The Language of Goals of Care: Response

Abstract

We thank Mr Allen and Dr Jesus for their efforts to engage some of the issues raised by our study.1Gehlbach TG Shinkunas LA Forman-Hoffman VL Thomas KW Schmidt GA Kaldjian LC Code status orders and goals of care in the medical ICU.Chest. 2011; 139: 802-809Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar One concern pertains to whether differences between a patient's code status preference and a surrogate's understanding of that preference might account for some discrepancies between their expressions of the patient's preferences and their actual code status orders. First, we agree that surrogate decision making for previously capable adults is expected to follow a standard of substituted judgment so that surrogates represent their loved one's preferences, not their own. Second, it is important to emphasize that when a surrogate served as a participant in our study it was because he/she was the patient's legally authorized decision maker. Whether surrogates' expressions of patients' preferences were accurate, those expressions would in fact serve as the basis for decision making unless a patient's physician had independent knowledge of a patient's previously expressed wishes or had reason to question the validity of a surrogate's decision making. Regarding the literature-based goals of care we used,2Kaldjian LC Curtis AE Shinkunas LA Cannon KT Goals of care toward the end of life: a structured literature review.Am J Hosp Palliat Care. 2008; 25: 501-511Crossref PubMed Scopus (129) Google Scholar we agree that their interrelationships caution against overinterpretation of differences between goals of care identified as most important by physicians as opposed to patients/surrogates. In terms of impact on clinical decision making, there may not be, for instance, a clinically meaningful difference between wanting to achieve a specific life goal vs simply wanting to live longer (though personal significance for patients may vary when a highly valued life goal is at stake). Last, we agree that different goals of care often are and should be pursued simultaneously. Early in the course of a disease trajectory it is common to pursue cure, longer life, increased function, and comfort. Even in incurable conditions, it is common (at least for some time) to pursue longer life, increased function, and comfort. However, it is also true that sometimes some goals of care are mutually incompatible and need to be prioritized,3Gillick M Berkman S Cullen L A patient-centered approach to advance medical planning in the nursing home.J Am Geriatr Soc. 1999; 47: 227-230Crossref PubMed Scopus (61) Google Scholar, 4Bradley EH Bogardus Jr, ST Tinetti ME Inouye SK Goal-setting in clinical medicine.Soc Sci Med. 1999; 49: 267-278Crossref PubMed Scopus (104) Google Scholar such as when a patient has to choose between comfort (resulting in an earlier death) and cure (resulting in a more burdened life) or between being alert (resulting in the ability to communicate with loved ones) and sedated (resulting in greater comfort and the ability to sleep). Since patients must at times choose between multiple preferred goals, we believe it is sometimes clinically necessary to engage patients in dialogue to learn which goal is most important to them. The Language of Goals of Care: Framing Preferences at the End of LifeCHESTVol. 141Issue 4PreviewWe were pleased to learn about the efforts of Gehlbach et al1 in “Code Status Orders and Goals of Care in the Medical ICU.” We applaud the questions posed by this contribution to CHEST (April 2011), and feel the authors' framing of these issues raises interesting points for further discussion. Full-Text PDF