Download Slides - IPCRC.NET

The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
E
P
E
C
EPEC – Oncology
Education in Palliative and End-of-life Care – Oncology
O
Module 9
Negotiating Goals of
Care
Overall message
Setting goals sustains hope
throughout the course of
cancer care
Objectives

Tell the truth while identifying
reasonable hope

Discuss potential goals of care

Use a 7-step protocol to negotiate
goals

Identify goals when a patient lacks
capacity
Video
Introduction

Oncologists' role to clarify goals,
treatment plan to achieve goals

Goals, expectations may change
over time

Sustain hope
Problems vs. Goals

List problems


Prepare a plan
to resolve each
problem
Determine
overall goal

Clarify priorities
among
competing goals

Choose plan to
reach goals


Reassess each
day
When problems
solved, patient
is better
Truth-telling and goals. . .
Hope

Hope: expectation that good things will
come
An optimistic frame of mind

Absence of hope is depression

Hopefulness can continue while object
of hope changes
. . . Truth-telling and goals
Wish

Wish: something desired, but
unlikely

Wishes need not prevent appropriate
choices
Potential goals of care:
A dichotomous intent
The interrelationship
of goals

Not a linear sequence

Multiple goals often apply
simultaneously

Goals are often contradictory

Certain goals may take priority over
others
Potential goals of care

Cure cancer

Relieve suffering

Avoid premature
death

Quality of life

Stay in control

A good death

Support for
families and
loved ones


Maintain or
improve
function
Prolong life
Palliative care

Focuses on relieving suffering,
improving quality of life
Any cancer
Any time during illness
May be combined with curative
therapies, or the focus of care
Includes supportive care
Changing goals

Some take precedence over others

The shift in focus of care
Is gradual
Can occur many times
Is an expected part of the continuum of
comprehensive cancer care
The interrelationship of
therapies with curative and
palliative intent
Set goals to sustain hope

Establish how information will be
shared

Define language

Prevent surprises

Prepare for decision points
Common language
Medical
Language
Cure
Control
Common Language
The cancer is gone and won’t
come back.
Slow or stop the growth for a
time.
There is no evidence of cancer,
but it could come back.
Complete
response /
Remission
Partial
The cancer is still there, but
response
smaller.
Stable disease The cancer is the same.
Progressive
disease
The cancer is worse.
7-step protocol to
negotiate goals of care . . .
1. Create the right setting
2. Determine what the patient and
family know
3. Ask how much they want to know
and discuss with you
4. Explore what they are expecting or
hoping for
Identifying goals to hope
for

False hope may deflect from other
important issues

True clinical skill to help find hope
for realistic goals
Determine priorities for
treatment, care

Based on values, preferences,
clinical circumstances

Influenced by information from
physician, team members
. . . 7-step protocol to
negotiate goals of care
5. Suggest realistic goals
6. Respond empathetically
7. Make a plan and follow-through
Language with unintended
consequences

Do you want to be aggressive?

Will you agree to discontinue care?

It’s time we talk about pulling back

I think we should stop fighting
Won’t they give up hope?

“Come on, you’re a fighter!”

“You can’t just stop”

“Its important to keep trying!”

The ‘war’ on cancer
Language to describe
the goals of care . . .

I want to give the best care possible
until the day you die

We will concentrate on improving the
quality of your child’s life

Our goal will be to shrink the cancer.
We’ll know in 6 weeks
. . . Language to describe
the goals of care



I’ll do everything I can to help you
maintain your independence
I want to ensure that your father
receives the kind of treatment he
wants
Your child’s comfort and dignity will
be my top priority
Cultural differences

Who gets the information?

How to talk about information?

Who makes decisions?

Ask the patient

Consider a family meeting
When the physician cannot
support a patient’s choices

Typically occurs when goals are
unreasonable, impossible, illegal

Set limits without implying
abandonment

Make the conflict explicit

Try to find an alternate solution
Decision-making
capacity . . .

Implies the ability to understand and
make own decision

Patient must
Understand information
Use the information rationally
Appreciate the consequences
Come to a reasonable decision for him /
her
. . . Decision-making
capacity

Any physician can determine

Capacity varies by decision

Other cognitive abilities do not need
to be intact
When a patient lacks
capacity . . .

Proxy decision-maker

Sources of information
Written advance directives
Patient’s verbal statements
Patient’s general values and beliefs
How patient lived his / her life
Best interest determinations
. . . When a patient lacks
capacity

Why turn to others
Respects patient
Builds trust
Reduces guilt and decision-regret
E
P
E
C
Summary
O
Setting goals sustains hope
throughout the course of
cancer care