The authors consider the legal and ethical considerations of offering a time-limited trial of a potentially non-beneficial intervention in the setting of patient or surrogate requests to pursue aggressive treatment. The likelihood of an intervention’s success is rarely a zero-sum game, and an intervention’s risk-to-benefit ratio may be indiscernible without further information (often, a matter of time).

End-of-life conversations are a difficult part of medicine. The COVID-19 pandemic has made them simultaneously more necessary and more difficult. Encouraging patients to have these conversations with their own providers and loved ones can help ensure, when the unfortunate time comes, their end-of-life wishes are carried out. This honors the patient and limits burden on others. Here, I reflect on how my personal experience as both a grieving grandson and as a resident physician has emphasized the importance of end-of-life conversations.

As the COVID-19 pandemic continues, more patients will require palliative and end-of-life care. In order to ensure goal-concordant-care when possible, clinicians should initiate goals-of-care conversations among our most vulnerable patients and, ideally, among all patients. However, many non-palliative care clinicians face deep uncertainty in planning, conducting, and evaluating such interactions. We believe that specialists within palliative care are aptly positioned to address such uncertainties, and in this article offer a relevant update to a concise framework for clinicians to plan, conduct, and evaluate goals-of-care conversations: the GOOD framework. Once familiar with this framework, palliative care clinicians may use it to educate their non-palliative care colleagues about a timely and critical component of care, now and beyond the COVID-19 era.

Introduction: Discomfort exists discussing goals of care with families of children with advanced life-threatening illnesses. There also exists important variability in the management of these patients. This study seeks to explore the perceptions of pediatric specialists involved in the care of children with life-threatening illnesses with regards to goals of care discussions and management during acute unexpected deteriorations. Methods: This single center survey study used 4 scenarios of children presenting to the emergency department with respiratory distress. Scenarios included patients with hypoplastic left heart syndrome, static encephalopathy, spinal muscular atrophy and refractory leukemia. Questions following each vignette were identical. Physicians from the specialties most involved in these scenarios completed the survey by email or in person. Data analysis used SPSS v.20 (IBM Inc.). Related samples non-parametric tests compared participants’ Likert scale answers. Results: Between May 2015 and May 2016, 60 participants completed the study; 14 were excluded (>60% missing answers). Most (80.4%) participants reported an interest in pediatric palliative care; 71.7% had 0-3 formal trainings. Participants believed goals of care were best discussed before an acute deterioration. Acute deteriorations were not seen as an opportune moment to initiate discussions about goals of care. However, validating these previous wishes was necessary, given that not discussing them was judged unacceptable by the participants. Pediatric specialists were seen as the most suitable teams to initiate these discussions, while the emergency department's role in these discussions was unclear. Several management options were less acceptable for the patient with static encephalopathy. Conclusion: Discussing goals of care during acute illness exacerbation involves many stakeholders, who may not always be available at critical times. Advanced care planning with these families is essential to prepare them for acute health events.

Introduction: Advanced care planning (ACP) and Goals of Care (GOC) discussions are becoming increasingly common in our emergency departments (ED). The national ACP task group has found that the majority of Canadians have not had prior ACP/GOC discussions, nor have they obtained proper documentation of their wishes. The task of having these difficult but important conversations falls frequently to the ED. Despite this, our emergency medicine (EM) residents receive little formal training in ACP discussions. To address this need, we developed and implemented a workshop in ACP/GOC conversations for the University of Alberta EM academic curriculum. Methods: A literature search was performed to identify best practices for ACP discussions in the ED, barriers to ACP in the ED, and tools for identifying ED patients appropriate for ACP. Experts in ACP/palliative care and staff ED physicians were asked to identify previous difficult ACP discussions and highlight aspects of these cases that were challenging in the ED environment. These experiences, best practices and published APC curricula informed the development of a 3-hour case-based workshop that was implemented in the 2016/17 academic year for EM staff and residents. Results: Cases utilized in the workshop emphasized common ACP/GOC situations that occur in the emergency department: Case 1: An 84 year old with C1 GOC whose family did not accept the GOC designation. Case 2: A 72 year old with multiple comorbidities arriving intubated with no GOC documented. Case 3: An 82 year old with decreased LOC whose family asks for an ACP discussion in the ED. Participants were divided into groups (5-6 members). Each small group analyzed and discussed each case before the participants reconvened and discussed their opinions in one large group. ACP experts from palliative care, emergency medical services and EM facilitated the discussions highlighting the best practices from the literature for each case reviewed. Pre and post Likert surveys were distributed to workshop participants to assess changes in confidence in a variety of domains. A Wilcoxon Signed Rank Test showed statistically significant improvement in learner confidence within the following areas (N=21; P<0.05): identifying patients appropriate for GOC discussions, initiating GOC discussions, and identifying barriers to GOC, in the ED. The majority (89%) of participants agreed the workshops should become part of our academic curriculum. Conclusion: An ACP/GOC workshop was successfully implemented and further ACP/GOC sessions are planned for the upcoming academic year. Looking ahead, we will look at using other teaching modalities such as simulation to further enhance the delivery of the curriculum. We will also attempt to capture defined physician behaviors (e.g. documenting GOC in the ED chart, sending letters to family physicians documenting GOC discussions) to gauge uptake of the workshop principles into clinical practice.

Palliative care is an interdisciplinary approach to caring for individuals and families who are suffering with serious illness. Medical and psycho-social-spiritual symptoms and needs are assessed and addressed. Much of palliative care is about working with patients and families to bring their context to light, that is, to understand not only their medical situation but also their wishes, values, cultural background, previous experiences, and quality of life. As palliative care clinicians, we have seen how popular understanding and misunderstanding about what it means to “honor thy mother and father” can influence medical decision making. Whether or not adult children of patients have familiarity with the honor commandment, the biblical text “honor thy father and mother,” or whether they identify with a particular religious tradition, this theme plays a central—and often unaddressed—role as adult children strive to make decisions with and for a seriously ill parent. In this article we examine the commandment to honor one's father and mother by exploring its religious, spiritual, textual, and cultural origins, as well as subsequent Jewish commentary. We also contextualize the honor commandment in the palliative care setting through clinical case studies that illustrate the concerns of adult children who wish to honor their parents but are perplexed or conflicted about what this mandate means in the face of difficult medical and psycho-social-spiritual circumstances.