Approaching Serious Illness Conversations

Garrett T. Wasp, MD and Amelia M. Cullinan, MD
Garrett T. Wasp, MD, and Amelia M. Cullinan, MD, lead the Serious Illness Conversation Model of Care intervention as part of the Promise Partnership.

The rewarding conversations I get to have with my patients should be the experience of everybody who takes care of seriously ill patients.

Amelia M. Cullinan, MD

Having conversations about the future with patients who have serious illness and their families is an integral part of providing advanced care, but discussing prognosis can be difficult. Research shows less than one-third of patients with a serious illness discuss their goals and preferences with their clinicians, and almost half of clinicians report being unsure of what to say. Garrett T. Wasp, MD, a medical oncologist at Dartmouth’s and Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC), is one of many clinicians who holds such conversations every day. “Acknowledging bad outcomes or dying can elicit strong emotions for patients, family and clinicians,” says Wasp.

However, Wasp is not on his own. Behind him is an entire data-driven strategic Learning Health System known as the Promise Partnership.

The Promise Partnership is a collaboration between Dartmouth-Hitchcock Health (D-HH), the Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy & Clinical Practice (TDI). Launched in 2020 at NCCC, the Promise Partnership’s six working groups of diverse clinical experts, health system leaders and community members are working side by side testing interventions designed to improve patient experience and fulfillment and joy in work for our clinical care teams.

Our Promise

The Promise Partnership is D-HH’s pursuit to bring together the full power of its collective expertise to provide the best possible care to our patients, our people and our communities. NCCC, with its already award-winning patient care, was chosen by leadership to pilot The Promise with the aim of improving outcomes for care teams, patients and families, and supporting better science and scholarship.

“The Promise Partnership will take patient experience and award-winning patient care to a whole new level with tools that enhance meaningful patient—provider relationships, bring joy and fulfillment to clinical care teams, and help us achieve our full potential as an academic health system,” says NCCC Director Steven D. Leach, MD. “The practices taught through the Promise learning network, unique to us as the only NCI-designated Comprehensive Cancer Center in northern New England, exemplify the truly patient- and family-centered care at the core of our cancer center.”

Serious Illness Conversations

The Serious Illness Conversation Model of Care intervention provides tools for building these all-important conversations into the routine work of clinical teams. Teams track their progress as well as the direct impact on patients. The goal is to make it easier and more rewarding for clinical teams to have important conversations with patients earlier and more often. “It’s a structured interview guide to support all clinicians in eliciting seriously ill patients’ priorities, values and goals before they have complications,” explains director of outpatient palliative care, Amelia M. Cullinan, MD, who leads the program with Wasp, who serves as the oncology physician lead.

The power of data to drive improvement

The Serious Illness Conversation Model of Care identifies barriers to clinicians having these conversations and provides measurable aims to overcome them. “We’ll know we’ve made improvement if we see an increase in conversations documented in the Advanced Care Planning Navigator, part of D-H’s electronic medical record,” explains Cullinan.

For example, Cullinan and coaches Maxwell T. Vergo, MD, and Matthew M. Wilson, MD, join weekly oncology team meetings at which patients are discussed by an interdisciplinary group of experts. Through a structured approach, the team determines the best time to introduce a Serious Illness Conversation into the patient’s care. Data is carefully tracked to give teams an accurate sense of progress. “The first time we reported data back to the teams, we identified five things that people wanted to revise in the process,” says Cullinan. “That demonstrated to me the power of data to not only improve performance but take the emotion out and approach things objectively.”

Building stronger teams

Wasp has found how much a quality improvement process brings the whole team forward. “Usually, conversations about goals and priorities fall on physicians’ shoulders. I’m proud that other members of my team feel empowered to join in. They’re doing a fantastic job,” says Wasp.

Cullinan tells the story of Catherine P. Anton, MSN, APRN, who had recently joined the team as a new grad. “We did coaching with her, and as she was willing to begin having these conversations, we scheduled one for her. I sat with her and the patient while she not only followed the [Serious Illness Conversation] Guide to a tee but added her warmth and her ability to respond to his emotion. Afterward she said, ‘I shouldn't have been so nervous!’ I was beyond proud of her and thrilled that this team had trusted others to participate in this responsibility. The Guide is useful. Our people are skilled, and we can let them flourish by using this Guide.”

Meaningful work

Cullinan believes the Serious Illness Conversation Guide improves clinical team engagement in numerous ways. “By having these conversations, providers and patients and their families feel more connected to each other. That's a lovely moment to be able to give to clinical teams,” she says. “Quality improvement (QI) work itself impacts engagement as well, in that we all wonder whether we're doing enough or doing well enough. Approaching challenges with the QI mindset of ‘How is the data showing that we can make this better?’ rather than feeling like ‘I’m not doing enough,’ is a very healing way of looking at the care we provide.”

Joy and fulfillment in work seem a far reach when that work involves discussing serious illness. With guidance from the Serious Illness Conversations Model of Care, a bridge is built. “The rewarding conversations I get to have with my patients should be the experience of everybody who takes care of seriously ill patients,” says Cullinan. “Patients and families also find them so important to their relationships with their care teams and their ability to feel engaged and empowered as they face a complicated and challenging time.”

The real significance of this work for patients is talking earlier with a loved one and thinking more deeply about what's important to them. “I’ve had patients really want to continue our initial conversation and tell me more about what’s critically important to them—a family vacation that they've now moved up in time—real-life tangible things like that,” says Wasp.

Piloting in 2021, Serious Illness Conversations are increasing in every clinic that is engaged, including a sustained 75 percent in Head & Neck and Sarcoma oncology groups as early pilot sites.

To learn more about the Promise Partnership, please visit: