Discussing Values, Goals, and Preferences

Guidelines for Physicians in Discussing Values, Goals, and Preferences with Patients Near the End of Life.

• If possible, begin these conversations early in the illness, rather than waiting until a medical crisis occurs or until death is imminent. Revisit these discussions when the patient’s condition changes substantially.

• Ask the patient about his or her understanding of the current medical situation and about additional diagnostic and therapeutic options.

• Assess the patient’s and family’s information-sharing preferences. What kinds of information do they wish to have, what would they prefer not to know, and who should be involved in discussions about the patient’s care? Similarly, ask about their preferences for decision making. How should important decisions be handled? Will key decisions be made by the patient, family members, or the clinician, or will the decisions be made collaboratively?

• Answer questions as clearly as possible and provide simple, clear, jargon-free information about the patient’s condition, prognosis, and options for treatment. Clarify any misconceptions the patient or family may have. In general, patients cannot make good decisions about their care without some understanding of their prognosis.

• Inquire about and address the patient’s concerns. For example, ask, “What are your main worries or fears about your situation?” Ensure that attention is paid to the patient’s comfort.

• Ask about “unacceptable states” — that is, states of existence or losses of critical functioning that a given patient wants to avoid (e.g., a state in which mechanical ventilation would be required indefinitely or in which the patient would be unable to communicate meaningfully with family members).

• After the patient has been informed about the situation and prognosis, discuss and clarify the patient’s values, goals, and preferences for care.

• With this shared knowledge about goals for care, recommend a plan for end-of-life care. The clinician should not simply ask, “What do you want?” nor should the clinician offer to use harmful or nonbeneficial treatments (e.g., cardiopulmonary resuscitation that will almost certainly be unsuccessful and will not serve the patient’s goals). When decisions need not be made urgently, allow time for the patient to reflect on choices, obtain further information, or discuss the matter further with family or other advisors.

* Recommendations in the table are based on published guidelines.12-15

IKA SYAMSUL HUDA MZ