RPACE - conversations

Conversations about a person's values and wishes can provide importance guidance for any healthcare decisions that need to be made now and in the future. Ideally, every person should have these conversations with their loved ones as part of Advance Care Planning.

After the diagnosis of a serious illness, these conversations take on a new importance and can be initiated at any stage of illness -- from time of diagnosis until end of life. We can prioritize those at highest risk for decline using some of the RPACE-recommended identification tools.

For people with a serious illness, these conversations provide an opportunity for them to express what matters most to them. They allow care providers to share their understanding of the clinical situation and their concerns about what lies ahead. As care providers, we can then tailor our recommendations for care in a way that aligns with their personal wishes and beliefs.

It is important to note that a person's wishes and priorities can change over time. These conversations should be revisited as the illness evolves, and at times they may lead to changes in the person's Advance Care Plan. ​​

Conversation frameworks

Serious illness conversation guide (original guide)

The Serious Illness Conversation Guide is an evidence-based tool that uses patient-tested language to assess a person's wishes and goals in the context of their serious illness. Ariadne Labs developed it in collaboration with the Harvard T.H. Chan School of Public Health. The Guide features nine different questions and includes guidance on how to start and end the discussion. It utilizes "hope… worry" and "wish… worry" statements to support honest but sensitive communication about the reality of the illness.

Four-question framework (for long-term care and assisted living)

The 4 questions framework was developed by Coastal Community of Care in VCH​. These questions help teams learn about a person's understanding of their illness, priorities, hopes and fears.

Download the Long-term care four-question framework.

The AFIRM framework

This framework assists clinicians in navigating conversations with family members who voice a concern or notice a change in a resident's health.

Download the AFIRM framework.

Adapted Conversation Guides​

Serious illness conversation guide adapted by First Nations Health Authority and BC Centre for Palliative Care

This adaptation of the Serious Illness Conversation Guide was published in 2019 by the First Nations Health Authority and the BC Centre for Palliative Care with the intention of being more culturally safe. This article describes the process that was followed in order to develop this adaptation. The RPACE Community of Practice webinar entitled Language and Cultural Considerations for Goals of Care Conversations featured a panel discussion on cultural considerations when having serious illness conversations and featured one of the authors of this culturally-safe guide.

Download the Adapted Guide by First Nations Health Authority and the BC Centre for Palliative Care

A guide for serious illness conversations with structurally vulnerable patients in hospital

Serious illness conversations (SICs) are an important step in empowering structurally vulnerable patients when making health care decisions.  However, both structurally vulnerable patients and their health care providers frequently encounter barriers and challenges during these conversations.  SICs are particularly challenging when they take place in hospital and are initiated by care providers that do not have a pre-existing relationship with the patient.

This evidence-based conversation guide (2021) and accompanying educational video illustrate how to apply trauma-informed practice to SICs and support the needs and preferences of structurally vulnerable patients. 

The guide was developed through: a review of the literature related to serious illness conversations and end-of-life care for patients with structural vulnerabilities; incorporation of trauma-informed practice; collaboration with a patient partner with lived experience and care providers working with members of this population; and partnership with Providence Health Care's Department of Indigenous Wellness and Reconciliation.

This guide was created for use with patients in hospital living with both:

A moderate to late stage serious illness, such as:

  • Cancer
  • Organ failure – (liver/heart/lung/kidney disease) 
  • Chronic neurological disease (Parkinson's, MS, dementia) 


​A structural vulnerability (evidence of marginalization)

  • Vulnerably housed or homeless
  • Substance use concerns*
  • Mental health concerns​​​
  • Living with disability

* Please note that for the purposes of this guide, Substance Use Disorder (SUD) is considered a structural vulnerability rather than a serious illness.  This guide is intended for patients whose substance use concerns co-occur with another serious illness (like cancer, organ failure, advanced neurological disease, etc.).

Download A Guide for Serious Illness Conversations with Structurally Vulnerable Patients in Hospita​l

View the Educational video including a conversation demo

Contact RPACE at if you would like additional information on this guide or have questions about education opportunities relating to this guide.

​​Recommended reading:

Serious illness conversation guide for Substitute Decision Makers

This adapted conversation guide (2019) is intended to support conversations between a health care provider and the Substitute Decision Maker (SDM) that is speaking on behalf of a patient, client, or resident. It was developed as a collaboration between Vancouver Coastal Health, Providence Health Care, and the Vancouver Division of Family Practice.

Download the Serious Illness Conversation Guide for Substitute Decision Makers

Conversation with the Substitute Decision Maker of a patient with dementia - Video demonstration

Conversation with the Substitute Decision Maker of a patient with a glioblastoma (brain tumor) - Video demonstration

Navigating the Serious Illness Conversation Guide for Substitute Decision Makers​ - ​ Instructional video

Rapid code status conversation guide

The rapid code status conversation guide (2020) was developed by Drs. Kei Ouchi and Naomi George to support clinicians in having urgent, values-based code status conversations that ensure that patients receive goal-concordant care. With the Emergency Department setting in mind, this guide provides a framework for time-sensitive conversations with seriously ill older adults at risk of acute respiratory failure.

Download the rapid code status conversation guide

A research article with video vignettes on the rapid code status conversation guide

EMCrit podcast on the rapid code status conversation guide with Dr. Kei Ouchi

Conversation dos and don'ts - tips for success

Conversation Don'ts: Things to avoid

Conversation Dos: Instead...try these

Do not provide facts in response to emotions. Do not assume that you know the reason for their feelings.

  • Allow for silence.
  • Explore their emotions. Ask them, "Tell me more..."

Do not make the conversation more about what you have to share.

  • Clinicians should talk < 50% of the time.
  • Listen and empathize.
  • Gather information about them so that you can make recommendations that resonate with their situation and their wishes.

Do not use formal medical terminology.

  • Use vocabulary appropriate to the patient's level of education and understanding of their condition. (E.g. breathing machine with a tube down your throat rather than intubation and mechanical ventilation).
  • Check that you have understood their responses correctly by paraphrasing what you've heard them say.

Do not give false hope or make premature promises.

  • Be open and honest. Use "I wish/hope...but I worry...and I wonder..." statements.
  • Your "wish/hope" should align with what you've heard them say. This allows them to feel heard.

Do not provide the patient with a list of menu options.

  • Make a recommendation that aligns with what matters to them and what is likely to assist them in achieving their wishes.

Do not make the conversation about life or death.

  • Recognize that there is more to life than quantity/time. This is about quality of life and the circumstances that patients find acceptable and unacceptable for their unique future.

Do not talk down to patients or convey closed body language.

  • Sit down at their level.
  • User open body language (e.g. uncross arms, lean into the conversation, nod your head in affirmation).

Related articles

RPACE - identification

RPACE - documentation

RPACE - resources

RPACE - education

RPACE - translations