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The Project to Educate Physicians on End-of-life Care
Supported by the American Medical Association and
the Robert Wood Johnson Foundation
Module 7
Goals of Care
Objectives . . .

Understand the different goals and
how they interrelate and change

Understand how to use the 7-step
protocol to negotiate goals of care

Be able to communicate prognosis
and its uncertainty

Understand how to tell the truth and
identify reasonable hope
. . . Objectives

Be able to use language effectively

Be able to set limits on unreasonable
goals

Be able to adjust care and
communication according to culture

Understand how to identify goals
when patients lack capacity
Introduction . . .

Every one has a personal sense of
who we are
what we like to do
control we like to have
goals for our lives
things we hope for
. . . Introduction


Hope, goals, expectations change
with illness
Physician’s role to clarify goals,
treatment plan
Potential goals of care

Cure of disease

Relief of suffering

Avoidance of
premature death

Quality of life

Staying in control

A good death

Support for
families and loved
ones


Maintenance or
improvement in
function
Prolongation of life
Historically, a
dichotomous division of
goals of care

Focus on curing illness

Little attention to relief of suffering,
care of dying

Hospice / palliative care arose in
response to a need
Figure 1: A dichotomous intent
Curative / life-prolonging therapy
Presentation
Death
Relieve suffering (hospice)
Multiple goals of care

Multiple goals often apply
simultaneously

Goals are often contradictory

Certain goals may take priority over
others
Goals may change

Some take precedence over others

The shift in focus of care
is gradual
is an expected part of the continuum of
medical care
Figure 2: The interrelationship of therapies with
curative and palliative intent
Curative / life-prolonging therapy
Presentation
Death
Relieve suffering (palliative care)
Palliative care: expanding
the options . . .

Interdisciplinary care

Symptom control

Supportive care
. . . Palliative care:
expanding the options

Any life-threatening diagnosis

Anytime during illness

Whenever patient / family prepared to
accept it

May be combined with curative
therapies

May be focus of care
7-step protocol to
negotiate goals of care . . .
1. Create the right setting
2. Determine what the patient and
family know
3. Explore what they are expecting or
hoping for
. . . 7-step protocol to
negotiate goals of care
4. Suggest realistic goals
5. Respond empathically
6. Make a plan and follow-through
7. Review and revise periodically, as
appropriate
Communicating
prognosis

Markedly over-estimate prognosis

Helps patient / family cope, plan
increase access to hospice, other
services

Offer a range or average for life
expectancy
Truth-telling and
maintaining hope

False hope may deflect from other
important issues

True clinical skill to help find hope
for realistic goals
Language with unintended
consequences

Do you want us to do everything
possible?

Will you agree to discontinue care?

It’s time we talk about pulling back


I think we should stop aggressive
therapy
I’m going to make it so he won’t suffer
Language to describe
the goals of care . . .

I want to give the best care possible
until the day you die

We will concentrate on improving the
quality of your child’s life

We want to help you live
meaningfully in the time that you
have
Language to describe
the goals of care . . .



I’ll do everything I can to help you
maintain your independence
I want to ensure that your father
receives the kind of treatment he
wants
Your child’s comfort and dignity will
be my top priority
. . . Language to describe
the goals of care



I will focus my efforts on treating
your symptoms
Let’s discuss what we can do to fulfill
your wish to stay at home
Let’s discuss what we can do to have
your child die at home
Cultural differences

Who gets the information?

How to talk about information?

Who makes decisions?

Ask the patient

Consider a family meeting
Determine specific
priorities

Based on values, preferences,
clinical circumstances

Influenced by information from
physician, team members
Reviewing goals,
treatment priorities

Goals guide care

Assess priorities to develop initial
plan of care

Review with any change in
health status
advancing illness
setting of care
treatment preferences
When the physician cannot
support a patient’s choices

Typically occurs when goals are
unreasonable, illegal

Set limits without implying
abandonment

Make the conflict explicit

Try to find an alternate solution
Reassess decisionmaking capacity . . .

Implies the ability to understand and
make own decision

Patient must
understand information
use the information rationally
appreciate the consequences
come to a reasonable decision for him
or her
. . . Reassess decisionmaking capacity

Any physician can determine

Capacity varies by decision

Other cognitive abilities do not need
to be intact
When a patient lacks
capacity . . .

Proxy decision-maker

Sources of information
written advance directives
patient’s verbal statements
patient’s general values and beliefs
how patient lived his / her life
best interest determinations
. . . When a patient lacks
capacity

Why turn to others
respects patient
builds trust
reduces guilt and decision-regret
E
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Goals of Care
Summary