By Stacey Kusterbeck
Ethics consults often involve conflicts at the end of life. Some of those conflicts could have been avoided with earlier goals of care discussions. “My own work, and the work of others, has consistently shown that there are missed opportunities to elicit patients’ values and treatment preferences prior to acute clinical deterioration in the hospital,” says Liz Chuang, MD, MPH, HEC-C, director of the Montefiore Einstein Center for Bioethics.
Chuang and colleagues wanted to better understand why these opportunities are missed. The researchers interviewed 15 clinicians (oncologists, hospitalists, and intensivists) on what leads them to decide to have a goals of care discussion with seriously ill patients.1
The researchers theorized that since multiple specialists often are involved with patients’ care, each healthcare provider assumes that another provider will have the discussion. This particular study did not support the idea that a diffusion of responsibility was a driving factor for missed opportunities to discuss patients’ values and treatment preferences. “Most of the participants were clear that the responsibility for having these discussions was a core part of the generalist or primary physician’s role, with some support from specialists,” says Chuang.
However, clinicians were hesitant to commit to the present moment as the right time to have a goals of care discussion. This results in an “it is always too early, until it is too late” phenomenon. Discussions are delayed until the patient becomes so ill that it no longer is possible to engage them in a discussion.
“There was a complex interplay between physicians’ mental model of goals of care discussions, and the particular circumstances of the patient’s clinical condition,” explains Chuang. Clinicians considered the patient’s clinical stability, the acuity of the clinical scenario, and how reversible the physician perceived the acute clinical scenario to be. Some physicians thought that “goals of care” only should be discussed when all disease-directed treatment was exhausted.
“Advance care planning is generally conceptualized as a process that occurs in the outpatient setting prior to an acute illness,” adds Chuang. The disadvantage of this approach is that patients must imagine hypothetical future scenarios without knowledge of the specific situation they will face. “Conversely, the concept of goals of care discussions is not clearly and consistently defined by physicians,” says Chuang. Thus, discussions may occur too late in the process of illness to include the patient themselves.
A new conceptualization of ongoing longitudinal serious illness conversations over time is needed, according to the study authors. “This may lower the threshold for physicians to engage in these discussions and help support a model of shared decision-making that can better align patient values and goals with the treatment that they receive,” concludes Chuang.
Reference
1. Chuang E, Gugliuzza S, Ahmad A, et al. “Postponing it any later would not be so great”: A cognitive interview study of how physicians decide to initiate goals of care discussions in the hospital. Am J Hosp Palliat Care. 2024;41(11):1307-1321.
Ethics consults often involve conflicts at the end of life. Some of those conflicts could have been avoided with earlier goals of care discussions.
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