February 22, 2015

Goals, Goals, and then What?

Last week’s New England Journal of Medicine asked readers to weigh in on who should initiate a conversation about goals of care with the patient described in a clinical vignette, a 59 year old woman with very advanced breast cancer. Should it be the primary care physician? The oncologist?  Or should it be a palliative care specialist? Three short pieces make the case for each perspective. But the reality is that it’s not who initiates the conversation about the goals of care that’s important; it’s what’s done with the information.

The primary care doctor might be the best person to start talking to the patient about “what is most important to her” if that physician has a longstanding relationship with her. The oncologist might be the best person to “elicit... values and goals” if he or she has the requisite communication skills. The palliative care physician might be the optimal choice if there are other issues to address, such as symptoms or social supports. Ideally, any of the three candidates could discuss with the patient what matters to her, given the realities of her disease and its likely trajectory.

What the three respondents leave out is the next crucial step: going from goals to decisions about treatment. The primary care advocate says that the physician should help the patient “match future care and treatment to her goals” but is principally concerned with recommending use of the POLST form (physician order for life sustaining treatment) as a means of documenting her wishes. She doesn't explain how wishes, expressed in terms of goals, are to be translated into actual medical orders. The palliative care advocate argues that the patient needs “help understanding what to expect and how to manage it” along with symptom control and emotional support, and is chiefly concerned with touting the importance of palliative care as a specialty. She says nothing about who or how anyone will infer from goals what the treatment should involve. The oncologist argues that the physician should provide information about prognosis and elicit the patient’s values and is mainly interested in assuring that the specialist physician not abdicate this responsibility. He alludes to the physician’s “judgment and advice,” but then states that the doctor's role is to to help the patient "understand her prognosis and options, articulate her values, and match her medical decisions to those values." Evidently the patient is supposed to make the leap from goals to treatment, though with the physician's advice.

What should the process of moving from goals to a plan of action look like? Figuring out what treatment plan is most consistent with a patient’s goals of care requires technical understanding of the treatment and its alternatives. Suppose the patient decides that focusing on comfort is most important to her; it is the physician (most plausibly the oncologist, in this scenario) who is in the best position to explain whether oral opioids, an infusion pump, or radiation therapy are most conducive to achieving that goal. Suppose the patient chooses to focus on life-prolongation. It is the physician who is best able to determine which, if any of the available chemotherapeutic regiments, is likely to prolong life. Or suppose the patient concludes that remaining as mobile, independent, and clear-headed as possible is her primary concern. It is the physician who is able to say, based on knowledge of the benefits as well as the burdens of each alternative, how best to accomplish this goal.

Shared decision-making, the gold standard of care today, involves the active participation of both clinicians and patients. It is a dynamic process that requires give and take by both parties. It demands skill, rests on trust, and takes time. But it’s important to realize that the physician and the patient bring different kinds of knowledge and expertise to the dialogue. A division of labor between patients and doctors is perfectly consistent with respect for both parties. Just as patients have a unique understanding of what matters to them, physicians have a special understanding of what it is like to go through a course of treatment. Physicians can help patients articulate their goals but then it is up to physicians to conclude what those goals imply for treatment. Patients may reject the conclusions drawn by physicians—usually because they realize, when faced with the implication of their stated goals, that their description of what was important to them was not quite accurate. 

The translation of goals of care into actual therapy should be the physician’s prerogative--with the patient maintaining veto power. What matters isn’t so much who starts the ball rolling as how to shepherd it into the end zone.

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