00:01
So, the next thing to think about
with goals of care
is going to be the How.
00:05
So, in clinical ethics,
the most important thing
is establishing a supportive
therapeutic relationship
with the patient.
00:11
So that's going to be
part of the how to.
00:14
in these conversations.
00:16
It's going to be a need
to make sure there's clarity
on the diagnosis and the prognosis.
00:21
So, maybe you've done that already.
00:24
But making sure the patient's
understanding is there,
and sort of setting the stage for
doing these goals
of care discussions.
00:33
If it's for a patient,
that you're really thinking about
their end of life,
and you have to think about
goals at the end of life.
00:40
What are going to be
the important things?
Those health values that
I talked about before?
Is a time with family and friend?
How do they feel
about hospitalization?
You know, if a person is
have advanced heart failure,
they might be back and forth
to the hospital.
00:54
If you've gone into the hospital
five or six times in a year,
might you rethink your goals.
01:00
In terms of, you know,
I want to stay home more?
How does patient
feel about procedures?
What's the goal of the procedure,
knowing that they might have
a life limiting prognosis?
What is it hoping to achieve?
It could be improved functionality,
could be maintaining the function
that they already have.
01:20
It could be trying to control
any kind of symptoms or pain.
01:23
Again, what are those
main goals of care,
in relation to quality of life, that
are important at the end of life.
01:34
And really, this is just
another way to help think.
01:37
Think about a treatment plans.
01:38
So it's providing
guidance to the patient,
on making sure they have an
understanding of their options.
01:44
If it's life sustaining treatments,
it might be an opportunity
to clarify what their
considerations and preferences
are for resuscitation
if they had a
cardiopulmonary arrest.
01:58
Should always be done in what
we've used in the previous lectures
for communication skills
is the ask-tell-ask method.
02:07
So it's always trying to
get the patient to say more.
02:10
So for the initial ask, it could be,
what do you know about your illness?
What do you want to
know about your illness?
Do you want full information
about your illness?
So starting there with
the patient's perspective.
02:25
And then the tell on your
end as the clinician,
it's going to be naming the illness,
naming the stage of illness,
naming what the treatment might be,
trying to figure out what the
goals of the treatment are.
02:40
So conveying, Yes,
this is something that we can cure.
02:43
We can treat this.
We can get you better from this.
02:46
Is it something that it's
going to be a chronic illness?
And we have to think about
longer term management?
Are there shorter term goals
that we're trying to achieve?
Whether it's palliation
of particular symptoms,
whether it's consideration of being
going into clinical research.
03:03
And maybe the patient wants to
consider investigational drug,
as a treatment for their condition.
03:10
Maybe it's a treatment that's
really focused at the end of life
of what's important
to them at that point.
03:17
So you tell them that information,
and then you follow it up
with an ask.
03:23
So, what did you take
away from our discussion?
Or what are you thinking
about what we discussed?
Or how do you feel about what
I've just shared with you?
So, ask-tell-ask is part of the how,
in the goals of care.
03:37
And it's also an
opportunity to ask them,
"Well, what about your loved ones?"
Either the loved ones are
present in these conversations,
or you're just meeting
with the patient,
but you know, that they might
have a particular person
that's going to be their surrogate
decision maker in the future.
03:55
So, what does the patient
want their loved one to know,
in the future in terms
of making decisions?
How do they want that
person to make decisions?
Do they want it to go exclusively
by what the patient thinks?
Do they want to share
the decision with
how their loved one thinks
about the situation?
That's part of the how in these
goals of care discussions.
04:16
The involvement of their loved one.
04:21
So that's the framework for thinking
about goals of care discussion.
04:25
It's the why. Why are we
doing this in the first place?
Figuring out what's
important to the patient.
04:30
We're going to go through the who,
the what, the where, the when, how,
Of how to have these conversations.
04:36
And really the ultimate goal
is goal can coordinate care.
04:40
We want to know
what the patient's goals are.
04:43
Making sure we're serving those.
04:46
Making sure our
informed consent process
is really done with
a holistic approach.
04:51
The whole person, who they are?
How does the treatment
decision factor into their life?
And what's meaningful to them?