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The Continuum Project at Massachusetts General Hospital supports interprofessional clinicians who care for patients with serious illnesses and their families. As part of our systems-based approach for serious illness care, we provide specialized training that builds upon and enhances non-palliative care clinicians’ communications skills for having serious illness conversations. We also promote a coordinated approach to engage patients in the process of serious illness care planning, where and when they need it.

Serious Illness Conversation Guide

At MGH, the Continuum Project works to implement the Serious Illness Care Program, which was developed by palliative care experts at Ariadne Labs to engage patients and families in serious illness care planning. The Serious Illness Conversation Guide is the centerpiece of our training program, which offers clinicians language to ask patients about their goals, values, and wishes. The guide is one element of our systems-based approach to supporting clinicians in having and documenting these important conversations.

As part of our work, we have collaborated with various MGH specialties to adapt the Serious Illness Conversation Guide for their respective patient populations.

Serious Illness Conversation Guides:

Hospital Medicine

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Medical ICU

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Memory Disorders & ALS – Patient

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Memory Disorders & ALS – Caregiver

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Oncology

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Oncology Infusion RN

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Oncology RN

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Pediatrics

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Primary Care – English

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Primary Care – Spanish

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Research Articles

The Continuum Project partners with interprofessional clinicians from MGH specialties who develop additional expertise in palliative care through a two-week palliative care course. These scholars help us optimize workflow, promote local culture change, and publish implementation science scholarship.

Highlights from published Continuum Project research are included below.

March 2019
To Prepare Patients Better: Reimagining Advance Care Planning

Leah B. Rosenberg, MD; Jeffrey Greenwald, MD; Juliet Jacobsen, MD

June 2019
Integration of a palliative care specialist in an amyotrophic lateral sclerosis clinic: Observations from one center.

Kate Brizzi, MD; Sabrina Paganoni, MD; April Zehm, MD; Fabiola De Marchi, MD; James D. Berry, MD

January 2020
Neurology clinicians’ views on palliative care communication

April Zehm, MD; Amanda M. Hazeltine; Joseph A. Greer; Lara Traegar; Margaret Nelson-Lowe; Kate Brizzi, MD; Juliet Jacobsen, MD

Materials for Patients

The following are resources on serious illness care planning that clinicians may share with patients.

Talking with Your Clinician About the Future

Thinking about your goals and wishes before talking to a clinician can better prepare you for future serious illness conversations.

Talking About Your Illness with Loved Ones

Sharing the future of your illness with family and friends and thinking about how to live well despite it can be difficult, but this guide can help you begin these important conversations.

Clinician FAQs

What is the Continuum Project?

The Continuum Project is a Massachusetts General Hospital (MGH) culture change initiative that grew out of a 2015 taskforce convened by MGH president, Dr. Peter Slavin, and charged with developing a comprehensive strategy to care for patients and families facing serious illness. Our team works to implement the Serious Illness Care Program at MGH, to engage patients and families in living well now and preparing for the future, and to develop educational material for clinicians, patients, and families.

How does the Continuum Project support clinicians?

The Continuum Project supports clinicians providing care to seriously ill patients and their families through the Serious Illness Care Program, a system-based approach for improving serious illness care developed at Ariadne Labs. The program includes (1) tools for patients and clinicians, including a clinician-facing serious illness conversation guide, (2) training for clinicians, and (3) systems change such as electronic medical record modification. The Serious Illness Care Program is being implemented at institutions across the U.S., including MGH.

Can non-physicians use the Serious Illness Care Guide to have serious illness conversations with patients?

Absolutely. Our program encourages an interdisciplinary, team-based approach to initiating and documenting serious illness conversations that includes advance practice providers, nurses, social workers, chaplains and other healthcare professionals.

Where are serious illness conversations documented?

At MGH, serious illness conversations are documented in the EPIC Advance Care Planning (ACP) Module. This enables clinicians across specialties to be able to review and document serious illness conversations that were conducted over time with patients, to ensure that the care provided to patients are aligned with a patient’s wishes.

Why are serious illness conversations important?

Serious illness conversations are valuable because they help clinicians learn about their patients’ wishes, and give patients an opportunity to express and develop their future plans with their clinician. Patients who have serious illness conversations with their care team experience less emotional suffering, reduced anxiety, and report a better quality of life.

Can I attend a Serious Illness Care training at MGH?

Please contact Kelly Spinelli at MGHContinuumProject@partners.org to inquire about serious illness care trainings.

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