Addressing Goals of Care in Primary Care Practice

Addressing Goals of Care in Primary Care Practice Posted By:
...

In this post, I want to continue discussing Adelaide's case and how she can teach us about practicing primary palliative care. If you recall from my previous post, Adelaide is a 76-year-old female with significant heart failure with reduced ejection fraction (HFrEF) and has had several recent hospital admissions, most recently requiring aggressive IV diuresis as well as pressor support. During that admission, the hospitalist PA began discussions concerning goals of care (GOC) and Adelaide was eventually discharged to rehab and finally back home.

Now, Adelaide is following up routinely with you, her primary care clinician. You've reviewed the hospital chart and noticed that conversations around GOC had been opened. So, how can you continue these conversations with Adelaide and perhaps prepare her and her loved ones for different outcomes?

During a routine follow-up visit, you decide to broach the topic of GOC with Adelaide. You refer to her admission and ask, "Do you remember discussing something called code status while you were hospitalized?" She cautiously admits that she does and says, "But I got better, do we have to talk about that?" This is your opening to confidently present the idea of Adelaide using her voice (remember, this is the same idea we touched on in my previous post) and being able to ensure that her wishes are respected. A good beginning goal is to simply have Adelaide name a healthcare proxy (designated person to make healthcare decisions on her behalf) and to provide her with some general information that she can review and share with family. You can explain that designating a person who can be her advocate and voice is like "insurance" that her feelings will always be respected. You also make a plan to continue these discussions at a future visit.

When patients are stable and living in the community, we have an opportunity to have GOC conversations in a controlled environment, with less stress than during a hospital admission and often with an audience who is more relaxed and willing to participate. As a primary care provider, these conversations may flow easier since you have had the opportunity to build trust. To facilitate these conversations, you must understand a patient's disease process and be able to make some generalized prognostications. You should also understand that you may not get "an answer" after 1 conversation—being flexible, informative, and supportive while a patient and their family navigate their options is part of being the GOC conversation facilitator. It is important to remember that, as healthcare providers, we are the vehicles of information—we provide the information that patients and families need in order to make the best decision. That is a vital concept: We provide the information so they can make the best decision for themselves, we are not delineating right or wrong. Every patient's journey is their own, we are simply here to make it the best journey possible and provide support—both emotional and medical—to patients and their loved ones.

Taking the time and committing to these discussions is often the most difficult hurdle in the outpatient setting. Office time is valuable, however if we agree that addressing advanced directives like GOC is as important as counseling a patient regarding their diabetes or hypertension, then we must make the time. Just like we stay up to date with current disease treatment guidelines, we need to educate ourselves on how to facilitate these important conversations. Having providers who recognize the importance of this will serve to improve the future of healthcare by fostering patient-provider relationships built on honesty and trust.

References

Share

Filed under: NPs & PAs

Related
The Importance of Shared Decision-making in Obesity

The Importance of Shared Decision-making in Obesit ...

Many areas of healthcare are starting to talk about the importance of shared decision-making (SDM), ...

Filed under: Cardiometabolic, NPs & PAs


Continue Reading
Addressing ASCVD Risk in HIV: An Update to the DHHS HIV Guidelines

Addressing ASCVD Risk in HIV: An Update to the DHH ...

The incidence of atherosclerotic cardiovascular disease (ASCVD) is estimated to be twice as high in ...

Filed under: Infectious Diseases, Preventive Medicine, Public Health, Cardiometabolic, NPs & PAs


Continue Reading
Did You Miss National Healthcare Decisions Day?

Did You Miss National Healthcare Decisions Day?

An important day on the calendar recently passed, and I am not talking about Tax Day. April 16 is Na ...

Filed under: Miscellaneous, NPs & PAs


Continue Reading
Understanding the Multifactorial Etiology of Obesity and the Metabolic Adaptations to Weight Loss

Understanding the Multifactorial Etiology of Obesi ...

Obesity Causes Overeating, Not the Other Way AroundOne of my favorite quotes from Dr Lee Kaplan is, ...

Filed under: Cardiometabolic, NPs & PAs


Continue Reading
Optimal Assessment and Management of Agitation in Alzheimer’s Disease

Optimal Assessment and Management of Agitation in ...

Agitation in Alzheimer’s disease (AAD) can be a serious safety risk for patients and caregivers. A ...

Filed under: Neurology, Psychiatry, NPs & PAs


Continue Reading
BTK Inhibitors in CLL/SLL and MCL: The Latest Guidance and Evidence for the Clinic

BTK Inhibitors in CLL/SLL and MCL: The Latest Guid ...

Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) and mantle cell lymphoma (MCL) a ...

Filed under: Oncology/Hematology, NPs & PAs


Continue Reading