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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 7: Goals of Care
    Goals of Care

    7-Step Protocol to Negotiate Goals of Care
    Identifying Goals to Hope For
    Cultural Considerations
    Communicating Prognosis
    Use of Language
    Setting Goals and Priorities for Treatment and Care
    Decision-Making Capacity

    Decision-Making Capacity

    Decision-Making Capacity Defined

    • Decision-making capacity implies the ability to understand and make medical decisions for oneself
    • Occasionally, patient choices that are unsupportable suggest that he or she is losing decision-making capacity
      • Reassess your patient if this seems possible
      • Any physician can determine, does not require a psychiatrist or a court ruling
    • Patient with decision-making capacity must:
      • understand information
      • use the information rationally
      • appreciate the consequences
      • come to a reasonable decision for him/her
    • Capacity varies by decision
    • Other cognitive abilities do not need to be intact

    For more information see Module 3: Whole Patient Assessment and Module 15: Legal Issues

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    When a Patient Lacks Decision-Making Capacity

    • When patients lack the capacity to express their own values and preferences for medical care, goals must be determined by others
    • Proxy decision-maker should be sought to help clarify the patient’s goals and consent to specific care plans
    • Appropriate proxy is a person selected in advance for this role by the patient (see Module 1: Advance Care Planning), or a person who has knowledge of the patient’s values and preferences and is willing and able to serve in this capacity
    • When the patient has not preselected a proxy decision-maker, this usually falls to the next-of-kin. Legal criteria for proxy selection vary from state to state (see Module 15: Legal Issues)
    • Sources of information: taken together this information will allow an assessment of what the patient would have judged (i.e., a substituted judgment)
      • written advance directives
      • patient’s verbal statements
      • patient’s general values and beliefs
      • how patient lived his/her life
      • best interest determinations
    • The physician should guide the proxy/surrogate in understanding his or her role in determining what the patient would have wanted based on available information
    • Where information is lacking, it becomes necessary to try to determine what would be in the best interest of the patient
    • This is often, but not always, the same conclusion and often errs more toward life prolongation
    • Why is this process helpful:
      • respects patient
      • builds trust that the health care team is acting in the best interest of the patient
      • reduces guilt and decision regret
    • Practical ways to elicit patient values and preferences in discussions with proxy decision-makers:
      • Help me to understand what your husband was like before he got sick. What was most important to him?

      • Has he ever said anything about how he would want to be treated if he could no longer make decisions for himself?

      • What would he say in this situation?

      • Do you have any other family members or friends who have experienced serious illness? Did he or she express how he or she would want to be treated in that situation?

      • Based on everything you know about him, what do you think he would have wanted in this situation?
    • Many of the approaches that work for an advance care planning discussion also work for establishing immediate goals of care, whether working with the patient or a proxy
      • In particular, it can help to go through a worksheet again, using predrafted scenarios, goals, and treatment options, prior to returning to the situation at hand

      • Often clarity and perspective return with this exercise for getting a broad perspective and allow a comfortable settling into current goals
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