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?