Bridging the Hesitation Gap: A Motivational Interviewing Approach to Earlier Goals of Care Conversations

Key Message: This session introduces a communication innovation that addresses a key systems barrier: clinician hesitation to initiate early goals of care conversations. Grounded in motivational interviewing, the model helps clinicians overcome their own ambivalence, fostering confidence, emotional attunement, and more timely and effective engagement in values-based ACP discussions.

Abstract: Clinician hesitation and discomfort in initiating goals of care conversations represent a significant barrier to delivering timely, values-based care. Many providers delay advance care planning (ACP) and goals of care (GOC) conversations, waiting for patients to bring it up first or for the “perfect” moment. This hesitation leads to missed opportunities and delays in goal-concordant decision-making.

We developed a scalable communication model grounded in motivational interviewing (MI) to address this behavioral barrier. The model offers a structured, empathic approach that attends to the relational dynamics of the conversation—emphasizing not only what is communicated, but how trust, readiness, and understanding are co-created. It equips clinicians to navigate patient and family ambivalence, initiate difficult conversations, and build confidence in high-stakes, values-driven encounters.

The innovation was implemented through an immersive faculty-led course for palliative medicine providers and is adaptable to other disciplines and settings. It blends didactic instruction, real-play exercises, reflective debriefing, and MI coaching using validated tools. Learners develop proficiency in recognizing a patient’s readiness for deeper discussion and selecting the appropriate MI task—Engaging, Focusing, Evoking, or Planning—while skillfully using OARS techniques (Open-ended questions, Affirmations, Reflective listening, and Summarizing). These skills are practiced and reinforced through simulated and real-world ACP and GOC conversations.

Structured communication frameworks offer essential guidance for ACP and GOC discussions. This MI-informed model creates synergy with those frameworks by addressing an earlier phase—when patient avoidance and ambivalence is high and clinicians may hesitate to initiate dialogue. By focusing on the provider’s internal experience and promoting authentic, patient-led conversation, this approach helps build the emotional readiness and trust that support more effective structured communication later.

Participants reported increased confidence, reduced reliance on scripted language, and a stronger sense of presence in difficult discussions. This model is adaptable across disciplines, specialties, and care settings.

We respectfully request a 60-minute session.

References: 1. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 4th ed. Guilford Press; 2023.
2. Pollak KI, Gao X, Arnold RM, et al. Feasibility of using communication coaching to teach palliative care clinicians motivational interviewing. J Pain Symptom Manage. 2020;59(4):787-793.
3. Wang T, Ho MH, Xu X, Choi HR, Lin CC. Motivational interviews to enhance advance care plans in older adults: systematic review. BMJ Support Palliat Care. 2024;14(e3):e2293-e2301. doi:10.1136/spcare-2023-004424
4. Back AL, Arnold RM, Tulsky JA. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. Cambridge University Press; 2009.