key: cord-029884-zl0uqmfi
authors: Horowitz, Robert K.; Hogan, Laura A.; Carroll, Thomas
title: MVP (Medical situation, Values and Plan): A memorable and useful model for all Serious Illness Conversations
date: 2020-07-30
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.07.022
sha: 
doc_id: 29884
cord_uid: zl0uqmfi

nan

to know at least the basic features of their illness, and a majority want to discuss prognosis. 16, 17 This understanding is fundamental to informed decision-making, optimal personal autonomy, and patient and family satisfaction with the chosen plan. To the extent that situational urgency allows, the provision of this information should be calibrated to the patient and family interest and preferences, so that they reasonably can assimilate it in often extraordinarily stressful circumstances. 18, 19 V: Values. This step explores the patient's beliefs, goals, ideology, narrative, hopes, fears, and communication, informational and decision-making preferences in the context of the now-understood medical situation. 20 Patient values may be general (i.e. inherent and "overarching") 21 or contextual (i.e. acquired through lived experience), 22 both of which are relevant in defining treatment preferences. That is why the Values step follows the Medical situation step; values can only be meaningfully explored when the extant medical situation is understood. In addition, the Values step mitigates the impact of physician biases and values by highlighting the patient's story, character and experience. Knowledge of the patient's Values in the unique context of their current Medical Situation informs the third step, Plan. P: Plan: A goal-concordant plan integrates the first two steps of the MVP process, and so it necessarily follows them in sequence. That is, it honors the patient's values in the context of their current medical situation and the communication process. Hence, a goal-concordant plan may regard the communication process itself, rather than a medical care plan. For example, a "bad news" discussion may focus little attention on treatment options, and considerable emphasis on when and with whom to reconvene the discussion at a later time. The integrity of the plan is ultimately proportionate with the clinician's skillful inquiry into and advocacy for the patient's vision in the face of serious illness and deliberation about it. 23 2. MVP is also a fluid and iterative process (Figure, dashed arrows), because SIC starting-and ending-points can defy expectations, and ultimately are discerned through the SIC itself. Hence, MVP guides a flexible response to the unpredictable unfolding of complicated discussions. Although the three steps and three skills are relevant to all types of SICs, their relative emphasis will vary and may actually be adjusted in response to the unfolding of the conversation. For example, if a "goals of care" meeting to define the optimal goal-concordant plan uncovers during the elaboration of the optimal goalconcordant plan (the "P" step) that the patient is counting on an unavailable or futile treatment option, then the clinician should re-explore the Medical Situation (the "M" step). This move transforms the conversation from a "goals of care" SIC focused on treatment-planning into a "serious news" SIC revealing difficult and heretofore ambiguous diagnostic, treatment or prognostic information. Note that the MVP model still applies; the change in focus and SIC type calls not for deploying a different SIC model, but rather for a pivot within the same MVP model. MVP is also iterative, since many SICs will not achieve clarity and closure in a single cycle, but rather over a series 4 of them, depending on clinical urgency, patient and family age, developmental and attentional factors, and participants' time-, cognitive-, and emotional-resources.

MVP's three core communication skills (Figure, legs of the stool) are interrelated (the rungs between the legs) and employed continuously throughout each step of every SIC:

Empower. An effective SIC requires the clinician to honor patient and family autonomy and personhood by: ensuring their assent to answer questions and receive information; tailoring that information to their needs, abilities, and preferences, as well as the situational urgency; valuing and learning their history and experience; informing them to the extent possible, reasonable and desired; and ensuring their centrality to the shared decision-making process. 24, 25 Clinicians do not empower patients by simply supplying them information, or neutrally encouraging them to select from a menu of options. Rather, the empowering clinician seeks to understand patient and family values in the context of the medical situation, and then engages with them to actively and intentionally explore, name, and advocate for the optimal means of transforming these into an action plan. [26] [27] [28] [29] Importantly, in some cases empowering a patient means honoring their preference to surrender decision-making agency to a surrogate, or even to bow out of the SIC entirely.

be Explicit. The crucial clinician skill of being explicit involves sharing information honestly, precisely, and concisely. This direct approach runs counter to the common practices of sharing copious details (to ostensibly "fully inform" patients), 30 hedging, changing the subject, and equivocation. 31,32 Such attempts to "protect" patients (or ourselves) by sharing more data, evading and euphemizing impose enormous costs: patient and clinician emotional and cognitive exhaustion, patient confusion and frustration, deferred discussions and decisions, and ultimately more time expended in subsequent corrective discussions. When being explicit, a clinician should also empower by tailoring the extent of detail-sharing to the patient's receptivity, comprehension, tolerance and informational preferences.

Empathize. Emotions are key to understanding and relating with patients and families, enhancing trust, and informing a meaningful response. 20, 33 Consequently, effective SICs require that clinicians continuously empathize, by which we mean anticipate, apprehend, validate and explore the emotions the conversations evokes. [34] [35] [36] [37] Although strong patient emotions are uncomfortable for most clinicians, it is neither empathic nor productive to "comfort" patients or family members by avoiding, minimizing or suppressing them. On the contrary, strong emotions are to be expected, and they may actually be evidence of clinician authenticity, skill and compassion. Importantly, despite our encouragement to empathize continuously, this skill too should be calibrated to patient and family preferences and clinical circumstances; some people 5 simply do not welcome "feeling talk," and some clinical decisions must be made so emergently that expressions of empathy should be compressed. 

To assess how memorable and useful MVP is, we surveyed all third-year medical students who participated in a mandatory 5-day course in SICs. 38 They were instructed in the MVP model in an introductory 30-minute presentation, and were encouraged to incorporate it into their encounters with standardized patients. Two successive daily learning objectives were to disclose a serious illness diagnosis ("deliver bad news"), and to facilitate a discussion to define a goal-concordant treatment plan ("define goals of care").

Over the two weeks following the course, we surveyed all 97 students using the REDCap tool (Research Electronic Data Capture) version 9.9.2, a secure electronic survey platform developed by Vanderbilt University. We promised confidentiality to encourage respondents to answer honestly via an automated email with an embedded link to the survey, with up to 2 weekly reminders for non-responders. All data were deidentified.

We asked the students to rate on a 5-point Likert scale how "memorable" and "useful" MVP is "for difficult conversations." We achieved a response rate of 100%. Nearly 9 out of 10 (88%) of these learners rated the MVP mnemonic moderately-to-very memorable, and the vast majority (95%) rated MVP as moderately-to-very useful. When asked what each letter stands for, 75% named all three correctly, and 90% named at least two of the three correctly.

These results suggest an immediate and accurate learner perception of MVP's memorability and, informed by experience, its usefulness. Further study is underway to determine whether MVP's memorability and usability are similarly positive across the range of multidisciplinary clinician-learners at all levels of training and experience. In addition, we will explore whether MVP's memorability and usability are durable, and, if there is time-linked attrition, whether it can be attenuated with longitudinal support and content reinforcement. 6 During the completion of this manuscript the COVID-19 pandemic introduced unprecedented possibilities into the domain of SICs, including a surge of telephone-and video-SICs, and SICs about potential resource limits. In response, authors TC and RH developed a COVID-focused MVP workshop, which we rapidly disseminated across our Medical Center. We will describe the teaching format in a forthcoming publication. Table 2 is the trifold pocket card we produced to both teach the MVP model and demonstrate potential MVP-informed clinician statements during four hypothetical COVID-specific conversations. Note the applicability of the MVP model to the range of SIC "types", including "bad news" and "goals of care" conversations. Table 2 . This 6-panel trifold card was provided to participants in a COVID-focused MVP workshop. Each panel is lettered a-f in the top right corner, in order of appearance when folded along the dotted lines such that panel a is the 'front' and panel b is the 'back'. Panel a. illustrates the MVP three-legged stool visual mnemonic. Panel b. depicts MVP's 3 step process and 3 core communication skills. Panels c-f portray MVP-informed clinician statements during hypothetical COVID-specific serious illness conversations regarding: c. proactive advance care planning grounded in worry amidst the COVID pandemic; d. treatment goals for a sick patient considering the possibility of serious COVID infection; e. a seriously ill patient with respiratory failure and unavailability of or ineligibility for a desired ventilator; f. discontinuation of a desired ventilator. Color coding is as described for Table 1 .

MVP is a unified model for facilitation of Serious Illness Conversations (SICs). It comprises three sequential steps and three core communication skills, and is encapsulated into a coherent visual mnemonic for pedagogic clarity, memorability and usefulness. It is quickly learned, accurately recalled and usefully deployed in the unpredictable, stressful and high-stakes unfolding of SICs. We hope these features, as well as its comprehensiveness and adaptability, will encourage its incorporation into medical communication education. More importantly, we hope that once it is learned, clinicians will welcome it into their conversational armamentarium, thereby easing and expanding the facilitation of SICs for the vast and growing population of seriously ill patients and their families.

Authors RH and TC dedicate this paper to the memory of our co-author, clinical teammate, fellow teacher, and friend, Nurse Practitioner Laura Hogan, who died during its writing. Laura told us with delight how well MVP served her during her final hospitalization. She described applauding her oncologist's skill and empathy when he shared the "bad news" of her cancer relapse. He humbly responded that he had just completed our Medical Center's Advanced Communication Training course, in which he learned MVP. She smiled, took a deep breath, and informed him with tears in her eyes: "I am one of the creators of that course. I'm so glad it worked." He then paused, took a breath, and with tears in his eyes thanked her for being his teacher. We thank Laura for being our teacher too.

Many thanks to our colleagues for reviewing this work and offering their wise perspective and substantial assistance in refining it: Sue Ladwig MPH; Tim Quill MD; Bob Holloway MD; Benzi Kluger MD, MS; Geof Williams MD, PhD; and Ron Epstein MD. We are also most grateful for the enthusiasm and generosity of the many multidisciplinary clinician-learners who helped us adapt and refine MVP over two years and countless iterations.

This paper was reviewed and deemed exempt by our institution's Research Subjects Review Board. None of the three authors has any conflict to disclose.

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Values Plan •I'd like to discuss some difficult information with you, okay? •Before I share the details, it will help me to know what you understand about the disease. •I'm afraid I have some bad news… •The treatment isn't working, and another round of therapy probably won't help you live longer or feel better.•I can see this is hard to hear. •I wish we had better options. •It's an honor to work with you. You've done a great job taking care of yourself, and your family.

•COVID is on many people's minds, and I think it is important to discuss with you, OK?•What have you been thinking about COVID? •I am hopeful you won't get COVID, but I am concerned… •… if you do get COVID it could be serious, and potentially life-threatening.•Yes, this is a scary situation. Talking about it now will help us and your family honor your wishes if you do get COVID.•Given your medical situation, what would matter most to you if you were to get severely ill?•If I hear you right, you value… (ex., quality over length of life…OR…doing everything to live another day… OR…)•Did I hear you right? •Who is your backup (HCP) if you can't speak for yourself? •I admire your courage in discussing this hard stuff.•Now that I understand your values, I'd like to offer a recommendation, okay?•If your breathing deteriorates I suggest we… (ex.,take resuscitation off the table, and treat your symptoms at home…OR…offer a time-limited ventilator trial…OR…)•Does this make sense? What do you think? •Let's complete 2 forms (HCP, MOLST) to make sure we and the medical team honor your wishes fully, okay?•Yes, this is hard. You've done a great job taking care of yourself, and your family.

MVP is a 3-step sequential, fluid process, supported by 3 core communication skills, to guide serious illness conversations •How does that sound to you? What do you think? •I'll document your wishes to make sure they are honored.•I admire your willingness to discuss these things. This will lighten your family's load in case of an emergency.

•I'm afraid I have some difficult news to share. (Pause) •This crisis has depleted our ventilator supply, and there aren't enough for everyone who wants one. So we are applying expert guidelines to everyone, and because of your severe illness, you won't be able to be treated with a ventilator.•I can see this is hard to hear. I wish we had more too. •I'd like to discuss what we can do for you, okay? •We will treat your shortness of breath. We can focus all of our energy on your comfort. We can also provide other treatments to try to keep you alive, but I am concerned that even so, you will probably die.•Yes, anyone would be angry to be denied what they want.•Given what you've heard, if you do get sicker, or appear likely to die, what you would hope for? What are you thinking? What are your worries?•If I hear you right, you would want… (EX: to be as comfortable as possible until you die…OR…every treatment that could possibly keep you alive…OR…). Do I understand?•Yes, this is a horrible situation, and it isn't fair.•Now that I understand your values, I'd like to offer a recommendation, OK?•I recommend that we…(EX: devote all our efforts to ease your breathing and other discomfort…OR…provide the IVF and meds to try keeping you alive longer… OR… ).•Does that make sense? •OK, let's complete 2 forms (HCP and POLST) so that we can document and honor your wishes.•I can see why this makes you angry.

Phone call to surrogate •I have some serious news about your father. (Pause) •I'm afraid because your dad is not improving, the guidelines require that we stop his ventilator. He will probably die within minutes, maybe hours, unlikely longer.•I can only imagine how hard this is to hear. •I want you to know that I believe (if sincere) that even with the ventilator, he would die soon.•Yes, I can see why you feel like we're killing him.•We can continue the other treatments to try to keep him alive, but I don't think they'll help, and they won't make him feel better. •I hear your grief; I really wish things were different.

•Now that I understand your father's values in this unprecedented situation, I'd like to suggest a plan, OK?•I recommend that we use medicine to make him comfortable, then stop the ventilator and… (EX: continue everything else to try to keep him alive longer… OR …focus entirely on keeping him comfortable as he dies…OR…)•What do you think about this plan? •I'm sorry you and your Dad are in this crisis predicament.•I promise to honor his wishes and dignity.

Acute planning, potential ventilator limit

Acute planning, actual ventilator limits

Discontinuing a desired ventilator f e d