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No time like the holidays to start talking about Goals of Care...

Arun S. Rao, MD

Dec 24, 2023

A heavy topic for this time of year, but a critical one for many older adults…“goals of care.”  

Just this past week, I had the opportunity to help a family begin the process of understanding this better as one of their members was facing a new difficult diagnosis and needed to start making choices about what was important to them.  

Establishing goals of care are part of the “bread & butter” for geriatricians.  However, the time limits of a busy practice or hospital service can make a meaningful outcome difficult.  Goals of care conversations- and notice I use the plural form of conversation, need to be multiple conversations over time as patients, families, & physicians get to know each other better.  Their aim is to elicit what is important to the patient at critical junctures of their life- when facing a new serious medical illness, when facing memory loss or dementia, or when having physical declines in function.  

Though challenging, these conversations are critical because we can truly understand who the patient is and what brings them meaning and joy.  To do this, we need to understand a patient’s medical history in detail along with who the patient is- functionally, cognitively, and socially.  Where are they coming from, what experiences have they had that can shape their goals and preferences, who is their support system, etc.? 

Through effective goals of care conversations and documentation, a patient, their caregivers, and their health care providers can be clear and aligned about what are the priorities for medical care, the characteristics that define an individual’s quality of life, and what to do in emergent situations.  

One big misperception among health care providers is that patients do not want to bring these issues up.  However, numerous studies have shown over and over that patients & families WANT their physicians to talk about these issues.  It just ends up becoming a giant elephant in the room that everyone ignores until it’s too late- until that crisis when the patient is facing an acute medical condition in a sterile hospital environment with everyone stressed and unable to think clearly as to what the patient would want.  

At Geriatrics Planning & Solutions, Inc, I can provide the patient and family the TIME and expertise necessary to navigate these difficult topics, questions, & documents. All of this done to deliver the answers you need, on your time, in your home- not in a rushed clinic or practice or hospital or….emergency room.

Some basics that I can help clarify- 

  1. Do you know what an Advance Care Directive/Living Will is and how it differs from a Durable Power of Attorney for Healthcare (i.e. Healthcare Proxy)?

    1. Advance Care Directive/Living Will: documents that specify what a person would/would not want for themselves medically; guidance for their caregivers when & if they do not have the capacity to make these decisions on their own.  

    2. Durable Power of Attorney for Healthcare/Healthcare Proxy:  documents that are part of the Advance Care Directive specifying who a person has chosen to be their “voice” and make decisions on their behalf if they do not have the capacity to do so.  

  1. Do you understand the hierarchy of decision makers in your state- what might happen if you have not appointed a Power of Attorney for Healthcare? 

    1. Who are the “next in line” in the chain- spouses, siblings, children, friends, guardians, the state?  

  1. The meaning of the following abbreviations and when do they apply?

    1. CPR (cardiopulmonary resuscitation)- the emergency procedure of chest compressions, mechanical ventilation, & shocks (if indicated) to preserve blood flow to critical organs when there has been a cardiac arrest.  

    2. Cardiopulmonary Arrest- the sudden unexpected loss of heart function & breathing

    3. DNR/DNI- Do Not Resuscitate/Do Not Intubate

    4. POLST- Physician Orders for Life-Sustaining Treatment; the “medical order” translation of a Living Will/Advance Care Directive

  1. What are the outcomes of cardiopulmonary resuscitation in older adults (especially over the age of 70)? 

    1. Generally, not good- maybe 5-7% survival after a cardiac arrest outside the hospital & about 10-15% for a cardiac arrest while in the hospital.

    2. Does not account for the potential functional losses & neurologic losses if an older adult survives.  

  1. How do my decisions impact my medical care- like my ability to have surgery, chemotherapy, infusions, transfusions, antibiotics, etc?

    1. Remember, a Do Not Resuscitate/Do Not Intubate does NOT mean do not treat! 

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