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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

    Setting Goals and Priorities for Treatment and Care

    Clarify Goals and Treatment Priorities

    • The patient’s goals for care should guide the therapies and care that patients and families choose and receive
    • In addition to helping them to establish overall goals, physicians can assist patients and families to clarify priorities for treatments and care as they negotiate an initial plan of care together
    • Subsequently, whenever the patient’s goals (or parents’ when the patient is a child) are uncertain or might be expected to change, goals and treatment priorities should again be clarified
    • Review is recommended at several types of juncture:
      • significant change in health status (e.g., worsening prognosis or unexpected recovery)

      • change in life expectancy (e.g., advanced age or serious life-threatening illness)

      • change in setting of care (e.g., from hospital to nursing home or vice versa)

      • change in treatment preferences (e.g., decide to discontinue dialysis or other therapies)
    • If the prognosis allows you to delay this conversation, give the patient time to acclimatize to his or her new circumstances
    • With a little time to settle, patients are more likely to again stabilize their goals and priorities

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    Determining Priorities for Treatment and Care

    • Once overall goals have been determined, the physician can help the patient (or parents if the patient is a child) to determine his or her priorities for treatment and care
    • Priorities should be based on individual patient values and preferences as guided by specific clinical circumstances
    • Priorities will be influenced by information from the physician and other health care professionals
    • The physician will want to describe the possible priorities and be open to the feasibility of others
    • Questions that can be used to elicit patients’ values and goals for medical care at the end of life:
      • What are you expecting?
      • What do you most want to accomplish?
      • What is most important in your life right now?
      • What are you hoping for?
      • What do you hope to avoid?
      • What do you think will happen?
      • What are you afraid will happen?
      • What do you expect the end to be like?
    • Examples of patient values and preferences:
      • No matter what happens, I want us to stay at home, No more hospitals
      • I’m worried what all of this will cost my family
      • What I fear most is pain
      • I would like to be alert and aware as long as possible
      • I just hope I have time to finish my memoirs
      • If I live to see my daughter married, I’ll die happy
      • When death comes, I want my family around me
      • I don’t want my wife to have to quit her job to take care of me
      • My wish is never to be hooked up to machines
      • It’s important to me to live as long as possible, and to go out fighting
      • It is important to me to try everything there is to cure my child
      • I don’t want my child hooked up to machines

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    When the Physician Cannot Support the Patient's Choices

    • Typically occurs when goals are unreasonable, illegal
    • Set limits without implying abandonment
    • Make the conflict explicit
    • Try to find an alternate solution

    Example of Physician Responses

    "I understand that your first priority is to live as long as possible by having a heart transplant. Unfortunately, I’m not able to do that because of your other health problems. Is there an alternative way that I can help you achieve your goal of living as long as possible?" or "I understand your goal is not to be a burden to your family and you would like me to assist you to die. Unfortunately, I cannot do that. Is there an alternative way that I can help you so that you will not be a burden?" More intractable differences are addressed elsewhere. (see Module 1: Advance Care Planning; Module 5: Physician-Assisted Suicide; and Module 9: Medical Futility)

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