Community paediatricians ideally situated to hold discussions on advance care planning

This post was written by Dr. Michael Hill, a community paediatrician in Newmarket, Ontario. 

As a community paediatrician with a special interest in the care of children with medical complexity, topics like “goals of care” and “advance care planning” are a big part of my work. This may be surprising as some may consider these concepts ones that are most often broached at the time of admission to an intensive care unit or in consultation with a palliative care team. However, community providers can be ideally situated to hold these discussions as we often get to know our patients and their families throughout their health care journey. 

I will admit that this can often be a difficult conversation to have—laden with emotion, uncertainty and sometimes both professional and ethical conflict. It requires a deep understanding of the patient—both medically, in terms of their diagnosis, prognosis and potential therapeutic options, and personally, including their values, hopes and beliefs. All this can be constrained by internal struggles—self-perceived limitations in our ability to communicate in challenging discussions or feeling a sense of surety in the advice we provide—and external factors such as the time pressures we experience daily. It also demands respect for the autonomy of the patient and their caregivers, even in situations where that can run contrary to what we may feel is best.

Thankfully, such conversations are best had over the course of time. This allows us as health care providers the opportunity to build a trusting relationship and achieve the depth of understanding required to support our patients and families to formulate their own goals when it comes to their health care. To assist us, the recent Canadian Paediatric Society position statement, Goals of care conversations and advance care planning for paediatric patients living with serious illness, written by Dr. Adam Rapoport is a welcome addition to the literature.  This guideline provides the fundamentals around advance care planning and goals of care discussions that all paediatric health care providers should be familiar with. 

Arguably, even those who do not routinely participate in advance care planning will find the principles outlined in the position statement invaluable. In any clinical encounter, it is important to consider the core features of any goals of care discussion: first, to ensure the patient and family have a thorough understanding of the problem, and then to develop a plan of care that incorporates their values and preferences. In doing so, we increase the chance that this plan is in the best interest of the patient in front of us. 

In some ways, this goes to show that that the promise of personalized medicine so often elevated in the discussion of the future of health care need not rely on advanced technologies or the latest pharmacogenetic test; it simply asks that we communicate with and understand our patients and their loved ones. 

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