Health care organizations in California and around the US are working incredibly hard to prepare for or respond to a surge of patients suffering from symptoms related to COVID-19. Appropriately, preparation has focused on trying to ensure adequate numbers of health care professionals and sufficient supplies and equipment in the right places at the right times as the demand grows.

That focus on numbers and logistics is essential. Also important but perhaps less widely acknowledged is the need to prepare our clinical workforce for the types of circumstances found in Washington and Italy and now emerging in New York, California, and other hot spots we read about every day. Clinicians and staff — in skilled nursing facilities, hospitals, and beyond — face the prospect of caring for increasing numbers of very sick people, some of whom will not recover. Talking with these patients and their loved ones with compassion and clarity about what is happening, what to expect, and what their options are is extremely important. To many clinicians, it is a daunting prospect.

Support is available: VitalTalk, a nonprofit organization dedicated to helping every clinician develop communication skills for serious illness, has created “COVID-Ready Communication Skills,” a customized, practical, specific set of tips and scripts for all clinicians caring for patients caught up in the COVID-19 crisis. CHCF and VitalTalk encourage the health care community to share these resources far and wide. Printable versions in multiple language are available online.

For those interested in online training for supporting people with serious illness, resources include the California State University Shiley Institute for Palliative Care, which has just made 20 self-paced online courses available for free until June 30, and the Center to Advance Palliative Care.

Additional COVID-19 tools and resources addressing communications, symptom management, and other issues are available on the Center to Advance Palliative Care’s COVID-19 Response Resources.

Thank you to Tony Back, MD, co-founder of VitalTalk, for permission to reprint this content, and to Dr. Back and his many collaborators noted at the bottom of this post for developing this thoughtful, practical guide.

VitalTalk Response Tips

Contents

Screening — When someone is worried they might be infected

Preferencing — When someone may want to opt out of hospitalization

Triaging — When you’re deciding where a patient should go

Admitting — When your patient needs the hospital, or the ICU

Counseling — When coping needs a boost, or emotions are running high

Deciding — When things aren’t going well, goals of care, code status

Resourcing — When limitations force you to choose, and even ration

Notifying — When you are telling someone over the phone

Anticipating — When you’re worrying about what might happen

Grieving — When you’ve lost someone

New talking maps for contingency and crisis — Proactive planning, resource limits, the last family call

Using These Tips

This is a super-concentrated blast of tips focused on COVID-19. We’ve pared away all the usual educational stuff because we know you’re busy. If you want more, check out VitalTalk’s videos and talking maps on fundamental communication skills, family conferences, and goals of care.

As the pandemic evolves, the caseload in your region will determine whether your clinic or hospital or institution is “conventional” mode (usual care), “contingency mode” (resources stretched, although care functionally close to usual), or “crisis” mode (demand outstrips resources). Most of the tips here are for conventional or contingency mode. If your region moves to crisis standards, how medicine is practiced will change dramatically — triage decisions will be stark, and choices will be limited. If needed, future versions of this doc will shift towards crisis. For now, please note that the crisis mode tips are marked [C] and should be reserved for a crisis designated by your institution. And remember that even in a crisis, we can still provide compassion and respect for every person.

Some of the communication tips in this document depict ways to explain resource allocation to a patient or family or caregiver. However, note that decisions about how resources are allocated — which criteria are used or where lines are drawn — should happen at the regional or state or country level. Rationing decisions should not be made at the bedside. In these tips, we steer away from complex discussions about rationing, and use language that is for lay people rather than for ethicists.

You Can Pitch In

Show this to the people you work with. Volunteer to edit so we can incorporate feedback in real time. Translate this into another language. Don’t just spread worries about how bad things will get — be the change you want to see. You can get in touch with us at [email protected] or [email protected].

Screening — When Someone Is Worried They May Be Infected

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Preferencing — When Someone May Want to Opt Out of Hospitalization

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Triaging — When You’re Deciding Where a Patient Should Go

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Admitting — When Your Patient Needs the Hospital or the ICU

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Counseling — When Coping Needs a Boost, or Emotions Are Running High

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Deciding — When Things Aren’t Going Well, Goals of Care, Code Status

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Resourcing — When Limitations Force You to Choose, Even Ration

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Notifying — When You Are Telling Someone over the Phone

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Anticipating — When You’re Worried About What Might Happen

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Grieving — When You’ve Lost Someone

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For Proactive Planning in Contingency

The COVID-as-a-starter preferences or goals talk for patients in a health care setting.

“CALMER”

CHECK IN

Take a deep breath (yourself!).

“How are you doing with all this?” (Take their emotional temperature.)

ASK ABOUT COVID

“What have you been thinking about COVID and your situation?”

(Just listen.)

LAY OUT ISSUES

“Here is something I want us to be prepared for.” / “You mentioned COVID. I agree.”

“Is there anything you want us to know if you got COVID / if your COVID gets really bad?”

MOTIVATE THEM to choose a proxy and talk about what matters

“If things took a turn for the worse, what you say now can help your family / loved ones.”

“Who is your backup person — who helps us make decisions if you can’t speak? Who else?” (Having 2 backup people is best.)

<p“We’re in an extraordinary situation. Given that, what matters to you?” (About any part of your life? About your health care?)

Make a recommendation — if they would be able to hear it. “Based on what I’ve heard, I’d recommend _______. What do you think?”

EXPECT EMOTION

Watch for this — acknowledge at any point.

“This can be hard to think about.”

RECORD THE DISCUSSION

Any documentation — even brief — will help your colleagues and your patient.

“I’ll write what you said in the chart. It’s really helpful, thank you.”

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[C] FOR CRISIS ONLY

Talking about resource allocation (i.e., rationing).

“SHARE”

SHOW THE GUIDELINE

“Here’s what our institution/system/region is doing for patients with this condition.”

(Start with the part directly relevant to that person.)

HEADLINE WHAT IT MEANS FOR THE PATIENT’S CARE

“So for you, what this means is that we care for you on the floor and do everything we can to help you feel better and fight this illness. What we won’t do is to transfer you to the ICU, or do CPR if your heart stops.

(Note that you talk about what you will do first, then what you won’t do.)

AFFIRM THE CARE YOU WILL PROVIDE

“We will be doing [the care plan], and we hope you will recover.”

RESPOND TO EMOTION

“I can see that you are concerned.”

EMPHASIZE THAT THE SAME RULES APPLY TO EVERYONE

“We are using the same rules with every other patient in this hospital/system/institution. We are not singling you out.”

NOTE: This talking map is used only when an institution has declared use of crisis standards of care, or a surge state. When the crisis standards or surge are discontinued, this map should no longer be used.

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When you need to talk to a family member by phone or video through saying goodbye to a patient who is in their last hours or minutes.

“LOVE”

LEAD THE WAY FORWARD

“I am [Tony], one of the [professionals] on the team.”

“For most people, this is a tough situation.”

“I’m here to walk you through it if you’d like.”

OFFER THE FOUR THINGS THAT MATTER MOST TO PEOPLE

“So we have the opportunity to make this time special.”

“Here are five things you might want to say. Only use the ones that ring true for you.”

“Please forgive me”

“I forgive you”

“Thank you”

“I love you”

“Goodbye”

“Do any of those sound good?”

VALIDATE WHAT THEY WANT TO SAY

“I think that is a beautiful thing to say.”

“If my [daughter] were saying that to me, I would feel so valued and so touched.”

“I think he/she can hear you even if they can’t say anything back.”

“Go ahead, just say one thing at a time. Take your time.”

EXPECT EMOTION

“I can see that he/she meant a lot to you.”

“Can you stay on the line a minute? I just want to check on how you’re doing.”

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Your Comments and Feedback

Thank you all for contributing edits and ideas — they are extremely valuable, and we have incorporated most of them. If I did not incorporate your suggestion and you are wondering, you can email me at [email protected]. Please note that this guide is designed as a completely standalone guide for clinicians, and thus some recommendations are slightly different than what we would teach in the context of an in-person or live virtual course.

Thank You

VitalTalk is a 501(c)3 nonprofit social impact startup dedicated to making communication skills for serious illness part of every clinician’s toolbox. This content will be in the free VitalTalk Tips app for iOS and Android very soon.

Kate Meyers

Kate Meyers is a senior program officer with CHCF’s People-Centered Care team, which works to ensure that Californians — particularly those enrolled in Medi-Cal — receive responsive, comprehensive, and coordinated care that supports their health and well-being. Her work focuses on care for people with complex needs, including older adults and people with serious illnesses. Read More

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