Commentary: Clarifying Medical Decisionmaking—Who, How, and Why?

2016 ◽  
Vol 25 (3) ◽  
pp. 556-560 ◽  
Author(s):  
Tyler S. Gibb ◽  
Michael J. Redinger
Keyword(s):  
Clinical Ethics ◽  
Goals Of Care ◽  
Code Status ◽  
Clinical Ethicist ◽  
Ethical Complexity ◽  
Ethics Cases

In its simplest interpretation, this is a case about goals of care and appropriate code status. At the outset, we must confess that we found this case to be extremely interesting—not for the novelty of the issues or its ethical complexity but because it is truly a case of the ordinary. Too often when teaching or discussing clinical ethics cases, we are distracted by the exotic and the unusual and ignore the mundane cases that every practicing clinical ethicist must be able to competently manage.1,2,3

Clinical ethics consultation in oncology.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 9121-9121
Author(s):  
Andrew G Shuman ◽  
Sacha M Montas ◽  
Andrew R Barnosky ◽  
Lauren B Smith ◽  
David W Kissane ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Advance Directives ◽  
Professional Education ◽  
Clinical Ethics ◽  
Interpersonal Conflict ◽  
Ethics Consultation ◽  
Clinical Ethics Consultation ◽  
Goals Of Care ◽  
Code Status

9121 Background: There is limited empirical research exploring the nature of clinical ethical consultations within the oncology population. Our objective is to review, describe and compare clinical ethics consultations at two NCI-designated comprehensive cancer centers, in order to identify opportunities for systems improvement in clinical care. Methods: This case series is derived from prospectively-maintained clinical ethics consultation databases at each institution. All adult oncology patients receiving ethics consultation from 2007 through 2011 were included as eligible cases. Both qualitative and quantitative analyses were undertaken. Demographic and clinical information were obtained from the databases for all patients, and verified via chart abstraction. Additional variables studied included the reason for and context of the ethical consultation, the patient’s code status before and after consultation, and involvement of palliative care or other adjuvant services. Opportunities for systems-level improvements and/or educational initiatives were identified. Results: A total of 207 eligible cases were identified. The most common primary issues leading to ethics consultation were code status and advance directives (25%), surrogate decision-making (17%), and medical futility (13%). Communication lapses were identified in 41%, and interpersonal conflict arose in 51%. Prior to ethics consultation, 26% of patients were DNR; 60% were DNR after ethics consultation. Palliative care consultation occurred in 41% of cases. Opportunities for systems improvement and professional education related to goals of care at the end of life, the role of palliative care involvement, and improved communication. Conclusions: Ethics consultations among cancer patients reflect the realities inherent to their clinical management. Appropriately addressing advance directives within the context of overall goals of care is crucial. Thoughtful consideration of communication barriers, sources of interpersonal conflict, symptom control, and end-of-life care are paramount to optimal management strategies in this patient population.

The pyramid of treatment levels: A tool to convey goal-based treatment options.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 147-147
Author(s):  
Heather Leeper ◽  
Andrew Kamell
Keyword(s):  
Decision Making ◽  
Medical Care ◽  
End Of Life ◽  
Symptom Management ◽  
End Of Life Care ◽  
Life Care ◽  
Care Providers ◽  
Goals Of Care ◽  
Code Status ◽  
Wide Range

147 Background: 60% of Americans die in acute care hospitals and under 40% of advanced cancer patients have end-of-life care discussions with their health care providers. Didactic methods and tools to teach about symptom management, navigation of treatment decisions, code status, and end-of-life care decisions within an inpatient setting are a necessity to meet this high demand. Methods: A model of medical care systematically dividing clinical management decisions into escalating levels of medical care relative to illness severity, treatment goals, and code status was created. The model is illustrated as a pyramid with a base of symptom management as the initial level of medical care. The second level represents disease-focused medical care including antibiotics, disease-modifying drugs, and chemotherapy administration. Hospitalization with increasingly complex and invasive interventions represents the third level followed by critical illness care including ICU admission and vasopressors as the fourth level. Intubation comprises the fifth level and CPR forms the top of the pyramid. Results: This model has been used extensively at our institution in educating medical students, residents, fellows, and faculty. All groups reported it was helpful in understanding POLST forms, code status, and collaboratively developing appropriate goal-based care plans with their patients. Symptom management remaining as a non-negotiable foundation of care emphasizes its importance. This depiction of medical care may facilitate goals of care and code status discussions and is particularly helpful for determining appropriate care goals or options when considering de-escalation of medical therapies. Used implicitly or explicitly in patient and family discussions, it has facilitated decision-making and discerning the appropriateness of the overall treatment plan relative to patient goals of care. Conclusions: This model of care with its companion pyramid accommodate a wide range of clinical scenarios, is an effective, high yield didactic device for patients, families, and healthcare providers alike, and has applications as supportive tool to optimize goal-based clinical decision making in the context of serious illness.

scholarly journals The value of history and goals of care with code status; even in an emergency setting

2013 ◽  
Vol 2013 (jan25 1) ◽  
pp. bcr2012006962-bcr2012006962
Author(s):  
A. Irfan ◽  
S. Hublikar ◽  
J. H. Cho ◽  
J. Hill
Keyword(s):  
Emergency Setting ◽  
Goals Of Care ◽  
Code Status

Is there a shift in use of subacute rehabilitation (SAR) instead of hospice referral since immunotherapy became available?

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11530-11530
Author(s):  
Jonathan Yeh ◽  
Louise Knight ◽  
Joyce M. Kane ◽  
Danielle Doberman ◽  
Arjun Gupta ◽  
...  
Keyword(s):  
Cancer Therapy ◽  
Discharge Planning ◽  
Drug Approval ◽  
Do Not Resuscitate ◽  
Post Discharge ◽  
Goals Of Care ◽  
Code Status ◽  
Hospice Referral ◽  
Electronic Chart ◽  
Time Of Admission

11530 Background: Immunotherapy has rapidly become mainstream treatment. Since the first drug approval in 2011, we have noted a decline in referrals from inpatient oncology to hospice, and an increase in referrals to sub-acute rehabilitation (SAR) facilities, possibly with the aim of “getting strong enough” for immunotherapy and other promising drugs. This study explores outcomes after discharge to SAR, including rates of cancer-directed therapy after SAR, overall survival, and hospice utilization. Methods: Electronic chart review of patients discharged from oncology units to SAR facilities from 2009-2017. Demographics, admission statistics, and post-discharge outcomes were gathered from discharge summaries and targeted chart searches. Results: SAR referrals increased from 28 in 2012 to 82 in 2016. Age 66, males 52%, solid tumors 58%. 358 patients were referred to SAR 413 times. 174 patients (49%) returned to the oncology clinic prior to re-admission or death, and only 117 (33%) ever received further cancer-directed treatment (chemotherapy, radiation, or immunotherapy). 219 of 358 (61%) died within 6 months. Only 3 individuals who were not on immunotherapy at time of admission went on to receive immunotherapy after discharge to SAR. Among all discharges, 28% led to readmissions within 30 days. 74 patients (21%) were deceased within 30 days, of whom only 31% were referred to hospice. Palliative care involvement resulted in more frequent do not resuscitate (DNR) code status (33 v 22%), documented goals of care (GOC) discussions (81 v 23%), and electronic advance directives (42 v 28%).(All p<0.05). Conclusions: A growing number of oncology inpatients are being discharged to SAR, but two-thirds do not receive further cancer therapy at any point, including a substantial fraction that are re-admitted or deceased within 1 month. Many patients lose the opportunity to use hospice for optimal end of life care, as few SAR facilities offer this. These data can help guide decision-making and discharge planning that aligns with patients’ goals of care. More clinical data are needed to predict who is most likely to benefit from SAR and proceed to further cancer therapy.

scholarly journals “Hooked up to that damn machine”: Working with metaphors in clinical ethics cases

2019 ◽  
Vol 14 (2) ◽  
pp. 80-86
Author(s):  
Susanne Michl ◽  
Anita Wohlmann
Keyword(s):  
Health Care ◽  
Health Care Professionals ◽  
Clinical Ethics ◽  
Ethical Problem ◽  
Medical Decision ◽  
Frequent Use ◽  
George Lakoff ◽  
Medical Health Care ◽  
Figurative Speech ◽  
Ethics Cases

The frequent use of metaphors in health care communication in general and clinical ethics cases in particular calls for a more mindful and competent use of figurative speech. Metaphors are powerful tools that enable different ways of thinking about complex issues in health care. However, depending on how and in which context they are used, they can also be harmful and undermine medical decision-making. Given this contingent nature of metaphors, this article discusses two approaches that suggest how medical health care professionals may systematically and imaginatively work with metaphors. The first approach is informed by a model developed by cognitive scientists George Lakoff and Mark Turner. The second approach is a close reading and thus a text-immanent, hermeneutical strategy. Using the double perspective of an ethics consultant and a researcher in literature studies, we take a case from Richard M Zaner in which a metaphor is central to the clinical-ethical problem. The article shows that the approaches, which focus on creativity and the intersections of form and content, may be helpful tools in clinical ethics, enabling a competent and mindful working with metaphors in complex cases as well as supporting the consultant’s thoughts processes.

Documentation of code status and discussion of goals of care in gravely ill hospitalized patients

2009 ◽  
Vol 24 (2) ◽  
pp. 288-292 ◽  
Author(s):  
Abigail Holley ◽  
Steven J. Kravet ◽  
Grace Cordts
Keyword(s):  
Hospitalized Patients ◽  
Goals Of Care ◽  
Code Status
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