Discussing Goals of Care: What

by Mark Hughes, MD, MA

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    00:01 The next step in the goals of care discussion is going to be, the what? So, what are you going to talk about in these conversations? Could be a range of things.

    00:08 So, obviously, it's happening when there's a serious or challenging illness, and you're trying to figure out how to institute a treatment plan for that.

    00:19 So, one of the things is going to be medical conditions that the patient might experience either they're experiencing now or might experience in the future.

    00:27 What would be acceptable medical conditions for them to seek treatment? And what would be so unacceptable that they would not want to seek treatment for? For instance, some patients will say, "Well, if I'm in a permanent coma, I would not want life sustaining treatment." That might be an unacceptable medical condition on their behalf, where it's going to change their goals of care what they want to try to accomplish, and accepting or not accepting certain treatments.

    00:55 There may be therapy outcomes of, "Well, you know, if we do this surgery, it might mean that we do an amputation.

    01:04 You're not going to have one of your limbs." Is that an acceptable therapy outcome, knowing that we needed to save your life in order to do it.

    01:12 Those kinds of acceptable or unacceptable outcomes in the actual treatment.

    01:19 Patients may have particular values that are important to them in terms of how they make medical decisions.

    01:26 There may be spiritual aspects, there may be emotional reactions that they're having to their disease process.

    01:32 Any kind of psychosocial goals that are important to them.

    01:37 So what's going on in their family? Do they want to try to make it to their daughter's graduation or to a wedding, or to their loved ones birthday? Are there certain goals that are important to them to achieve? And that's going to be part of this goals of care discussion.

    01:55 And at some point, especially as the disease gets more serious, they're going to be a need to talk about life sustaining interventions.

    02:04 So, if you anticipate that they might need a ventilator, or might need artificial nutrition and hydration, or might need dialysis, those kinds of life sustaining interventions, you need to know how the patient feel about those things, and how would they frame their goals of care, and accepting or not accepting those life sustaining treatments.

    02:28 The way to help figure out, how the patient would think about these treatments is to explore their health values.

    02:35 And many people will come at their values from different perspectives.

    02:40 These are just a few things that you should keep in mind and might ask, explicitly about in these goals of care discussions.

    02:49 So, the first is longevity, living as long as possible.

    02:54 And we talked about quantity of life versus quality of life.

    02:58 Hopefully, you try to achieve both a good quality of life and living as long as possible.

    03:02 But maybe sometimes there needs to be treatment decisions that favor one versus the other.

    03:07 So you want to know, how important is longevity to the person.

    03:11 Another important health value might be bodily integrity.

    03:15 So, is there going to be breakdown of the skin and damage to the body, that might say the person loses their integrity, then that that would be something that they don't want to happen? How comfortable are they with the potential of being dependent on a machine like a ventilator or needing dialysis or getting tubes like artificial nutrition and hydration? Is that an invasion of their bodily integrity that they would not want? Or is it something that they might be able to accept? In order to have continued life.

    03:51 So, bodily integrity is another important health value.

    03:55 There may be some patients that focus on their physical functioning.

    04:00 So are they able to do the activities of daily living? Can they take care of their own dressing, bathing, grooming, and eating on their own? Is that kind of important physical function important to them.

    04:14 And if those things are not achievable, might they make different treatment decisions? How important is cognitive function? So some patients would say, "If I'm not able to be able to thinking or communicating loss of cognitive function would be a state where I might make different treatment decisions.

    04:36 If I don't have that ability to relate to other people and communicate.

    04:43 Some people will say, you know, my autonomy, my ability to control what's going on in my life is an important goal.

    04:49 So, their own ability to make decisions.

    04:52 So, if I lose that ability, then I might not want life sustaining treatments.

    04:58 There might be some patients the health value is their ability to have social and emotional engagement with other people.

    05:06 So, being able to hold conversations or interact meaningfully with others.

    05:10 Maybe they're bed bound. They lost physical function, but they're still able to communicate and share important events with their family.

    05:21 How does that inform, how they make treatment decisions.

    05:26 Another important health value is going to be avoidance of burdensome symptoms.

    05:30 So, often in disease processes, they're going to be symptoms that come along or side effects of medications that come along.

    05:37 So, how important is it for the person to avoid any ongoing discomfort either from pain from shortness of breath, thirst, any other symptoms, might they make treatment decisions based on avoidance of burdensome symptoms.

    05:53 And then another important value is going to be spiritual beliefs.

    05:58 Some, some people will rely on their faith or their spiritual beliefs to help inform how they would make medical decisions and guide those recommendations that are given by the physician, but informed by their faith or their religious beliefs.

    06:15 So, as a few of the things that you can explore in the what of the goals of care.

    06:20 Then after you've had these conversations is going to be important to clearly document what you've discussed with the patient.

    06:27 This is going to be a record for the future that you can look back on and say, well, it's such an important time they made these decisions.

    06:34 And now we have to think about new decisions.

    06:37 How do we think about the goals of care with this new information? It is an opportunity when you've documented it to help inform family of those discussions that have happened prior with the patient.

    06:49 And it also keeps the healthcare team apprised of the goals.

    06:53 So as an interdisciplinary team, you want to make sure everyone's communicating about what are the patient's goals, what are their hopes, what are their fears, what's important in their life? And how we're taking care of them in managing their condition?

    About the Lecture

    The lecture Discussing Goals of Care: What by Mark Hughes, MD, MA is from the course Breaking Serious News and Advance Care Planning.

    Included Quiz Questions

    1. Acceptable medical conditions
    2. Medical values
    3. Acceptable therapy outcomes
    4. Psychosocial goals
    5. Hospital quiet hours
    1. Longevity
    2. Bodily integrity
    3. Physical functioning
    4. Medicine diversion
    5. Long-term care insurance
    1. Mechanism of action of immunotherapy
    2. Physical functioning
    3. Cognitive function
    4. Personal autonomy
    5. Spiritual beliefs
    1. It keeps the healthcare team apprised of the goals.
    2. It keeps the family in the dark about the patient's goals.
    3. There is no need to document a discussion about goals of care.
    4. It maintains patient anonymity.

    Author of lecture Discussing Goals of Care: What

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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