Brigham and Women's Hospitals

Pal Care Remap

The REMAP Framework for Goals of Care Conversations

Step

Rationale

What you might say

Reframe

Talk about how the illness has changed (i.e. patient sicker now, fewer treatment options)

Use ASK-TELL-ASK framework above.

Ask: What’s your understanding of where things are at with this illness?

Tell: Despite our treatments, he’s gotten sicker and I’m worried he may not recover. I think we are in a different place now.

Ask: I wonder if we could talk about where we go from here?

Expect Emotion

Expect and respond to emotion throughout the conversation.

Use NURSE statements above.

I can only imagine how difficult this must be?

Can you tell me more about what’s making you most worried?

Map Values

Pause to explore the patient’s values (hopes, worries) before discussing specific treatment options.

Given where things are at with your illness, what are your most important goals?

If time were shorter than we hoped, what feels most important?

As you think about the future, what worries do you have?

If your father could share his thoughts with us now, what do you think he would say?

Align with Values

Summarize and reflect the values (hopes, worries) you heard from the patient. Helps patient/family know you heard them correctly.

From what I hear, it sounds like your father values his independence and would like the chance to have more time with his family. At the same time, if his body couldn’t recover, it sounds like he wouldn’t want to linger on machines. Does that sound right?

Propose a Plan

Make a recommendation that upholds the patient’s values and your knowledge of the medical situation.

Given what you’ve told me about your dad, and given where things are at with his illness, I’d recommend we try another 48 hours on the breathing machine, to see if he might improve. If things get better, that’s good. If he doesn’t improve, we can talk more about how we’ll continue to care for him, even if he can’t recover.