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Hi Momita, I'm running so late I barely have time to finish coffee my coffee.
Well, have a good day mom. Don't work too hard.
I'll see you later. You going to be ok? I'll be ok.
Oh, my purse. On the table. Gracias momita, see you later.
bye, bye.
Mrs. Flores is a 78-year-old woman with a two-year history of breast cancer
refractory to treatment including chemotherapy and radiation
which is now metastasized to her spine
and lungs. Her functional status has been declining significantly over the past
several months she presents today for follow up with her PCP
For patients there are numerous possible
goals for health care including being
cured, living longer, improving or maintaining functional quality of life,
being comfortable, achieving life goals,
providing support for family or caregiver. Patients and families
experiencing life threatening illness usually have
very personal hopes and goals for their lives.
Initially they may hope that nothing is wrong
that the diagnosis is not true. As they realize
more the meaning of the illness many will hope for a cure and long life.
As each patient realizes that the illness will likely take his or her life
most will hope for the support to relieve suffering and improve
both quality and quantity of life. As their hopes
change so can their goals for care and their priority for treatment.
That is why clinicians should clarify
patient and families goals for care and current treatment priorities
before developing or negotiating any plan of care.
My understanding is that Mrs. Flores is
no longer responding much to her cancer treatments so I would like to discuss
the big picture
or goals of care with her during my visit today.
Once I understand her goals
I can make better treatment recommendations
and I can make these based on Mrs. Flores goals.
Our collaboration will be strengthened and I will no longer be at risk for
providing treatments that will be inconsistent
with her goals.
Good morning Mrs. Flores, good to see you again
how you doing? Well not so good
I'm got some bad news from my cancer doctor.
Please tell me what they told you. Basically they've said that
in spite of all my cancer treatments the cancer is still spreading
and I'm not doing so well.
My cancer doctors tell me that there's no
further treatment he can give me.
I'm so sorry to hear that
from what I reviewed as well it seems that
the cancer has spread to your spine and your lungs.
Your oncologist, your cancer doctor
is even worried that any further treatment with chemotherapy
may just make you even sicker. You seem frustrated
this must been so hard for you.
Well why is this happening?
I've done all up the treatments that they said would make me better.
I know you did everything right.
I'm very disappointed too. We're here to do everything that we can for you Mrs. Flores.
Thank you, Thank you.
When discussing goals of care with my patients
I consider the following four steps. Step 1:
the right setting. I will create the right setting
by reserving a room with privacy and making sure I have scheduled
enough time. I also keep my phone and pagers
off to minimize interruptions. Step 2:
Clarify understanding of the medical problem.
Next, I will try to confirm my patients
understanding about his or her illness. This will be a good time to address
misconceptions or provide information so that we are all
on the same page. Step 3:
Ask about personal goals for health care.
Elicit big picture goals or values. I then
transition to discuss about goals. I may ask about the impact of the illness
on their future or ask their personal goals of care with an open-ended
question such as: please tell me what your goals of care are for this
hospitalization.
I me ask followup questions like
what are you expecting during this hospitalization
or ask closed ended questions using the different goals of care categories.
Step 4: Recommend a care plan that addresses goals values and concerns.
I then offer to make a recommendation to discuss treatments consistent with the
patient's goals
values and verified that they are acceptable.
Thinking about the future with this
illness do you have any concerns?
All, I can't keep running back and forth to the doctors every day
It's too much for me.
What are you expecting are hoping
with your health care?
Well, I want to stay at home be comfortable
and when the time comes
I want to be around my family. From my experience
I'm very aware that different people can
have different goals for their health care and I think that your goals
are very reasonable
Mrs. Flores. We'll do everything we can to keep you comfortable
at home. Now that
I understand more about your situations let's
take a look at the treatment plans that will allow you to work
towards your goals. Is it okay for me to make a recommendation?
Yes please. I will recommend that
we start home hospice. Have you ever had experience with hospice before?
Yes. my husband had hospice when he was dying.
They were very helpful. The hospice
team well especially help control your pain
your symptoms to allow you to remain
comfortable at home. They will also assist
in relieving some of the burdens on your family.
Does that sound like a reasonable plan to you Mrs. Flores?
Yes. I'm feeling some hope this conversation
Thank you thank you doctor.
Mrs. Flores, I will update your daughter
over the phone about what we've just discussed. If you or your family has any questions
please feel free to call me or we can plan to meet again.
Yes please.
Meja
Momita. Did you forget something?
No, I just decided to take a little time off today.
So, make some more coffee?
Yes, together.