Transcript The Project to Educate Physicians on End-of
E P E C The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation
Module 7
Goals of Care
Objectives . . .
Understand the different goals and how they interrelate and change
Understand how to use the 7-step protocol to negotiate goals of care
Be able to communicate prognosis and its uncertainty
Understand how to tell the truth and identify reasonable hope
. . . Objectives
Be able to use language effectively
Be able to set limits on unreasonable goals
Be able to adjust care and communication according to culture
Understand how to identify goals when patients lack capacity
Introduction . . .
Every one has a personal sense of who we are what we like to do control we like to have goals for our lives things we hope for
. . . Introduction
Hope, goals, expectations change with illness
Physician’s role to clarify goals, treatment plan
Potential goals of care
Cure of disease
Avoidance of premature death
Maintenance or improvement in function
Prolongation of life
Relief of suffering
Quality of life
Staying in control
A good death
Support for families and loved ones
Historically, a dichotomous division of goals of care
Focus on curing illness
Little attention to relief of suffering, care of dying
Hospice / palliative care arose in response to a need
Figure 1: A dichotomous intent Curative / life-prolonging therapy Presentation Relieve suffering (hospice) Death
Multiple goals of care
Multiple goals often apply simultaneously
Goals are often contradictory
Certain goals may take priority over others
Goals may change
Some take precedence over others
The shift in focus of care is gradual is an expected part of the continuum of medical care
Figure 2: The interrelationship of therapies with curative and palliative intent Curative / life-prolonging therapy Presentation Death Relieve suffering (palliative care)
Palliative care: expanding the options . . .
Interdisciplinary care
Symptom control
Supportive care
. . . Palliative care: expanding the options
Any life-threatening diagnosis
Anytime during illness
Whenever patient / family prepared to accept it
May be combined with curative therapies
May be focus of care
7-step protocol to negotiate goals of care . . .
1.
Create the right setting 2.
Determine what the patient and family know 3.
Explore what they are expecting or hoping for
. . . 7-step protocol to negotiate goals of care 4. Suggest realistic goals 5.
Respond empathically 6.
Make a plan and follow-through 7.
Review and revise periodically, as appropriate
Communicating prognosis
Markedly over-estimate prognosis
Helps patient / family cope, plan increase access to hospice, other services
Offer a range or average for life expectancy
Truth-telling and maintaining hope
False hope may deflect from other important issues
True clinical skill to help find hope for realistic goals
Language with unintended consequences
Do you want us to do everything possible?
Will you agree to discontinue care?
It’s time we talk about pulling back
I think we should stop aggressive therapy
I’m going to make it so he won’t suffer
Language to describe the goals of care . . .
I want to give the best care possible until the day you die
We will concentrate on improving the quality of your child’s life
We want to help you live meaningfully in the time that you have
Language to describe the goals of care . . .
I’ll do everything I can to help you maintain your independence
I want to ensure that your father receives the kind of treatment he wants
Your child’s comfort and dignity will be my top priority
. . . Language to describe the goals of care
I will focus my efforts on treating your symptoms
Let’s discuss what we can do to fulfill your wish to stay at home
Let’s discuss what we can do to have your child die at home
Cultural differences
Who gets the information?
How to talk about information?
Who makes decisions?
Ask the patient
Consider a family meeting
Determine specific priorities
Based on values, preferences, clinical circumstances
Influenced by information from physician, team members
Reviewing goals, treatment priorities
Goals guide care
Assess priorities to develop initial plan of care
Review with any change in health status advancing illness setting of care treatment preferences
When the physician cannot support a patient’s choices
Typically occurs when goals are unreasonable, illegal
Set limits without implying abandonment
Make the conflict explicit
Try to find an alternate solution
Reassess decision making capacity . . .
Implies the ability to understand and make own decision
Patient must understand information use the information rationally appreciate the consequences come to a reasonable decision for him or her
. . . Reassess decision making capacity
Any physician can determine
Capacity varies by decision
Other cognitive abilities do not need to be intact
When a patient lacks capacity . . .
Proxy decision-maker
Sources of information written advance directives patient’s verbal statements patient’s general values and beliefs how patient lived his / her life best interest determinations
. . . When a patient lacks capacity
Why turn to others respects patient builds trust reduces guilt and decision-regret
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