Palliative Care

Getting a handle on goals of care


She presented to the trauma bay after transfer from another hospital. She had fallen out of bed at the nursing home, and they had sent her to the emergency department for evaluation. Her head CT demonstrated a subacute chronic subdural hematoma. She had fallen a month ago and had been seen at the same hospital and was transferred to us then, too, but not as a trauma. Admitted to another service for a few days, she had subsequently been sent to the nursing home with weekly head CT scans for follow-up. Today’s CT showed continued resolution of her subdural hematoma, but since she had fallen and had an abnormal CT scan, she was transferred to us as a trauma for further evaluation.

Dr. Christine Toevs

The patient was elderly, in her 90s, with end-stage dementia. The trauma team descended on her as we do with all traumas – to evaluate for life-threatening injuries. Airway, breathing, circulation. Does she need to be intubated? What is her blood pressure? Place IVs and draw blood. Put her quickly on the monitors, undress her completely. Roll her on her side to examine her back. Make sure she is in a rigid C-collar and cannot move her neck until we are sure it isn’t fractured. She cannot sit up despite her desire to do so, thus requiring us to hold her down, so she doesn’t injure herself or others. In the midst of all this, she kept screaming, "Why do you keep doing this to me?" That was all she said. Repeatedly. As I sorted out the events of the past month, read the radiologist report from the referring institution that documented improvement in her scans, and reviewed all the CTs on disc, I wondered the same, "Why are we doing this to you?" She didn’t need a trauma center or the trauma team. What she needed was a goals of care discussion and POLST (Physician Orders for Life-Sustaining Treatment) document.

We, as doctors, are poor at discussing goals of care. Even for those patients who are expected to do well, we do not address code status, or ask them what they want if things go poorly. Recently, the University of California published their results with a quality improvement program to document advance care planning discussions. Between July 2011 and May 2012 on the medical service, they created an incentive program for documentation of goals of care and identification of a surrogate decision maker. If 75% of patients had the two items documented in the medical record, then the residents received a $400 incentive. Documentation (and likely actual discussion) increased from 22% in July to 90% by October and remained at that level. There were reminders and feedback, and it seems likely a component of peer pressure among the residents to ensure everyone received the incentive. The study did not track outcomes or documentation rates after the program was over. The study did show that behavior of initiating difficult end-of-life (EOL) planning discussions can be improved in a quality improvement program. (JAMA Intern. Med. 2013 [doi: 10.1001/jamainternmed.2013.8158]).

Ideally, the next step would be to document the use of POLST ( orders. POLST is a bright pink form that documents the patient’s preferences for code status, treatment options (full including ICU, limited, or comfort measures including no transport to hospital) artificial nutrition and hydration, and antibiotics. POLST is signed by a physician and, therefore, it can be applied across care settings. If it is signed by the patient, it cannot be overridden by the surrogate, and there are legal protections for health care providers.

We admitted the patient in the trauma bay, not because she needed acute care, but because she needed goals of care defined. We consulted Palliative Medicine and had the social worker identify a decision maker. Palliative Medicine worked with the surrogate decision maker to set goals of care: feeding tube, follow-up scans, code status, and most importantly POLST orders. Regrettably, it took a trip to the Trauma Bay after multiple interactions with the health care system to evaluate what really was in the best interest of the patient and what she would have wanted. She told us as best she could that she did not want what we were doing to her. This time, we listened.

Dr Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh, Pa. She has a Masters degree in bioethics and board-certification in hospice and palliative medicine.

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