Goals of Care Discussions

AJ Winer

What is “goals of care” / a “goals of care discussion”?

A goals of care discussion is a phrase used to describe a specific type of serious illness conversation that aims to elicit a pt’s priorities in the context of their illness. These discussions often 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:
    • understanding a pt’s wishes
    • informing a pt about their condition to
    • formulate a medically realistic treatment plan that aligns with the patient’s values.
  • When do goals of care discussions come up?
    • When a patient's acute/chronic illness clinically worsens and there is concern about
      • a patient’s recoverability to near baseline and/or
      • further decompensation
    • Concerns that:
      • current interventions are ineffective
      • current treatments are more harmful than beneficial
      • 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” Source: (El-Sourady, Martin. JPM 2021)
    • Rationale: For pts with complex medical problems, it can be difficult to assess and articulate prognosis. This tool helps prepare and conduct GOC discussions.
    • How it works: The three-question framework helps:
      • assess survivability
      • create potential medical trajectories
      • elicit a patient’s wishes
  • Example: Pt with metastatic lung cancer presents with septic shock due to pneumonia. Also has AKI.
    • Q1: Is this acute condition survivable?– make a problem list and consider a pt’s baseline comorbidities.
      • If NO → deliver bad news and support
      • If YES or MAYBE → move to Question 2
      • Resolution: While she may eventually die from cancer, she may be able to survive this acute illness.
      • Q2: What would it take to survive this acute illness? Determine a best-case, worst-case, and most-likely scenario. Are they frail? Do they have baseline cognitive issues that would make recovery difficult?
        • If it is clear the patient cannot survive → deliver bad news and support
        • If it is possible to survive → move to question 3
        • Resolution: Best case: recovery with minimal debility. Worse case: she dies. Most likely: she survives the acute illness but has a prolonged recovery that delays cancer treatment. She may need IV antibiotics and dialysis.
      • Q3: Would the patient want to try treatment? Determine potential roads ahead for the patient. The following is one way to present treatment: “Some patients would choose aggressive medical intervention in the hope of improving from acute illness. Other patients would decline aggressive treatment if there was little chance of recovery. Can you share with me what you hope for and what is off limits so we can make the right plan for you?”
        • If NO → deliver bad news and support
        • If YES or MAYBE → discuss roads ahead, determine a realistic plan that aligns with a patient’s goals and values.

Image description: A flow chart for Goals of Care discussion questions. Source: https://doi.org/10.1089/jpm.2021.0282 

Goals of care discussion flow chart question

The ‘Headline’

  • Definition: A Headline is a concise 1-2 sentence statement that summarizes a patient’s medical issues and their clinical significance. It is used to communicate a clear, explicit message. Headlines should always include medical facts and meaning.
  • Rationale for its use: Patients and families often do not understand the significance of medical facts if they do not have a medical background. When clinicians deliver bad news, they often communicate this information with vague messaging due to their own discomfort which results in more confusion for patients and families. - Patient example: 80yoF with PMH metastatic lung cancer, in the ICU with septic shock due to pneumonia complicated by acute renal failure requiring dialysis.
  • Example of a poor headline: “your mother has a pneumonia and is very, very sick.”
    • This vague message can easily lead to misinterpretation and confusion.
  • How to create an impactful headline:
    • Part 1 - Summarize the medical condition: “Your mom was hospitalized with a lung infection that caused her kidneys to fail. Despite what we have done, her kidneys have not gotten better.
    • Part 2: Summarize what this means for the pt: “Your mother is getting sicker despite treating her PNA and kidney failure. I am worried your mom is dying / she will die this hospitalization.”

Takeaway: A good headline provides a concise, clear message with information and meaning. The message needs to be explicit with minimal room for misinterpretation.

REMAP

(Source: Childers et al, J Onc Practice, 2017)

Definition: REMAP is a framework that provides a structure for GOC conversations. It stands for Reframe, Expect emotion, Map out pt values, Align with values, Propose plan.

Rationale for its use: GOC discussions are difficult to navigate. It is difficult to break bad news, understand a pt’s values, and develop an aligned plan of care. SPIKES is helpful for delivering bad news, but it is not all-encompassing.

REMAP Explained: (ex pt: PMHx metastatic cancer, disease progression on 5th line tx)

  • Reframe - discuss plan isn’t working. 1st assess a pt’s understanding, then provide new info:
    • What do you understand so far about the current medical situation? Would it be ok if to step back and talk about the big picture? We’ve been through a lot of treatments. I’m wondering if it’s time to reevaluate where we are. More treatments might be doing more harm than good.
  • Expect emotions - allow room to process and respond with empathetic statements: This is hard to talk about. It is understandable that you would feel sad. I know this is not something you wanted to hear. I wish things were different.
    • Ask permission to move forward: Is it ok if we talk about where to go from here?
  • Map out values - find out what is most important to the patient: To figure out a plan, ask open-ended questions to elicit what matters most:
    • Given that time might be limited, what is most important to you now? What do you hope for? What do you worry about? As you look toward the future, are there things you would want to avoid? What does a good day look like for you now?
  • Align with values - Before proposing a plan, confirm your understanding of the pt’s values:
    • It sounds like the most important things right now are to stay out of the hospital and to not be in pain so that you can enjoy time at home. Is that right?
  • Propose plan - develop a plan that matches these values:
    • Is it okay if I make a recommendation? Given what you told me about your goal to be at home as much as possible and to focus on being comfortable, I would recommend that we focus on… How does that sound?

Common pitfalls of Goals of Care discussions

  • Overwhelming a patient
    • A patient or family may not be ready to receive all information at once. That is okay. Rarely is an immediate decision needed.
  • Expecting too much
    • These discussions are a process. Often, the goal is to plant the seeds. If you have opened a line of communication, you have succeeded.
  • Miscommunication
    • If the message is not clear (things are sugarcoated), a patient may misinterpret the message (see ‘Headline’ above)
  • Do not rush
    • 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.
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