Friday, August 9, 2013

Research Amplifies Need for Patient-Centered Goals of Care Discussion



How important is reducing the risk of one ailment if it increases the risk of another?

A class of drugs to treat hypertension (antihypertensives) is among the most commonly prescribed medications in the United States. That probably comes as little surprise to anyone reading this. Recently, however, the online version of JAMA Internal Medicine, reported findings from a study that showed the risk of breast cancer more than doubledin postmenopausal women who took one of the drugs in this class, a calcium channel blocker, for 10 years or longer. That led me to think about the impact that these kinds of studies have on patients and families who make decisions about burdens and benefits in caring for a loved one in an aging society, where living with multiple chronic conditions is becoming the norm.

While the study underscores the importance of goals of care discussions between provider and patient, it highlights even more the critical nature of those conversations for patients living with multiple chronic diseases. How important is reducing the risk of one ailment if it increases the risk of another – especially, as in this case, dramatically?

We already know that clinicians rarely engage patients and families in goals of care discussions about anything, relying instead on what they know to be “in the best interest” of the patient. And, in the rare case where they do have the conversation, the discussion is limited only to treatments or interventions. This underscores how we need to broaden the goals of care discussion to aspects of our lives that include important considerations that go well beyond specific interventions. Goals of care conversations need to include topics like quality of life, comfort and functional status.

Two out of three seniors over 60 report having two or more chronic conditions and just under half have three or more, so we’re talking about a lot of folks facing these kinds of considerations. Their answers depend a lot on what their goals are. What factors should be weighed? Is watchful waiting a good option? What about adherence to regimens if the patient has dementia? What are the most important aspects of their lives? These questions need to be raised by patients, by families and thoughtful practitioners. And in raising them, we need to craft responses that reflect values, preferences and goals that clearly matter to them; not what’s clinically expedient or meets some prescribed pathway.

This study is just one example of the ethical issues raised by “advances” in medical treatment. Shared decision making is a process, a two way street. Devotion to sound ethical practice in light of the patient’s values and preferences requires us to a commitment to meaningful dialogue – talking about real life, real issues in real time, and then implementing a plan that clearly reflects the goals of patients.

Folks who share an investment in achieving a shared outcome, work harder together to get it. We just might find that we’re a lot more successful in achieving goals “for” patients if we could see that achieving goals “with” them was a pre-requisite for success. It isn’t hard to accept the concept that patient involvement in goal setting is a good thing. We just need to resolve that anything short of that is failure.

by: John Carney, President & CEO Center for Practical Bioethics

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