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Chapter 4: Goals of Care & Consideration of Prognosis

Eric Widera; Alexander K. Smith

GENERAL PRINCIPLES OF GOALS OF CARE DISCUSSIONS

Goals of care discussions provide a broad framework for decision making, helping align patients’ underlying values and hopes with the realistic and achievable options for care given the current medical circumstances. This is no easy task, however, as patients and their family members may simultaneously express multiple goals for their health care, which may include maintenance of independence, prevention of illness, prolongation of life, relief of suffering, and maximization of time with family and friends. The relative importance placed on each goal may change over time as new information is shared with the patient or family, such as a new diagnosis or a worsening prognosis. These goals should serve as a guide from which patients and their physicians can develop specific plans for treatment when dealing with acute or chronic illnesses.

A PRACTICAL GUIDE TO GOALS OF CARE DISCUSSIONS

Goals of care can provide a guide for various decisions, including immediate decisions regarding life-sustaining treatments and decisions regarding preferences for preventive therapies such as cancer screening, and for the completion of advance directives. There is no one right way of having these discussions; however, the following outlines seven practical steps for having a discussion (see Table 4–1 for words to use, and Table 4–2 for words to avoid).

Table 4–1.Words that may be useful when discussing goals.
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Table 4–1. Words that may be useful when discussing goals.

1

Prepare

“At our next visit, I would like to talk about your health and the ways we can go forward with your care. Is there someone who you think should be at this meeting?”

2

Create structure

“Some patients feel it is important to know all the details of their illness, prognosis, and treatment options; others don’t and want others to make decisions for them. How do you feel?”

3

Explore understanding and values

“Tell me how things are going for you?”

“What do you understand about your current health?”

“Given what we know about your health and prognosis, what things are most important to you? What are your hopes? Fears?”

“When you think about getting very sick, what worries you the most?”

4

Define overarching goals

“It seems to me that what is most important to you is that you remain comfortable and that we get you back to your home. Is that correct?”

5

Assist in making a decision

“Considering how important being pain free and remaining at home appears to be for you, I recommend that we.…”

6

Plan for follow-up

“It sounds like you could use some more time to think about these issues and discuss them with your family. Can we talk more tomorrow afternoon?”

“I am sure you will have lots of questions later. Here is how to reach me.”

7

Document goals and decisions

“Considering your wishes, I think ...

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