Breaking the Cycle: Using Serious Illness Communication to Optimize Care Transition Planning in Serious Illness

It is widely recognized that many older adults in their last year of life will cycle between hospitals and skilled nursing facilities—a phenomenon described as “rehabbing to death.” Several strategies to address this complex problem have been proposed, including developing and testing serious illness communication models to provide goal-concordant care by aligning what matters most to patients with how they spend their time in the last months of life. Serious illness communication (SIC) includes structured skills clinicians can use with patients and caregivers to assess illness understanding, goals and values, share information, and make recommendations.