Pro-tip for updating a surrogate of a pt in the ICU. Enlarge the frame of the conv to the big picture every day. It's not enough to say the pt is stable, or "a little better" or to merely give information about how that is the case (ie lower vent settings, etc). /1 #pallicovid

People might be curious about those details, but what most ppl really want to know about their critically ill loved one is, "what does this mean for the chances of my loved one meeting goals that are important to them?" such as recovery and QOL goals. /2

Of course, people want to know the "delta" from yesterday to today. They attempt to guess based on tone of caller and first words that are said. So, I will commonly dive in pretty quickly with a vague update on the delta, especially if there is no delta (ie pt stable). /3

It's pretty easy to shift to the big picture quickly after a brief update. "What have you been hearing about what this might all mean for (name) going forward?" or "I know we've talked about the big picture before, what have you been thinking about that?" /4

Here's the thing: "Stable" from yest to today doesn't always mean the big picture is good, "some improvements" doesn't mean the big picture is good, "new issues" doesn't always mean the big picture is bad. /5

Every day, think through this big picture. Talk about it on rounds. Where is this going? Think functional recovery, cognitive issues, and how other pre-existing comorbids may play into recovery. Don't think just survival or potential procedures like trach, RRT, etc /6

Offer to give more information about big picture. "Here's what I think this all might mean for the (name)." Acknowledge uncertainties. Think best case/worst case. Think of what you'd read in a well written newspaper headline and first paragraph. @vitaltalk /7

Treat this like you're giving serious news. There have been many times when I've done this, and people have rec'd several updates, but no comment on the big picture. Assume nothing about what they already know or have heard. /8

Then, it's a perfect time to ask a goals/values question: "What would (name) say about all of this?" Goals of care conversations are iterative- get started early. Then, with future updates, you can incorporate goals that you hear into your big picture update. /9

Example of incorporating past goals conversations into today's daily update: "I know you talked about how much she loves going to church. She's been in the ICU for 12 days now, and we can expect weakness and it will take rehab to get her back to that, but it's possible. /10

This need not take a long time. You don't have the heat of making decisions on your back. If tough decisions need to be made in the future, you'll thank your past self for giving high quality big picture updates and exploring goals along the way! /end #pallicovid