Goals of Care Discussions

Overview

Goals of care discussion: a conversation aimed to elicit a pt’s priorities in serious illness. These discussions can cover code status, specific treatments, intensity of care, advanced care planning, withdrawal of support, and transitions to end of life care including hospice care.

• It is predicated on: (1) understanding a pt’s wishes (2) informing a pt about their condition to (3) formulate a medically realistic treatment plan that aligns with the patient’s values. 
• Remember that our patients have lived full lives. Our job Is to make sure the medical decisions are In line with the practices and purposes of that patient's life.

When should I have goals of care discussions?

• Ideally, prior to hospitalization. Medicare wellness visits are great opportunities for aligning patient's goals with treatment.
• When a patient's acute/chronic illness clinically worsens and there is concern about (1) a patient’s recoverability to near baseline and/or (2) further decompensation.
• Concerns that: (1) current interventions are ineffective, (2) current treatments are more harmful than beneficial, (3) a patient may require more intense/invasive therapy.

Strategies for Goals of Care (GOC) discussions

• There is no best framework. Below are tools to guide your approach to a GOC discussion:
• The Three-Question Framework (El-Sourady, Martin. JPM 2021):
  • Q1: Is this acute condition survivable? – If NO à deliver bad news and support. If YES or MAYBE à move to Question 2.
  • Q2: What would it take to survive this acute illness? Determine a best-case, worst-case, and most-likely scenario. If it is clear the patient cannot survive à deliver bad news and support. If it is possible to survive à move to question 3.
  • Q3: Would the patient want to try treatment? If NO à offer supportive treatment. If YES or MAYBE à discuss roads ahead, determine a realistic plan that aligns with a patient’s goals and values.

The ‘Headline’

• Concise 1-2 sentence statement that summarizes medical condition and what It means for the patient.
• Patients/families often only process the first thing said, especially with bad news. Be factual, specific, honest, and succinct.
• Put thought into your headline. Do not attempt to wing It.
• Example: 80yoF with PMH metastatic lung cancer, in the ICU with septic shock due to pneumonia complicated by acute renal failure requiring dialysis.
  • Poor headline: “Your mother has a pneumonia and is very, very sick.” Too vague, easily misinterpreted.
  • Better headline: “Your mom was hospitalized with a lung infection that caused her kidneys to fail. Despite treatment, your mother is getting sicker. I am worried your mom will die this hospitalization.”

Set up for success

• Appropriate setting: Be sure to pick a private, quiet place where all participants have a comfortable place to sit.
• Realistic Expectations: A patient or family may not be ready to receive all information at once. That is okay. Rarely is an immediate decision needed.
• Open a line of communication: These discussions are a process. Often, the goal is to plant the seeds.
• Clear messaging: If the message is not clear (things are sugarcoated), a patient may misinterpret the message.
• Take your time: Pause when communicating. Pts and family need time to process, reflect, and ask questions. These conversations require careful planning, intentional communication, and your complete attention.
• Be present: Put away your phone, roll a pager to your colleague. The patient/family may consider this the most important conversation of their life. Be sure to listen fully.

View video example on Learning Exchange, “Navigating Difficult Conversations With Patients.”