Goals of Care. Cancer Education Day. January 13, Wally Liang MD, CCFP(COE), JD, MHSc

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1 Goals of Care Cancer Education Day January 13, 2017 Wally Liang MD, CCFP(COE), JD, MHSc

2 none Conflict of Interest

3 Goals of Advance Directives Promote patient autonomy Prevent interventions that are not desired by patients and are not anticipated to be beneficial if not outright harmful Wishes patients make while they are capable and in a different health situation 11/01/2017 3

4 Challenges with Current Process Patient autonomy Disagreement Binary choices DNR or Resuscitate Does that mean patients are less assiduously cared for and denied potential life-prolonging therapies other than CPR? Medical error or reversible conditions? 11/01/2017 4

5 Advance Care Plans Only a wish list Not a consent form The audit 2013 Less than 50% has DNR sheet on chart Less than 40% done by patients Less than 15% done by SDMs Less than 15% SDM properly identified Less than 10% documented a discussion 11/01/2017 5

6 ER Do not rely on advance care plan documents from patients Do not rely on Level of Care from LTC Must obtain informed consent from the patient (if capable) or the SDM (if incapable) in any non emergent cases Initiate the discussion 11/01/2017 6

7 CPSO Policy 4-15 Physicians must obtain consent to withdraw life sustaining treatment. 42 Physicians cannot make a unilateral decision to withdraw life sustaining treatment Law is unclear regarding consent for a no-cpr order Physicians cannot make a unilateral decision on no CPR order CPSO requires the physicians to discuss with the patient or her SDM at the earliest and most appropriate opportunity when a no-cpr order is being considered.44 11/01/2017 7

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11 Proposed Goals of Care A patient centric approach that integrates patient s values, wishes and goals in the context of medically appropriate treatment It provides the framework and tools for clinicians to be able to meet the criteria of this policy It provides resources for individuals and families to engage in advance care planning The Goals of Care are based of Advance Care planning conversations 11/01/

12 Windsor Regional Hospital 11/01/2017 university Health Network 12

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17 Windsor Regional Hospital 11/01/2017 university Health Network 17

18 Tracking Form A tracking record Goals of care conversations Core elements of discussion Date of discussions Participants in the discussions Key decision and outcomes 11/01/

19 Goals of Care Designation that can capture broad goals that are agreed to by the patients and their care teams Life prolonging or sustaining therapy with use of interventions available in ICU(R), curative or sustaining medical therapy without the use of ICU(M) Comfort care focus on symptom management(c) 11/01/

20 Goals of Care Capture the conversation Allow room for explanation Flexibility Approach from the perspective of LIFE and how to better life vs. an act to terminate life Reflective of the conversation so it will not be buried in the medical records 11/01/

21 Goals of Care and the Family Doctor s Office Robinson C et al. Awareness of Do-Not-Resuscitate Orders: What do patients know and want? Can Fam Physician 2012; 58: e patients over age 40 presenting for routine primary care visit in Vancouver, BC 86% chose family doctors as among the people with whom they most wished to discuss DNR decisions 56% believed that initial DNR discussion should occur while healthy 46% felt the office setting was most appropriate Only 8% of patients who were aware of DNR had ever discussed it with a health care provider Only 16% of patients found this topic stressful 11/01/

22 Goals of Care and the Family Doctor s Office Potentially valuable site for starting the discussion about advance care planning before arrival in hospital Prompts patient to start thinking about values, beliefs, goals of care, choice of SDM Lack of incentives: need a billing code for end-of-life discussion/planning in Ontario Speak Up Advance Care Planning Workbook for Ontario ( 11/01/

23 Summary Although not a panacea for ethical dilemmas They are an improvement over resuscitate or DNR orders and prior conversations details buried in the health records The frameworks are implemented with advance care planning initiatives normalizing early reflections and communications, which can assist in health care decision making 11/01/

24 Q&A