Key Feature 7: In patients with serious medical problems or end-stage disease, discuss code status and end-of-life decisions (ex: resuscitation, feeding tubes, levels of treatment), and readdress these issues periodically.
Skill: Patient Centered
Phase: Treatment, Follow-up
Whenever a patient is admitted to hospital, it is standard of care, at least in Canada, to review goals of care. At the very least, this means documenting the patient's or substitute decision maker's choice regarding code status (i.e., if the patient were on death's doorstep, up to what degree of intervention would they want to receive). The specific choices of graded intervention may vary regionally and by institution, but the general choices range from doing everything possible, no matter how invasive, to providing only comfort care. In my last post, I mentioned that one of the reasons to terminate (or ideally, not start) resuscitation of a patient with cardiac arrest is if it is learned that the patient has a DNR or Do Not Resuscitate Order, which means the patient or substitute decision maker has expressed that resuscitation is not in the patient's best interest. Ideally, conversations around goals of care go beyond whether or not someone wants to receive the full gamut of ICU care with all of the tubes and mechanical life saving interventions one can have, to include what the patient's values and wishes are. The different provinces in Canada have their own set of resources available for patients and clinicians to use to navigate these conversations. The government of BC's website has a webpage called Advanced Care Planning that provides information and tools for this.
When I was first reading around the subject of broaching a goals of care discussion with patients, I tried to learn when it was best to introduce this concept to patients. The people who work in this area will tell you there is no time too early to start thinking of your goals and wishes for end of life, and then there are the people in hospital who ask the bare minimum to check off the box on the goals of care orders that are mandatory when admitting a patient. I think the ideal is probably somewhere in between. My rule of thumb is: If I think the patient's disposition is such that they may not wish to have all possible interventions done to save their life, then it would be appropriate to open the conversation about advanced care planning, and the earlier the better. In this way, a more meaningful conversation can be had, with the opportunity for the patient to talk with their loved ones and to decide who they would like to be their substitute decision maker should they not be able to speak for themselves in the future. Ideally, this conversation and the decisions that are made would be explored and documented by the patient's primary health care provider, one who has a meaningful and long-term relationship with them, and who, by extension, can best help the patient understand how their decisions may impact them as the individual they are with the particular values and hopes they hold. As a future family physician I believe it is my duty of care to initiate this conversation with my patients as indicated by their circumstances. Certainly these circumstances would include anyone with consequential medical illness as well as those who are at increased risk of developing consequential medical illness. I consider this when I think about screening as well, as there are a batch of screening health considerations I address when patients turn 65 years old and it is, I think, a good time to broach this conversation if not already indicated based on previous health status.