A 75-year-old man with pneumonia was transferred from the ICU to a step-down unit after being intubated and on a ventilator for several days. He had a history of diabetes and end-stage heart failure, and his condition was worsening. His wife reported her husband had frequent falls and difficulty ambulating due to swelling in his legs.
The oncoming hospitalist assessed the patient, who was experiencing difficulty breathing despite oxygen and diuretics. The patient’s wife confirmed that her husband did not want to be placed back on a ventilator. After a brief discussion, the physician reviewed the patient’s goals of care (GOC) and treatment options with both the patient and his wife.
Key Takeaway: Healthcare providers (HCPs) should regularly revisit GOC conversations, especially during key transitions in care. This ensures that the care provided aligns with the patient’s evolving preferences.
Analysis: Studies show that many patients receive end-of-life care (EOLC) that doesn’t align with their wishes. Research suggests that only 37% of patients with advanced cancer discuss their EOLC preferences, and 20% to 33% of patients change their preferences as their illness progresses. These findings highlight the importance of having early and ongoing GOC discussions, particularly when patients have serious, life-threatening conditions.
Early GOC conversations allow patients to understand their illness and make informed decisions. This is associated with improved quality of life and more likely alignment with EOLC preferences. Delaying these discussions increases the risk of providing care that doesn’t match the patient’s wishes.
When to Revisit GOC: Certain moments in a patient’s illness are key to revisiting GOC discussions:
- As the illness progresses or after multiple hospitalizations
- Before any new procedures or interventions
- When there are changes in the patient’s ability to manage daily activities or support network
Experts recommend clinicians ask themselves if they would be surprised if the patient passed within the next year. If the answer is “no,” it’s time to revisit GOC.
A Team Approach: GOC discussions should be seen as ongoing conversations, not one-time events. The responsibility falls to the HCP involved in the patient’s care at the time of decision-making. Clear communication and documentation of these discussions are essential to ensure that care decisions are shared and understood by the entire healthcare team.
Structured Approaches to GOC: Using a structured
model for GOC conversations (e.g., REMAP, SUPER, or SAFE GOALS) helps ensure
the conversation is thorough. Key elements include:
- Explaining
the patient’s condition and prognosis
- Eliciting
the patient’s values and preferences
- Developing
care plans that reflect the patient’s goals
- Providing
emotional support to the patient and family
By engaging in ongoing GOC conversations, healthcare providers can better align care with patient preferences, improving outcomes and satisfaction for both patients and families.