Skip to main content

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

Comments

Popular posts from this blog

Practical Advice for the End of Life: A Podcast with BJ Miller

This week we talk with BJ Miller, hospice and palliative care physician, public speaker, and now author with Shoshana Berger of the book "A Beginner's Guide to the End."

As we note on the podcast, BJ is about as close as we get to a celebrity in Hospice and Palliative Care.  His TED Talk "What Really Matters at the End of Life" has been viewed more than 9 million times.  As we discuss on the Podcast, this has changed BJ's life, and he spends most of his working time engaged in public speaking, being the public "face" of the hospice and palliative care movement.

The book he and Berger wrote is filled to the brim with practical advice.  I mean, nuts and bolts practical advice.  Things like:
How to clean out not only your emotional house but your physical house (turns out there are services for that!)Posting about your illness on social media (should you post to Facebook)What is the difference between a funeral home and mortuaryCan I afford to die?  …

Improving Advance Care Planning for Latinos with Cancer: A Podcast with Fischer and Fink

In this week's GeriPal podcast we talk with Stacy Fischer, MD and Regina Fink, RN, PhD, both from the University of Colorado, about a lay health navigator intervention to improve advance care planning with Latinos with advanced cancer.  The issue of lay health navigators raises several issues that we discuss, including:
What is a lay health navigator?What do they do?  How are they trained?What do lay health navigators offer that specialized palliative care doesn't?  Are they replacing us?What makes the health navigator intervention particularly appropriate for Latinos and rural individuals?  For advance care planning? Eric and I had fun singing in French (yes French, not Spanish, listen to the podcast to learn why).
Enjoy! -@AlexSmithMD




You can also find us onYoutube!



Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher

Transcript

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, I'm really excited about toda…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …