Studies asking patients to describe their own health care goals have identified categories such as healing, comfort, or staying home. As a person ages or faces a serious illness, healthcare decisions become more difficult. When a disease cannot be cured, treatments focus on other goals, such as improving symptoms or extending life. In addition, both the underlying disease and the treatments can cause suffering to the patient.
Finally, as patients age, the outcomes of medical interventions are more uncertain due to comorbidities or frailty. Because people are more likely to differ in their preferences for or against treatment under these circumstances, decisions are often referred to as “preference-sensitive.” Patient model and surrogate factors, the process, and the outcomes of conversations about the objectives of care. As patients age, their ability to make their own decisions is more likely to be affected due to dementia, and delirium is a common cause of decreased capacity during acute illness. Therefore, substitute decision makers, usually close family members, are often involved in the decision-making process.
Conversations about the goals of care for older adults can take place with patients, surrogate mothers, or both, but they can consider the same basic components. Surrogate mothers are usually asked to rely on the patient's previously stated preferences, when they know them. When specific preferences are unknown, surrogate mothers are asked to consider how patients' goals and values should influence treatment decisions, a process called surrogate judgment.2 While surrogate decision-making introduces additional ethical and emotional considerations, the approach involves many of the same concepts and skills as the objectives of conversations with patients about the goals of care. Conversations about goals of care require doctors to effectively communicate complex information about a medical diagnosis and prognosis to the patient and family, obtain information about patient preferences, provide support and make shared decisions, and ensure that treatments and outcomes are aligned with patient and family preferences.
The struggle of doctors to have conversations about health care goals is particularly important for providers of geriatric services, since the need to communicate the prognosis and set care goals to alleviate suffering is commonplace and urgent. Sometimes, these conversations are conducted by palliative care specialists who are experts in the goals of care, but they are often the patient's primary care doctor or specialists at the patient's hospital. These communication problems occur at a high rate during end-of-life care, when decisions depend more on preferences. Conversations about effective goals of care generally explore values and preferences before considering specific treatment interventions.
Studies in which patients are asked to describe their own health care goals have identified categories such as healing, comfort, or staying at home. 5 objectives that may be broad or specific, but most importantly, be defined by the patient or their surrogate. Analyzing goals before making treatment decisions will help doctors understand patients' motivations for or against certain treatments. Conversations about the patient's or surrogate mother's personal goals or general treatment goals, such as preserving life or focus on comfort.
Examples include being able to recover enough to engage in a meaningful conversation, feel comfortable, or live up to a specific event. Using open-ended questions to ask patients about their own goals can help promote communication about specific treatments. Affirming patient goals can be a positive way to connect and build trust. Sometimes, the goals set by the patient may be impossible or uncertain. Doctors can follow up with additional tests, asking if there is additional hope.
By taking the “hope for the best but preparing for the worst” approach, doctors can collaborate with patients and their families and, at the same time, help develop realistic plans for medical treatment. 6 When counseling patients, an important role of the doctor is to explore how a particular treatment will help the patient achieve their goals and is in line with their values.7 When patients select inconsistent treatment plans. Incoherent plans have the potential to cause suffering to patients without achieving objectives. The most specific level of decision-making about treatment involves a particular intervention, such as surgery or medication.
They should generally be considered in light of the broader categories of general treatment values, goals, and preferences, as well as medical evidence and expert opinion about the value of a particular treatment. In the primary care setting, older adults are at risk of having to resort to polypharmacy, of requesting duplicate or unnecessary tests and of referring them for potentially unwanted evaluations. The American Geriatrics Society has joined the Choosing Wisely campaign and has made a series of recommendations for specific treatments aimed at reducing onerous polypharmacy and ordering screening tests that are unlikely to benefit older adults. 12 There is ample evidence that culture, race, and religion play a role in the goals of care and in the treatments that patients receive (figure).
There are some general trends that doctors they must know. On average, African-American patients and more religious patients and family members tend to prefer more life support treatments in case of serious illness.13,14 However, many patients in these groups want and receive high-quality palliative care as the disease progresses, 15,16 It is essential to ask questions about the patient's individual priorities and the patient's individual values. The goals of care also depend on the clinical situation and prognosis. Knowing the potential outcomes of the patient's condition, as well as the range of options, is essential to the decision-making process.
Among geriatric patients, clinical characteristics, such as frailty and functional status, vary widely from one patient to Other. Comorbidities also complicate prognostic estimates for older adults 17. These factors can contribute to inconsistent patient outcome estimates among different providers. In some cases, prognostic calculators can help the doctor estimate the prognosis to guide conversations about care goals, 18,19 Many of these calculators are easily available online, 20 An essential responsibility of the doctor is to evaluate these factors before talking to the patient so that the patient can learn about their condition and set realistic goals. Studies have shown that patients and caregivers want different amounts of information, since patients often want less information and caregivers want more.
Physicians must be attentive to the patient's desire for information and to their ability to understand. Teaching or asking, saying and asking is a useful approach to confirm understanding. 21 After a conversation about the goals of care, decisions must be communicated and translated into medical treatments. Adequately documenting the decisions made, as well as the reasons for them, can be important for future decision-making.
The decision may lead to surgery, hospitalization, or other major intervention. Treatment planning also involves deciding in advance on emerging interventions, such as intubation or intubation. These decisions can be documented by DNR orders at the hospital or orders not to hospitalize in a nursing home. An important tool for documenting these types of treatment preferences is the Physician Orders for Life Supporting Treatment (POLST) paradigm and form 10. The POLST has the advantage of being transferred from one location to another, such as the nursing home or the community.
Legally valid POLST forms are available in nearly every U.S. state. In the United States, although the names of the formulary and treatment options vary. POLST forms include preferences for three categories of medical interventions: wellness-focused, intermediate or “selective” treatments, and “complete” or life support interventions.
Patients also indicate preferences for cardiopulmonary resuscitation. Some states include preferences for antibiotics or artificial nutrition. Unlike advance instructions, POLST forms are medical orders that must be signed by a doctor (or an NP or PA in some states). There are frameworks that guide conversations about POLST forms, such as Respecting Choices Advanced Steps, in which a trained facilitator guides the patient through a conversation to identify values, goals, and treatment preferences.22 A recent survey of primary care physicians and medical subspecialists who regularly see older adults revealed that sixty-eight percent of doctors report that they have no training related to talking to patients about end-of-life goals and desires.26 This occurred despite the almost universal consensus among survey participants that it's important to have conversations about the end of life. During medical education, communication training is often carried out passively through observation of more experienced doctors and trial and error by trainee students.
Since teachers may not be well aware of best communication practices or teaching principles, face-to-face teaching may be subject to the “hidden curriculum”, with the risk of transmitting bad habits. When caring for patients who are stressed out because of a serious illness and who are faced with complex, value-sensitive decisions and who are mired in uncertainty, well-trained faculty doctors can teach communication through role models and counseling. There is a great need for training in communication skills to ensure that providers adapt treatments to the goals and values of seriously ill patients 27. Because conversations about goals of care occur frequently during clinical worsening, patients often experience difficult emotions during conversations. Physicians should expect strong emotions when giving bad news or talking about care goals.
Patients and their families can support each other with actions that convey empathy, such as recognizing the patient's emotions, remaining silent when the patient expresses their emotions, and statements that suggest having a partner and not abandoning28. By transmitting empathy, doctors can ensure that conversations are focused on attainable patient-oriented goals and values related to quality of life, even when other goals are not attainable. When the patient sets unattainable goals, the doctor's empathy can be used to provide support during grief and resolve conflicts, 28,29 There is also evidence that, while spiritual and religious support is important for and benefits patients, doctors often ignore these issues when patients and their families raise them. 30 Published and online resources for doctors who have conversations about the goal of care with geriatric patients. Data from references 7, 29 and 35 The objectives of care have the potential to pose difficult ethical problems and can cause conflict between families, patients and doctors, and even between doctors. Physicians may experience moral stress, the feeling that they know what they should do but can't do it.
Discordance between values, objectives, and treatments can be a major source of moral distress and ethical conflict. In such cases, palliative care visits and ethical consultations can help to reapproach decision-making. In addition, when emotional or religious concerns are important, social workers and chaplains can play a role in providing support and facilitating the decision-making process. Conversations about goals of care are an important but complex skill for doctors who care for older adults. While doctors tend to focus on specific medical interventions, these conversations are more successful if they begin with a shared understanding of medical conditions and potential outcomes, and then an analysis of values and goals.
While training in the medical field is incomplete, there are many published and online resources that can help doctors acquire these valuable skills. Conversations about care goals should address the patient's clinical situation, values, and goals before talking about specific medical treatments. Consultations about ethics and palliative care can help resolve the challenges posed by making decisions about the objectives of care. and related treatments.
Conversations about care goals should explore values, goals, and treatment preferences. In resuscitation care, the primary goal of care is to prolong life by curing or controlling health status. A person's care goals are their general priorities and health expectations in relation to care; they are based on their personal values, desires, beliefs, and perception of quality of life, and on what they consider significant and important. Examples of care goals might include curing illness, prolonging life, alleviating suffering, optimizing quality of life, maintaining control, achieving a good death, and obtaining support for family and loved ones. The objectives of care are not the same as decisions about health care or consenting to treatments.
These are eight key components of a conversation about the goals of care, with examples of empathetic questions and answers or suggestions that doctors can use to guide the debate about the objectives of care. The difference is that the goal of advance care planning is to plan care in case the patient is unable to make their own medical decisions, while the goal of conversations about care goals is to prepare for current medical decision-making. Because conversations about goals of care occur frequently during clinical worsening, patients often experience difficult emotions during conversations. If your goals include a desire to avoid going to the hospital for treatment, talk to your doctor about treatments that may be available and useful for you in your home or care facility.
The use of simulated patients encourages clinicians to reflect on individual communication skills that are important for each step of the process of talking about the goals of care. A recent survey of primary care physicians and medical subspecialists who regularly see older adults revealed that sixty-eight percent of doctors report having received no training related to talking to patients about end-of-life goals and desires. Early consideration of treatment goals, values, and preferences in the outpatient setting can prevent older adults from undergoing unwanted interventions and help them analyze their priorities with substitute decision makers. The American Geriatrics Society has joined the Choosing Wisely campaign, which makes a series of recommendations for specific treatments aimed at reducing onerous polypharmacy and requesting screening tests that are unlikely to benefit older adults.
Both advance care planning and conversations about care goals involve exploring what is most important to the patient and making sure that their values and preferences in regard to health care are known. Decisions about care goals often come about over time, through conversations between you, your family or loved ones and your health care team. Percentage of people with identified palliative care needs who have documented conversations with a health professional about their care goals in their medical records palliative.
