Plan

Essential Option in Serious Illness

Not all patients/families want aggressive interventions (medications/surgery etc…) for disease.
Always offer maximal symptom control and allowing natural disease progression.
Be prepared to support patients decision.

Talk tip: “Although we may be able to manage this disease, you can always decide to focus on therapies to control your symptoms, and allow the disease to take its natural course.”

Intervention info for patients and families

Here’s what the patient and family needs to know. How will the intervention affect:

length of life
ability to maintain current health
ability to think and function (i.e. cognitive impairment)

What is involved in the intervention:

potential complications
potential burden/suffering

CPR outcome statistics

Cardiopulmonary resuscitation may be available in some hospitals. Based on the patient’s current medical situation, CPR may or may not be recommended. To inform discussion with patient/family:

Survival to discharge from hospital for in-hospital cardiac arrest

all conditions: 15-22%
pre-existing major trauma: 3.9%
pre-existing septicemia: 13.5%
pre-existing early metastatic cancer: 13.5%
pre-existing stroke: 4.1%
pre-existing dialysis: 3.9%
Of the patients discharged 28.1% had clinically significant neurological disability.

Talk tip: if CPR not recommended, “We’ll do everything we can to help you live as well as you can for as long as you can, but when you die, we’ll help you have a peaceful and natural death.”

Talk tip: for patients who may not understand the percentage figures above, “Out of 100 patients in hospital who have a cardiac arrest, about 18 people will live to discharge. The other 82 people will die. And of those 18 people who leave the hospital, almost 5 will have brain damage.”

Goals of care

Typical goals of care:

live longer or stay alive
improve or maintain function, quality of life, independence
be comfortable
achieve life goals
support family and loved ones

May be helpful to ask patient to identify which are the most important and why.

Ask patient about specific life goals (e.g. live to daughter’s wedding, birth of grandchild).

Talk tip: See Communication section on Goals of Care discussion.

Reconsider medications in advanced illness

Consider whether to continue or stop medications depending on the following questions for each medication: What is the treatment target for medication?:

prevention/risk reduction of disease
life prolongation
prevention of morbidity/mortality
maintenance of current function/state
treatment of acute illness
symptom control

Is the treatment target in keeping with patient/family goals of care?

What is the time to benefit for the medication?

(symptom control opioids=short, statins for prevention of stroke=several years, controlling blood sugar to prevent complications = more than 5 years)

Will the patient live long enough to benefit from this medication?