Goals of care discussions: which approach is best?

In the emergency department, although we are the first line for the sickest patients, we tend to defer the “goals of care discussion” to the admission team. Reasons are numerous: it is time-consuming, we often do not have access to all the information necessary, and in geriatric we are confronted to cognitively non-intact patient frequently without available proxy. There is always a good reason to not do it!

But, in fact, we should engage in these discussions because it can totally change the clinical management! For example, an old demented non verbal person with pneumonia and desaturation, it is so much easier to get him on IV antibiotics, ask the hospitalist and go see the next patient. But. if you talked to the daughter, she might say: please let her go in peace and make sure dad is comfortable. It totally changes your management, potentially avoid an admission and unnecessary tests.

As our ED population is getting older, I think this is best practice to engage in those discussions as soon as possible in the course of the acute disease, in the ED.

Now that I convinced you to do it, lets talk about the HOW, and that is my reflection of this week. Is there a very best way to do it?

I learned a few ways to do it in my medical training. Lets review a few of them. There is the “there is not such a thing as an open bar for advanced medical directive”. It means that Physicians know better than the patient and their family and they should strongly advised for this and that. There is some truth in this more paternalistic discussion. It has the advantage of taking off the family`s shoulder this very heavy decision. But it is also kind of brutal and some family with religious or other spiritual beliefs might feel bullied in this situation. Hum… not perfect.

There is the “I am going to scare you with awful outcomes” discussion. This is when doctors talk about CPR as the action of painfully breaking all your ribs, you are not going to wake up the same and end up in long term care as a vegetable, but you have a choice, you decide! Again, there is some truth in this but it is so scary for patient and families that they can end up fearing usual basics care. Also, when another doctor has a softer way to say it, patient and family may loose confidence in the health care system and their providers. A doctor once told me: “When something is awfully scary, it is usually not entirely true”. I do not think this is the way.

Then you have the “do you want us to save your life” discussion. This is when doctors do not explain what CPR and intubation actually mean and turn it in a way that for example if your pneumonia gets worse, do you want us to save your life with extra-ordinary measures. “Of course I want you to save my life, that is what I am here for!”. But, this may ends up to inappropriate advanced medical directive for the patient condition.

Then you have the “How was your Dad like as a person back in the days”. I like this way. By asking this question to the family, you get a sense of what kind of character the patient was. Was he very independent, stubborn and proud? You can also ask this question: “What Dad would tell you about himself at the moment if he was able to appreciate his condition?”. By asking these 2 questions, you removed a lot of pressure on families shoulder because they feel like they speak with his own words and thoughts. It is his decision now! By knowing those two things, you can adjust the content for the rest of the discussion with more detailed questions turned in his own words. The downside of this one is that we assume that because they are family and at bedside, they must know the patient, but sometimes it is not the case.

The goals of care discussion provides essential and crucial informations for patient care. It has to be done at some point, the sooner the better. In the community with their family doctor is probably the best way. But then, we have to make sure that this information is communicated.

The more often we do it, the more comfortable we become.



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