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COVID-19 and Beyond: Values Guide Decisions

Conversations about values can reduce anxiety around COVID-19 health care decisions and life planning.

Profile in Medicine

COVID-19 and Beyond: Values Guide Decisions

Christine Ritchie, MD, a geriatric and palliative care specialist, describes how Mass General helps families with difficult conversations during COVID-19 and beyond.

Terry Byrne
May 28, 2020

Christine Ritchie, MD, MSPH, director of research for the Division of Palliative Care and Geriatric Medicine and the Kenneth L. Minaker Chair in Geriatrics, shares her thoughts on how COVID-19 is helping individuals think carefully about what’s important to them when it comes to health care decisions.

When seriously ill COVID-19 patients are admitted to Mass General, is there time to counsel families about their future medical care?

It’s hard for patient families to have these conversations when they are already feeling overwhelmed about a loved one’s health. I’ve seen that clarifying values and having a meaningful conversation about what’s important can make a difficult situation less overwhelming. The discussion can be uncomfortable, but it can also provide a sense of relief. What we hope to do is normalize this conversation. And we do that by providing more patients and families with access to individuals who can guide them.

“If something positive can come out of this crisis, I hope it’s that we can leverage our vulnerability to help us be better prepared to face the future.”

The reach of the COVID-19 pandemic, and our vulnerability to it, has been stunning. If something positive can come out of this crisis, I hope it’s that we can leverage our vulnerability to help us be better prepared to face the future. This issue is not only important for older people and those with serious illness – it’s important for everyone. Encouraging people to take time to reflect on what is important to them will mean that when they are confronted with a challenging situation, making health care decisions can be informed by their values.

How has the Palliative Care team met the growing need for these conversations?

Mass General has been a leader in Palliative Care for many years. Through the Palliative Care Continuum Project, we help patients, families and clinicians have the knowledge, skills and resources to ensure the highest quality serious illness care.

Christine Ritchie, MD
Christine Ritchie, MD

This project has already trained clinicians in specialties across the hospital in how to handle difficult conversations when patients are confronting any kind of serious illness. Whether patients are coping with COVID-19, cancer, the aftermath of a stroke or other neurological injury, having a conversation about what’s important to them has a positive impact on an individual’s resiliency, and can reduce the stress of a difficult situation.

During the COVID-19 pandemic, we encourage primary care physicians and care managers on their team, to reach out to patients to check in and see how they are doing. We also began building a cohort of volunteer clinicians from across the institution — breast cancer surgeons, social workers, medical school students and others, who could also reach out and check in with patients with chronic or serious illnesses.

“We continue to learn about the disease and where the decision points are, so we can help paint a picture of what this journey could look like.”

We provided clinicians with a tool kit. It includes tips for having goal-clarifying conversations, along with resources for addressing concerns around food security or elder care issues. We’ve made this tool kit available on our Partners-wide intranet, so that any clinician across the system can access it as needed.

How are you involved on a day-to-day basis?

For a number of weeks, a team of palliative care clinicians worked with COVID-19 patients and families in the Emergency Department to provide support and clarify what is important to them should they become more ill. We have conversations with the families and patients of all ages. Based on our continuous learning about COVID-19 and a growing body of knowledge of where the decision points are, we try to paint a picture of what this journey could look like.

COVID-19, or any serious illness, can lead to burdensome treatment, experiences, or even death. With COVID-19, some people sail through, while others need a ventilator. It’s important that we prepare for the best- and worst-case scenarios. As someone who may be at increased risk of contracting the virus, I talked through best- and worst-case situations with my husband and our kids, printed out an advance directive from, and documented my own values and treatment preferences.

How do you care for clinical colleagues?

Not everyone has experience managing these hard conversations. My colleagues have created a Peer Support Serious Illness Hotline that encourages clinicians to call and talk about their experiences. We have made a concerted effort to reach out to clinicians to debrief with them if they need to reflect on these conversations. Sometimes we struggle with finding the right language, other times we struggle with our own emotional response to our patients’ situation. The hotline provides that essential support for caregivers.

“We are fortunate to work as teams to support patients, families and each other.”

We are fortunate to work as teams to support patients, families and each other. Bringing together complementary skills is hopefully not only reassuring for patients, but also helps us share in the burden and difficulty of this time

How do you help patients and families?

In conversations with patients and families, we try to make these decisions less abstract by asking an array of questions that might include the following:

  • Are you comfortable with a long recovery?
  • How important is it to die at home?
  • Is it essential to have control of your cognitive abilities?

Every answer is valid, the goal is to engage in thoughtful reflections together.

To learn how you can support Mass General’s response to the COVID-19 pandemic, click here.