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• W2046131873 abstract "When I first met Jean I was still adapting to clinical medicine, a student on his second clerkship. Absorbed in recording her history from the EMS provider, I barely noticed the brief chief complaint—”She fell out of her wheelchair”—that would come to emblemize Jean's story for me, a superficial truth unmoored from an understanding of the patient. Jean later recounted how, many months earlier (while she was still living independently) she felt “content to surrender” to her multiple medical conditions, consciously disinterested in lifesaving measures. Yet when her health deteriorated, she found herself first confined to a nursing home that she had been counseled would be temporary, and then an ICU, from which she returned to the nursing home in a wheelchair and with a gastrostomy tube that she barely remembered discussing with her doctors. A month later, sepsis brought her to our emergency department, where my team admitted her, treated her, and kept her very much alive. From one point of view, we saved her life; yet in thinking back, the chief complaint we did not or perhaps could not hear was “I want to die.” Although the physician's ethics have remained static for generations—primum non nocere; first, do no harm—medicine's armamentarium has rendered the meaning of harm plastic. We are relearning how to care for patients like Jean, as our abilities to prolong life now carry with them an unsettling capacity to inflict suffering. Palliation stands chief among our ethical challenges, demanding extraordinary balance between what we can do—CPR, intubation, ECMO, transplantation—and what we should do. The ethos of medical education has evolved to embrace the role of palliative care: as students we are shown evidence that it improves quality-of-life and patient outcomes, and we learn that our foremost obligation is to our patients' desires. Yet in the clinical trenches, Jean was not the only patient whose wishes I saw compromised. Fundamentally, doctors and students are still mastering how to talk to our patients about palliation; how to partner with them and establish their goals of care. In A Palliative Ethic of Care, Dr. Joseph Fins describes how an ideal therapeutic relationship positions patients such that “Instead of letting available technology drive the goals of care … the goals of care drive the therapy. Setting goals is both the implicit organizing principle and explicit objective of end-of-life discussions.”1 True goals of care reach beyond DNR/DNI orders, guiding patients to understand their conditions and articulate plans that are accurate, honest, nuanced, and clear. Establishing such goals with every patient must be our goal of care. The mandate for training is strong: several recent studies demonstrate that residents feel inadequately prepared to engage in end-of-life discussions, with most reporting never having had one appropriately modeled.2, 3 These same studies also found that many patients don't recall such conversations, and when they do physicians are ambiguous regarding prognosis and CPR recommendations—the two most important elements of end-of-life counseling, according to current guidelines.4, 5 As recently as a 2012 editorial in the New England Journal of Medicine, physicians have called for improved resident and student training, highlighting the role trainees must play in advancing this issue, as both advocates for our patients and the generation of physicians positioned to demand education that will perpetuate such advocacy throughout our careers.6 The moment has come for us to reinvent the physician's goals of care and look beyond do no harm towards the tools we need to perceive our patients' fears and offer comfort, to discuss their prognoses honestly and appraise treatment options together, and to help them articulate what harm means to them. Thinking about Jean one last time, it's clear to me that she knew, as Dr. Harvey Cushing once wrote, “there is only one ultimate and effectual preventive for the maladies to which flesh is heir, and that is death.”7 For Jean and the many patients like her we'll care for, there may be no more meaningful and essential therapy we can offer than releasing our hold on life's last panacea." @default.
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• W2046131873 date "2013-08-24" @default.
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• W2046131873 title "The Goals of Care" @default.
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• W2046131873 doi "https://doi.org/10.1111/acem.12194" @default.
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