing models and key elements' and "Communication of prognosis in palliative care", section on 'How to discuss prognosis' and "Communication in the ICU: Holding a meeting with families and caregivers".)

In some circumstances, part of the palliative care clinician’s task is to introduce words such as “death” or “dying” into the dialogue with the patient and family, grounding the conversation in reality and, ideally, detoxifying the words to the extent that the imminent loss can become a potential topic of family discussion. When patient understanding or hopes seem quite unrealistic, it can be useful to employ “wish statements” to reframe potentially unrealistic hopes as “wishes” [50]:

●“I wish that were possible”

●“I wish that I had better news to share”

●“I wish medicine was more powerful than it is”

●“I wish we had better treatments for your disease”

Care planning: Establishing goals of care and making a recommendation — Patients with a serious life-threatening illness often face challenging treatment choices, and high-quality discussions about what is important to them promote good decision-making and patient-centered care. Understanding the patient’s values, preferences, and care goals in the context of an understanding of the seriousness of their disease allows the clinician to align the care provided with what is most important to the patient. Discussing goals of care is a unique skill that should be separated conceptually from talking about prognosis or delivering bad news. While discussions about goals of care may involve some of the same principles as other difficult communication tasks, these discussions demand a different framework. (See "Discussing goals of care".)

Frequently when patients and families are faced with difficult management decisions, clinicians try to simply and clearly present the major pros and cons of various alternative strategies without influencing choices in one direction or another. While this approach may be well-meaning, aiming to involve the patient/family in the decision-making process and to avoid an appearance of paternalism on the part of the clinician, patients also deserve our expertise and guidance in such situations [51]. When the patient and family share a common understanding with the clinician about the clinical situation and the patient’s goals, values, and preferences, the clinician can offer a recommendation for further medical management consonant with the patient’s wishes in light of the reality of their clinical condition. Likewise, when the medical professional has a strong view of the best path under the circumstances, patients and families should not be deprived of the clinician’s expert recommendations because of false concerns about interfering with patient autonomy [52,53]. This can be initially posed as a question such as, “Given what I know about your medical condition and about you as a person, would you like to hear what I would recommend?” This approach is contrasted with asking the patient and/or family, “What do you think we should do?” which places the burden of a potentially life-or-death decision fully on them without guidance from the clinician.

Sample recommendations might include:

●“Now that we have thoroughly discussed the situation and your wishes, I recommend that we get you home with help from hospice.”

●“Given your desire to try anything that might help, I think it is reasonable to enroll in this experimental protocol. It has a small chance of the treatment helping and is not overtly toxic. At the same time, I think you should do some preparation in case this treatment does not help.”

●“From what you have told me about your mother’s wishes, even though she cannot express them now, I think the loving and ethical thing to do is to allow her to die peacefully by removing the ventilator.”

Of course, patients and families may disagree with a clinician’s recommendations, but that should expand the conversation about their specific goals of care, which might reveal their reasons for choosing a different path. The clinician should search for common ground with the patient and family that integrates the patient’s values in light of the realities posed by their disease.

The principle of patient autonomy, and other ethical issues that arise in the palliative care setting are discussed in more detail elsewhere. (See "Ethical issues in palliative care".)

An important point to recognize throughout the interview, and especially in the recommendation phase, is that a focus on palliative care is not “giving up” and does not exclude the simultaneous provision of the full range of other disease-directed treatment modalities. At the same time, the clinician should recommend against treatments that have little or no chance of providing benefit and are very likely to cause harm. (See "Palliative care: Medically futile and potentially inappropriate therapies of questionable benefit" and "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults".)

Having the patient and family evaluated by other key members of the palliative care team (eg, depending on circumstances, this might include other clinicians, nurses, nurse practitioners, social workers, chaplains, pharmacists, the primary care team, and/or others) is recommended at times for added input around information gathering, support, and for clinical management. The routine interdisciplinary palliative care conference about each patient, which includes both clinicians who have had direct contact with the patient and family and those who can simply share their expertise, can also provide a rich review of the case and an opportunity for input on a wide variety of topics. If patient requests for treatment are very challenging to respond to (eg, requests for near-futile medical treatment or requests for active assistance in dying), the multidisciplinary team meeting is an excellent setting for clinicians to begin to explore how to evaluate and potentially respond to such requests while receiving support from colleagues. A formal ethics consultation may also be helpful in challenging cases. (See "Palliative care: Medically futile and potentially inappropriate therapies of questionable benefit" and "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults" and "Physician-assisted dying".)

Based upon a mutual understanding of the medical situation and the patient’s values, goals, and preferences, the clinician can also make recommendations on how to approach some of the challenges that may quite predictably occur down the road [54]. This may lead to identifying and then informing a health care agent or surrogate, or preparing a formal advance care directive or Medical Orders about Life-Sustaining Therapies (MOLST) form to capture patient preferences about cardiopulmonary resuscitation (CPR), mechanical ventilation, comfort care, or other invasive procedures (eg, dialysis, artificial hydration and nutrition) as well as transfer to home, hospice, or other medical facilities (table 6). (See "Advance care planning and advance directives" and "Palliative care: The last hours and days of life", section on 'Assessing end-of-life expectations and preferences' and "Kidney palliative care: Withdrawal of dialysis" and "Stopping nutrition and hydration at the end of life" and "Assessment of decision-making capacity in adults".)

Some representative statements about introducing these subjects are below:

●“I understand that you want to be at home, and I am wondering if you would want to stay at home as long as you were reasonably comfortable and secure there, perhaps even die there. Hospice can be very helpful with such a plan. Would you be willing to learn more about what hospice could provide for you at home?”

●“Given your clinical situation, I want to advise that in my opinion attempting to perform CPR in the case that your heart has stopped would not help you. It won’t bring you back to an acceptable state of health or a meaningful existence, and it may put your family in the awful situation of having to remove you from a respirator. I strongly advise against it in your situation, and I would like to enter a medical order not to attempt this procedure.”

Arranging follow-up — Non-abandonment is a key ethical principle in both palliative and end-of-life care [41]. Patients and families are facing regular losses as they face serious, potentially fatal illness, and the clinician-patient relationship should not occasion another loss. One of the most important outcomes of a palliative care consultation in the hospital is to make sure that there is a central clinician decision-maker both in the hospital and upon discharge.

The consulting palliative care clinician should make clear what kind of follow-up will be provided and who among the many treating individual’s teams will be both available and responsible for care decisions when the patient leaves the hospital. Who will be the “quarterback” to help make medical decisions and to assure coordination of care? It might be the main treating specialist, the primary care clinician, or the palliative care specialist, but it is important to be very clear about who it will be, and to make sure that a qualified person or well-coordinated team is willing to take on this task. Additionally, there is a formal requirement to identify a primary treating clinician if the patient is transitioning to hospice. (See "Hospice: Philosophy of care and appropriate utilization in the United States" and "Palliative care and hospice outside of the United States".)

COMMUNICATING WITH THE CARE TEAM — The palliative care consultant must communicate with the referring clinician and care team about their encounter with the patient and family. A sample format for documentation of the palliative care consultation is provided (table 4). However, in addition to a formal consultation note, it is important to talk directly in person or by phone about any recommendations to the clinicians who are most responsible for the patient’s medical treatment. This task may sometimes involve dealing with conflict among providers and negotiating solutions.

Several tools are available to facilitate data collection and documentation; they are available in separate topic reviews on symptom assessment in palliative care, spirituality, and advance directives. (See "Approach to symptom assessment in palliative care" and "Ethical issues in palliative care" and "Overview of spirituality in palliative care", section on 'Integrating spirituality into palliative care'.)

CLINICIAN SELF-CARE — Clinician self-care demands opportunities for discussion among team members or other trusted colleagues about challenging cases and for regular debriefing about deaths [55]. The team meeting provides an excellent context for input about realistic expectations for a patient’s care and for reinforcing the feeling, despite a death, that one has done good work. Self-care involves maintaining a satisfying life outside of work and increased self-awareness, which includes identifying and working with emotions that may affect patient care [56].

SUMMARY

●The initial clinical interview in palliative care has the purpose not only of gathering key biomedical and psychosocial/spiritual data but also of developing an intimate, trusting clinician-patient relationship that is therapeutic in itself and facilitates fully exploring and addressing the suffering patients and their families face when encountering serious illness. (See 'Goals of both patients and clinicians' above.)

●Begin the interview with introductions and then broad open-ended questions. Encourage patients to elaborate on their story of illness, and avoid interrupting. (See 'Greeting' above.)

●Clinicians miss many opportunities for eliciting and responding empathically to patient emotions. (See 'Patient-centered interview: Process' above.)

●Clinicians tend to avoid discussing troubling topics, perhaps colluding with the patient and family, who also may prefer to circumvent such matters. Additionally, studies indicate that most patients feel they do not get enough information and often do not understand the information they were given. (See 'Patient-centered interview: Content' above and "Discussing serious news", section on 'Patients’ preferences when receiving serious news'.)

●Key areas for added exploration in the interview include the patients’ understanding of the illness and its prognosis, their hopes and concerns, their attitudes about the acceptability of diminished functional status, and preferences for the use of “aggressive” life-sustaining care. (See 'Patient and family education' above.)

●The treatment phase of the interview needs to be a dialogue rather than a monologue. Repeatedly using “ask-tell-ask” and being prepared to respond to emotion are key strategies to ensure active patient/family engagement in this part of the clinical encounter.

●Once the values, goals, and preferences of a well-informed patient are understood, the clinician may be able to make a recommendation for further medical management (“Would you like to know what I think is the best course for you?”) rather than withholding that information and asking, “What do you think we should do?” (See 'Care planning: Establishing goals of care and making a recommendation' above.)