"Has Anything Changed Since Then?": A Framework to Incorporate Prior Goals-of-Care Conversations Into Decision-Making for Acutely Ill Patients.

Abstract

When assuming care for a seriously ill hospitalized patient, we should find documentation of previous decisions about goals of care so that our conversation takes advantage of previous discussions and reduces decision-making burden on the patient, particularly when the patient is clinically declining and time is short. This article presents a framework to help clinicians incorporate prior goals of care conversations into decision-making for an acutely ill patient. When there is strong evidence that a previous decision still applies, clinicians should, after a brief check-in about the previous decision with the patient, then present a plan consistent with their previous decision as a default option, to which they can opt out. If there is less evidence of the basis for a previous decision, clinicians should explore the thinking behind the decision and, if there is clarity about patient preferences, propose a treatment plan. If there is conflict or uncertainty about the patient's preferences, clinicians should engage in a more comprehensive goals-of-care conversation, which involves exploring the patient's understanding of their illness, patient values, and reasonable treatment options, before offering a plan. By giving the patient the ability to opt out of a previous decision they made about goals of care, rather than another choice, we make it more likely that they will receive care consistent with their known wishes.