“After John's second glioblastoma surgery, he never recovered his speech. Thankfully, his family had discussed this kind of possibility before. Some wanted another operation, others wanted hospice. By recalling those conversations all could agree that we had passed John's personal threshold for wanting palliative care.”
This situation is still too rare. Many avoid advance care planning, believing that it is difficult and rarely works. Then dilemmas toward the end of life wind up by hurting all concerned. It need not be so.
Evidence shows that people's goals for care in diverse illness scenarios predict their treatment choices, and their goals vary based on the scenario.[1,2] So the thing to know about your patients is their personal threshold for switching from curative to palliative goals. A good way to find this threshold is with a validated worksheet.[3,4]
We can do a short version right now. First, consider your current health but with a life-threatening, reversible condition such as hemorrhage due to an accident. What would your goal for care be? OK. Now consider a delirious state due to terminal cancer. What would your goal for care be? If your goals shifted from curative to palliative, your threshold lies between those situations. To further pinpoint your threshold, consider the scenarios in a validated worksheet.[5]
Once your patient knows how to find his or her own threshold, most of the discussion can be had without you. Just be sure it comes back to you for confirmation.
More information on advance planning can be found elsewhere.[6–8] But remember: The essential part takes a few minutes and can make a world of difference.
That's my opinion. I'm Dr. Linda Emanuel, Professor of Geriatric Medicine and Director of the Buehler Center on Aging, Health & Society at the Northwestern Feinberg School of Medicine.
For more information visit www.medicaldirective.org
Footnotes
Reader Comments on: Advance Care Planning for Decisional Incapacity: Keep It Simple – Find Your Patient's Goal Threshold in Under 5 Minutes See reader comments on this article and provide your own.
Readers are encouraged to respond to the author at l-emanuel@northwestern.edu or to Peter Yellowlees, MD, Deputy Editor of The Medscape Journal of Medicine, for the editor's eyes only or for possible publication as an actual Letter in the Medscape Journal via email: peter.yellowlees@ucdmc.ucdavis.edu
References
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