3: Goals of Care & Consideration of Prognosis

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 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 illness.

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, 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 7 practical steps for having a discussion (see Table 3–1 for words to use, and Table 3–2 for words to avoid).

1. Prepare: Clinicians should establish an appropriate setting, one that is quiet with enough space for all participants to sit down. The clinician should identify appropriate participants, including extended family, other consultants, or team members, such as social work or chaplaincy. A facilitator should be identified in advance if more than one clinician or team member will be present. Also, ensure adequate time is set aside for the meeting and that interpreters are used if needed.

2. Create structure: At the start of the meeting, all participants should introduce themselves. The purpose of the meeting should be made explicit. Clinicians should also ask about patient and family preferences for information sharing and decision making.

3. Explore understanding of medical situation and underlying values: Effective decision making depends on both health care providers and patients having an understanding of the patient’s illness and prognosis. Clinicians should determine what the patient and family members understand about the patient’s illness and its expected natural course. Information should be given in small, easy-to-understand statements with frequent checks to assess for comprehension. This is also a time to explore what outcomes patients and families are hoping for and which ones they would want to avoid, as well as what is most important in their lives and what they would like most to accomplish.

4. Define overarching goals: Based on what was learned about the patient’s and family’s hopes and expectations, providers can explore or suggest overarching goals. This should also be a time to address hopes and goals that may be unreasonable or unrealistic given the current health state or future prognosis.

5. Assist in making a decision based on the ...