Discussing Goals of Care: Where

by Mark Hughes, MD, MA

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    00:01 The next step in the goals of care discussion to think about is the where.

    00:04 So this might happen in the outpatient setting.

    00:08 So you're seeing the patient in the ambulatory clinic environment.

    00:14 There, there might be their current treatment plan.

    00:18 You're just having these goals of care conversations in relation to those particular treatments.

    00:24 Or it's also an opportunity to sort of look into the future and say, as part of an advanced care planning process, we need to think about goals of care.

    00:33 Maybe there's not an immediate decision that needs to be made, but we can sort of anticipate future goals of care discussions.

    00:39 So, having these opportunities in the outpatient setting when the patient can go home reflect on these things, is an important aspect of the where and goals of care.

    00:51 It may also happen in the inpatient setting.

    00:53 Certainly when a person has an acute illness and needs to be hospitalized.

    00:57 This is an opportunity to say, "Okay, this is what we're trying to achieve during your hospitalization.

    01:02 How does this fit in with your overall goals of care?" Maybe the patient has chronic illness.

    01:10 They've got heart failure, and now they've had an exacerbation of their heart failure.

    01:15 They're needing to be hospitalized for this.

    01:17 Maybe there have been prior goals of care discussions.

    01:20 Now we need to have a new goals of care discussion based on an exacerbation of this chronic illness.

    01:26 Perhaps a patient is needed to go in for a procedure or for an operation.

    01:31 Hopefully, everything's going to turn out great.

    01:34 They're going to get through the surgery just fine.

    01:36 But maybe you need to anticipate, well, what if there are complications? What if there are side effects? We need to have goals of care discussion, I need to know.

    01:44 What do we do in case a complication arises? How does this fit in with your perioperative management? Maybe they've had decisions already about, you know, not wanting certain life sustaining treatments.

    01:56 Like not wanting cardiopulmonary resuscitation, and they're going into an operation.

    02:01 Well, what if the anesthesia causes a cardiac arrest? Would you want there to be resuscitation in those circumstances knowing that it might be reversible, because the anesthesiologist is right there to respond to the emergency? Has a patient gets much sicker when they become critically ill? Maybe they're in an intensive care unit, this is another opportunity for goals of care discussions.

    02:24 What are we trying to achieve in the intensive care that they're getting in that setting? Maybe the patient's not able to participate in those conversations, but it's a family member.

    02:35 So, again, having goals of care discussions with them.

    02:38 And then lastly, maybe the patient's recovered during their hospitalization.

    02:42 You're anticipating that they're going to be discharged.

    02:45 They're going to be a transition of care, back to the ambulatory setting or maybe to another healthcare facility.

    02:51 You also want to sort of clarify the goals of care in anticipation of that hospital discharge.

    About the Lecture

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

    Included Quiz Questions

    1. Advance care planning
    2. Planned surgery requiring anesthesia
    3. Treatment in the intensive care unit
    4. Exacerbation of heart failure requiring admission
    5. Planned discharge to a skilled nursing facility

    Author of lecture Discussing Goals of Care: Where

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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