REMAP: A Framework for Goals of Care Conversations

Article First Author, Year, Journal

Childers JW et al., 2017, Journal of Oncology Practice

 
Although oncologists frequently have conversations about goals of care with patients, these conversations remain challenging and junior physicians may feel they lack the training to have these discussions effectively and in a timely manner. Because of this, the authors of this paper propose a guiding framework around which to structure the discussion: REMAP – Reframe, Expect emotion, Map out patient goals, Align with goals, Propose a plan.
 
Reframe refers to setting up the conversation to deliver bad news (often that cancer treatments will not result in a cure) and to gauge a patient’s understanding. Expect emotion involves actively attending to the patient’s emotional response and providing appropriate reflective statements (“I know this is not something you wanted to hear”). The emotional response will guide if the patient is ready to move forward with a plan. Mapping patient values steers the discussion towards the patient’s goals for themselves and reflective statements ensure alignment. Finally, a plan can be proposed to meet those goals, which can simultaneously include further life-sustaining chemotherapy (including clinical trials) and supportive care.
 
This paper was limited by its adult focus and did not include discussion of some of the essential differences between pediatric and adult end of life care (specifically the challenge of transitioning away from cure-directed therapy). Regardless, many of the concepts are still relevant to the pediatric population.
 
The REFRAME mnemonic aims to promote patient centered decision making during a very difficult but critical conversation. It emphasizes that the conversation be guided by the patient, allowing oncologists to be flexible in their approach and ultimately aligned with the expectations of the patient in that moment. Ultimately, better communication should lead to better end of life care.
 
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