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    Establishing Goals of Care in Sick Elderly Patients in the ED

    Cardinal Presentations / Presenting Problems, Critical Care / Resuscitation, Special Populations

    Last Updated Dec 19, 2019
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    Context

    • Caring for critically ill, frail patients in the ED is an increasingly common challenge. It is well known that the Emergency Department is not an optimal environment for discussing goals of care due to many factors. Physicians encounter limitations such as:
      • Lack of an established relationship with the patient and or family/substitute decision makers
      • Paucity of medical information
      • Shortage of time
      • Challenges with privacy/space
      • Little training in leading goals of care conversations
    • By being able to establish timely and patient centered goals of care for individuals in the ED, the clinician will be able to provide goal concordant care that will lead to both patient and physician satisfaction.

    Why is this important?

    • Patients seen in the ED are increasingly medically complex, elderly, and frail. This phenomenon poses a challenge to the modern-day clinician both in understanding chronic disease management and in understanding the patient’s wishes for their care.
    • There are few opportunities in training to gain confidence in having these difficult conversations in an efficient manner (1).
    • Having an approach to these discussions may lead to greater physician and patient satisfaction with the encounter, and likely lead to fewer unnecessary and expensive interventions near the end of life.

    Facing Conflict in the ED

    • Sentiments expressed by loved ones such as ‘Do everything for my loved one’ are commonly encountered by clinicians working in the ED.
    • Conflict may arise when the clinical assessment of the patient and the stated wishes for care come in to conflict.
    • Taking the time to understand the patient’s/caregiver’s perspective may enable one to de-escalate a potential problem. Utilizing phrases such as:
      • “Tell me more about your e.g. loved one”
      • “I believe that we should provide everything for your parent that would be beneficial”
    • During stressful times of critical illness, it may be common to encounter fears of medical abandonment. By expressing empathetic statements, the patient and or caregiver may experience fewer feelings of such abandonment. This may lead to a more satisfactory doctor/patient experience.

    What are you required to do?

    • From a medicolegal and ethical perspective, there is an increasing distinction between withholding care/procedures (e.g. CPR) and withdrawal of care (e.g. ventilatory support) (2, 3).
    • Based on recent court findings (2) in Ontario that reinforce this distinction, it is likely that these findings will be persuasive in future case law across Canada.
    • Despite the establishment of the difference between withholding and withdrawing care, it is emphasized that even if a clinician establishes that a procedure (e.g. CPR, intubation) would prove to be futile for a particular patient, thoughtful and timely communication of these recommendations to the patient/family should be a priority.

    Providing Compassionate Guidance

    • Current medical training prioritizes the importance of patient autonomy as a key aspect of care.
    • By making autonomy the most important factor in contemporary medical ethics, clinicians may lose the opportunity to provide guidance to their patients when it comes to navigating difficult decision-making around care.
    • The consideration of providing compassionate recommendations has been gaining more traction in medicine. A 2018 article (4) outlined a concise approach to providing recommendations to patients with serious illness, which included:
      • Understanding treatment options for estimated prognosis of 3-6 months.
      • Determining what is important to the patient/how does one want to be cared for.
      • Provide a recommendation focusing on goals compatible with prognosis/treatment options.

    Summary

    • Encountering seriously ill, elderly patients in the ED is more common than ever based on advances in therapies leading to increased survivorship.
    • With these advances, there are more interactions with patients who present with dynamic goals of care in the face of complex medical issues at the end of life.
    • Having an understanding of what one is medico-legally required to do as well as having the tools to provide compassionate care with an emphasis on clear communication is a key to ensuring good care and avoiding conflicts.

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