In 2017, the Institute for Healthcare Improvement (IHI), the John A Hartford Foundation (JAHF), the American Hospital Association (AHA) and the Catholic Health Association (CHA) of the United States attempted to address the development of age-friendly health systems using a clinical framework to improve the complex care of older adults.

These organizations defined and operationalized age-friendly care following the guidelines of beneficence, evidence-based medicine, and patient/family aligned goals and concerns. The 4M Framework was the result: What Matters Most, Mentation, Mobility, and Medication.  A 5^th M is often incorporated to include Multi-Morbidity, which calls attention to the multiple, often inter-related, health problems that many older adults face.

What Matters Most: This “M” aligns care to what the patient feels is most important in their life.  It provides both an opportunity and a tool to communicate this information with family, surrogate decision makers, and the healthcare team.  In doing so, it builds the central core for the other “M’s” of the IHI framework.

The framework creates a forum for difficult topic discussions such as:

• Approaches and limits to care (e.g., DNR, DNI, rehospitalization).
• Degree of invasiveness of therapies/treatments (e.g., surgery, chemotherapy, invasive nutrition support). 
• Appropriateness of shifting towards palliative care measures or instituting other end of life care.
• Issues of independence (e.g., living arrangements, driving, personal goals).  

Sample steps in addressing what matters most with a patient:

1. Develop a plan to address the question:

• Identify who within the team will discuss the topic.
• Identify what time of day may be best for the discussion (if options exist).
• Identify key stakeholders from the healthcare team and the individual’s family/caregivers.
• Identify individual or cultural perspectives on the topic.
• Build trust, and listen in a non-defensive, non-judgmental way.
• Understand that the person may not be willing or ready to have the discussion. Sometimes even addressing the question, without generating an answer, can allow the individual to consider what matters most to them.

2. Consider your opening script:

Examples may include:

• “I want to help figure out the next steps together.  Can we talk about what matters most to you right now?” 
• “To make sure you’re getting the care that is right for you, I’d like to learn more about what matters most for you.”
• “A lot has happened in your care.  To be respectful of you as a person, and to guide how we approach your care in the future, can you share with me the things that matter most to you?”

In some circumstances, the patient cannot respond to this question themselves.  It is appropriate to discuss the topic with the individual’s healthcare proxy or Power of Attorney for Healthcare.  Sample scripts include:

• “If ___ were asked what mattered most to them at this point in their life and healthcare journey, what do you think they would say?”
• “You know ___ better than anyone on the healthcare team could.  How do you think they would answer the question of what matters most to them?” 

3. Navigate the conversation:

• Open ended questions will help start the conversation.  Details can be elaborated upon based on the answers.
• These questions may generate different responses over time, depending on the individual’s circumstances and place in their healthcare journey.  It may be important to revisit the topic and the answers, as further contemplation may change or expand the individual’s answers.
• Acknowledge the patient’s emotions.
• Returning to this response will help frame your approach to the other “M’s” in the IHI framework.  Be prepared to adapt the care-plan to honor and align with the patient’s responses. 

4. Document the conversation:

Useful tools and resources for defining and documenting include:

• POLST: Physician Orders for Life Sustaining Treatment. Https://polst.org. State specific forms can be found by searching “POLST” and the state or region name.
• Power of attorney for healthcare documents:  These tend to be state specific, and there is no national document that is universally accepted.  Ideally, search terms should include “Power of attorney for healthcare” and the state / region name. One example is “Five Wishes advance directive documents”:  Https://fivewishes.org.