Determining a patient’s goals of care is one of the most complex conversations that occurs in the Emergency Department. This is far more than “DNR or not” “intubate or not.” Taking the time to move beyond those simplistic formulations of care towards getting a good sense of what the patient and the family want leads to more satisfactory outcomes for everyone.
- No one goal is more valid than others
- Multiple goals can exist at the same time
- Goals can change over time or even rapidly
Goals may include one or more of the following:
- Treatment/cure of disease
- Prevention of further decline
- Treatment of symptoms
- Prolongation of life
- A dignified death
- A trial of aggressive intervention
- Return home
- Admission to hospital
A “goals of care” conversation needs to include a clear awareness of global trajectories and prognosis. It will help the patient, family, and care-giving team guide decisions and choices regarding care. Patients and families look to the Emergency physician for accurate and reliable information that is empathically communicated.
It can seem strange that it’s an Emergency physician, who knows the patient only briefly, who is having this conversation. However the patient’s presence in the ED almost always signals a turning point in their trajectory. It is an opportunity to move beyond “intubate or not” and make a real contribution to the patient’s well-being.
The following pages review the components of a goals of care discussion using videos to illustrate them.