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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 8: Sudden Illness
    Seven Guiding Principles

    Principle 4. Use the General Goals of Care to Guide Decision-Making Principle 5. Take Sociocultural Differences Into Account

    Principle 4. Use the General Goals of Care to Guide Decision-Making

    Reassessing Goals of Care

    • As prognosis changes and decisions come up, use the general goals of care to guide decision-making about:
      • Treatment priorities
      • The use of technology
    • Assessing or reassessing the general goals of care is an important step in all medical decision-making, since the overall goals of care provide the basis for further decisions about specific treatment priorities (see Module 7: Goals of Care)
    • In situations of sudden critical illness, radical readjustment of goals of care is often appropriate
    • The physician, patient and family need to work together to assess and re-prioritize the goals of care in light of:
      • Recent developments
      • Patient values
      • Advance directives
      • The range of possible outcomes

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    Informed Consent

    • The goal of informed consent is to enable patients (or parents if the patient is a child) to make choices consistent with their own personal goals, beliefs, and values
    • Achieving informed consent can be a special challenge at times of sudden life-threatening illness because of the uncertainty and changing nature of the situation
    • Four conditions need to be met for informed consent to occur:
      • The patient (parents) must have the capacity to make an informed decision

      • Pertinent information must be provided to the patient (parents)

      • The patient (parents) must comprehend the information well enough to make a rational choice

      • The decision itself must be voluntary, not coerced

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    When the Patient Lacks Capacity

    • If the patient does not have the capacity to make an informed decision, then the physician’s next step is to work closely with the proxy decision-maker
    • Focus on what the patient would want if the patient were able to speak for himself or herself
    • Avoid asking the proxy, "What do you want us to do?"
    • Instead, use words like
      • "Can you help me identify what he would want in this situation?"
      • "What would she say?"

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    Steps in Decision-Making

    In order to make informed decisions, patients, parents, and proxies need to know:

    • The nature of the illness
      • Clarifying the nature of the illness serves to verify that the patient, parent, or proxy has an accurate understanding of the situation
    • The recommended treatment
      • Discussing the recommended treatment includes a description of:
        • What is recommended
        • How it will be done
      • This information could also include the rationale for the treatment based on the patient’s current medical condition
    • The reasonable alternatives
      • Provide information about reasonable alternatives and the chance of each alternative achieving its intended goal

      • Give information about:
        • What the most likely outcomes of each alternative are
        • The evidence on which the statements are based
    • The burdens and benefits of each option
      • For each option being considered, list the most common and the most significant burdens and benefits

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    Focus on the Degree of Recovery

    • Focusing on the degree of recovery that would be acceptable to the patient (or parent if the patient is a child) can help families cope with confusion and guilt in situations of prognostic uncertainty
    • By identifying the desired and acceptable degree of recovery, and comparing this with the markers of recovery, it is possible to outline decision points
        For Example
        "If it becomes clear that the goal of complete recovery of mental function is not possible, then we will withdraw mechanical ventilation"
        "If we don’t see an improvement in x, y, and z in 1 week, then I would recommend that we discontinue the medications maintaining blood pressure"

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    Time-Limited Trials: Burdens and Benefits

    Time-Limited Trials: General Principles

    • In situations of prognostic uncertainty, all treatment can be thought of as a time-limited trial
    • Use terms like, "We’re doing everything we can, but in 48 hours we may find that it’s not working"
    • The use of time-limited trials in situations of prognostic uncertainty should be given careful consideration to assure that the trial is consistent with the general goals of care and goals of recovery
    • Informed consent is necessary, as there are both benefits and burdens associated with time-limited trials

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    Benefits of Time-Limited Trials

    • Plan can be used while more information is gathered
      • Often in situations of prognostic uncertainty, there is the perception that the choice is limited to either initiating a treatment or not

      • Characterizing treatment in terms of a time-limited trial offers another option that allows treatment to continue while time allows the prognosis to become clearer
    • Provides structure to situations of uncertainty
      • May help families to cope with the uncertainty of the situation

      • Life-sustaining treatment can always be stopped at a later time

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    Burdens of Time-Limited Trials

    • May result in a poor or undesired outcome
    • Decision to stop treatment may become more difficult
      • Once treatments have begun, a variety of powerful forces tend to perpetuate them

      • It is important to establish clear guideposts or criteria for decision-making in advance to prevent a difficult future decision-making process

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    Consider the Role of Palliative Care

    • When considering reasonable alternatives, aggressive palliative care should always be discussed
    • Physicians often inadvertently leave the impression that they will either "do everything" or "do nothing"
    • Aggressive relief of suffering is not an alternative to medical care, or the opposite of medical care, or what we do when we decide we "don’t want to do anything"
    • It can be included in curative approaches to sudden illness as well as in chronic and incurable conditions
    • When aggressive attempts to maintain comfort are included in the care plan from the beginning, it permits these aspects to be continued when other treatments are discontinued
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