Clinical Pearls & Morning Reports
For too long, we as health care providers have erred in not giving patients enough guidance about resuscitation decisions. We often enable decisions that we do not think will be helpful to patients because we are wary of expressing our genuine concerns about the likelihood of benefit. Read the latest NEJM Case Records of the Massachusetts General Hospital here.
Q: How is advance care planning best understood?
A: Advance care planning is a complex process. It is not only about preparing for incapacity and death; it also has social elements. It is about maintaining personal relationships, relieving burdens placed on others, and preparing patients and families for the decisions and conflicts they may encounter.
Q: How is patient autonomy best protected when decisions about cardiopulmonary resuscitation (CPR) and intubation need to be made?
A: Patients who face serious illness have conflicting emotional and informational needs. Even though they may give the impression of wanting to avoid poor prognostic information, they often want regular and honest communication about likely outcomes so that they can prepare. By negotiating this complexity, clinicians create deeper and more meaningful relationships with their patients. These engaged relationships require clinicians to be sensitive to the amount of information the patient wants to hear. They also require clinicians to share medical opinions and to be open about biases. Clinicians should be accepting when the patient disagrees and should stay connected despite any differences. This relationship-centered process relies on honest communication by both parties — the patient and the clinician. It has been called an enhanced autonomy model, based on the assumption that patient autonomy is best protected by an open dialogue.
A: Shared decision making is an approach we take when the patient’s illness is advancing and it is unclear whether the benefits of CPR and intubation would outweigh the burdens, because at this point the decision depends heavily on the patient’s values and goals. During shared decision making, we discuss medical options in the context of the patient’s values and goals to understand the patient’s informed preference — not just a first reaction, but a decision that has been informed by thoughtful consideration of the good and bad consequences of the options. We use shared decision making until the patient becomes so sick that we are convinced that CPR or intubation is highly unlikely to be beneficial, and then we shift to a different approach.
A: If the patient is at risk for decompensation and death and our clinical judgment is that CPR or intubation is unlikely to be beneficial, then we shift to an informed-consent conversation in which we focus on our assessment of the low likelihood of benefit and the high risk. With an understanding of the patient’s values and goals, we disclose that, because the patient is so sick, some treatments are highly unlikely to be beneficial. We make recommendations for treatments that we think will help and against treatments that are unlikely to help. These conversations are difficult because they mix shared decision making with disclosures of life-altering news. We are giving patients the information that they are very sick, perhaps sicker than they thought, and that treatments that once may have been helpful are now unlikely to prolong survival and result in an acceptable quality of life.