Just ask: discussing goals of care with patients in hospital with serious illness

Abstract

CMAJ, April 1, 2014, 186(6) 425 O ur population is aging, and older patients are living longer with chronic illness. Technology-laden end-of-life care is associated with poorer quality of life, lower satisfaction with care and increased anxiety and depression for family members.1 Ad vance care planning can increase the quality of life of dying patients, improve the experience of family members and decrease health care costs. 1-3Advance care planning is a process by which patients consider options for future health care decisions and identify their wishes. These decisions and wishes can vary depending on the setting. For example, during an acute stay in hospital, the plan may pertain to the goals of care for the current stay in addition to any care that may be required after discharge. In other settings, the plan may result in an advance care directive -a verbal or written instruction de scribing what kind of care a patient would want (or not want) if he or she were no longer able to speak for him or herself, and the values that guide the patient in making important health care decisions. Advance care planning may also result in the nomination of a substitute decision-maker -someone who makes decisions for the pa tient if the patient is incapable of doing so.Patients in hospital with serious illness and their family members have identified improvements in end-of-life communication and decision-making as high-priority targets for quality improvement; 4,5 however, hospital-based health care providers infrequently engage patients and families in such conversations.6 Accordingly, the focus of our review is to provide guidance for advance care planning as it pertains to the inpatient setting (i.e., determination of goals of care for the patient in hospital). Although health care providers in the outpatient setting (e.g., family physicians, consultant physicians) play a key role in advance care planning, hospital-based providers share this responsibility. In fact, a stay in hospital presents an important opportunity for engaging in discussions about goals of care, because it signals a change in the trajectory of the patient's illness, giving in creased relevance to these conversations, and because potential substitute decision-makers (e.g., the most involved family members) are often present.To organize our review, we use a communication and decision-making framework consisting of the following components: identifying patients at high risk of dying who need to have a discussion about goals of care; information exchange (regarding prognosis, values, and the risks and expected outcomes of various treatment options); and reaching a decision through discussion and deliberation.7 By providing structured guidance, specific advice and practical tools, our aim is to increase clinicians' confidence in engaging in meaningful end-of-life communication with patients in hospital and their family members. To inform this review, we drew on a broad range of evidence, from expert opinion to randomized controlled trials and systematic...

What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families

“…19 Our results build on that work by providing further direction on which specific elements should be discussed with patients and families in hospital. For example, both patients and family members rated prognostic disclosure as highly important.…”

Palliative and end of life care conversations in COPD - a systematic literature review

“…This will help to build a therapeutic relationship with the patient [30]. These opportunities/triggers can be: the presence of cor pulmonale [22]; the need for ventilation in the previous year [22]; arterial partial pressure of carbon dioxide >45 mmHg or FEV1 <30% [22]; recent hospital admission or consultation [26,30,39,50]; oxygen dependency or weight loss [22]; observed deterioration in the patient's condition [22,30,39,50]; age above 70 years [18,22]; assessment of therapy options [30,50].…”

“…Any disagreements identified should be negotiated with the patient, to come to a shared decision [24,50,55]. [37] Lack of time in appointments to discuss all topics [18,37] Discussions may take away patients' hope [37] Lack of feedback and documentation [18,30,40,45] Lack of thorough knowledge of the patient [3,18] Difficulty to start conversations and to choose the right time [3,18,22,26,30,39,40,44,45] Difficulty for patients to understand and accept information in short periods of time [3,29,52] Vision of palliative care as confined to the last days of life and exclusive of life sustaining treatments [29,30] Uncertainty to prognose in COPD [5,18,22,39,40,45] Reluctance of palliative care services to care for patients with COPD [29] Complex discharge planning for COPD patients [18] Facilitators Patients who had relatives or friends who had died recently [37] Patients' trust in their physician [37] Patients interpret physicians' skills as very good [37] Patients' belief that physicians truly care about the patient [37] Good patient-physician relationship [29,37] Physicians who cared for many...…”

What are the ethical questions raised by the integration of intensive care into advance care planning?

“…It has previously been shown that when physicians address end-of-life issues with patients, there is subsequently a greater likelihood that the patient's preferences will be respected, and there are lower levels of anxiety, stress and depression among the family (33). To this end, it is essential for the patient and family to be able to come together to deliberate at a quiet time, when emotions are not running high, and outside the context of acute events, and together with the intensivist, so that this latter may explain the therapeutic options available in case of organ failure, and also so that the patient and family may communicate their preferences for such a situation (46). Explaining what can be done implicitly suggests what will not be done.…”