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Correspondence |

The Language of Goals of CareFraming Preferences at the End of Life: Framing Preferences at the End of Life FREE TO VIEW

Matthew B. Allen, BA; John E. Jesus, MD
Author and Funding Information

From the Department of Emergency Medicine (Mr Allen), Brigham and Women’s Hospital; and Department of Emergency Medicine (Dr Jesus), Christiana Care Health Services.

Correspondence to: John E. Jesus, MD, Department of Emergency Medicine, Christiana Care Health Services, 4755 Ogletown-Stanton Rd, Newark, DE 19718; e-mail: jjesus@christianacare.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(4):1126. doi:10.1378/chest.11-2883
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To the Editor:

We were pleased to learn about the efforts of Gehlbach et al1 in “Code Status Orders and Goals of Care in the Medical ICU.” We applaud the questions posed by this contribution to CHEST (April 2011), and feel the authors’ framing of these issues raises interesting points for further discussion.

One consideration relates to the decision to combine patients and surrogates into a single population, “patients/surrogates.” While we acknowledge the critical care setting frequently necessitates discussion with surrogates rather than patients, we feel it might be problematic to treat these populations as interchangeable in studying patient preferences and how they differ from code status. Code status orders are usually intended to represent patients’ wishes, not those of surrogates, and a large trial demonstrated that patient and surrogate wishes frequently differ.2 We wonder whether the recorded discrepancies between preferences and code status might reflect latent differences between patients and surrogates in addition to confusion and miscommunication.

Another point relates to the discussion surrounding discrepancies in goals of care between physicians and patients. The authors conclude that discrepancies exist in 67.7% of cases, but we are curious as to whether they considered that physicians and patients might use different language to express goals that are closely related or even in agreement from a clinical perspective. For example, the results show that patients are more likely to prioritize achieving life goals, whereas physicians are more likely to prioritize prolonging life. These goals appear to overlap in many clinical scenarios, yet this distinction accounts for the two most significant subsets of discrepancies between physician and patient priorities.

Finally, we are curious about the decision to prompt patients, surrogates, and physicians to identify a single goal of highest priority, particularly in framing the relationship between curative and palliative therapy. While it is true that many physicians view these approaches as mutually exclusive, recent studies have indicated a simultaneous care model may provide substantial benefits, including prolonged life.3,4 Attending to patients’ comfort may actually help them live longer.5 We are concerned that framing goals of care in terms of singular priorities risks propagating a notion of care as either palliative or curative and may impede integration of these approaches to patient care. We thank Gehlbach et al1 for their thoughtful investigation of these issues and their ongoing commitment to the task of improving current practice.

Gehlbach TG, Shinkunas LA, Forman-Hoffman VL, Thomas KW, Schmidt GA, Kaldjian LC. Code status orders and goals of care in the medical ICU. Chest. 2011;1394:802-809 [CrossRef] [PubMed]
 
Layde PM, Beam CA, Broste SK, et al. Surrogates’ predictions of seriously ill patients’ resuscitation preferences. Arch Fam Med. 1995;46:518-523 [CrossRef] [PubMed]
 
Fadul N, Elsayem A, Palmer JL, et al. Supportive versus palliative care: what’s in a name? A survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer. 2009;1159:2013-2021 [CrossRef] [PubMed]
 
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;3638:733-742 [CrossRef] [PubMed]
 
Kelley AS, Meier DE. Palliative care—a shifting paradigm. N Engl J Med. 2010;3638:781-782 [CrossRef] [PubMed]
 

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References

Gehlbach TG, Shinkunas LA, Forman-Hoffman VL, Thomas KW, Schmidt GA, Kaldjian LC. Code status orders and goals of care in the medical ICU. Chest. 2011;1394:802-809 [CrossRef] [PubMed]
 
Layde PM, Beam CA, Broste SK, et al. Surrogates’ predictions of seriously ill patients’ resuscitation preferences. Arch Fam Med. 1995;46:518-523 [CrossRef] [PubMed]
 
Fadul N, Elsayem A, Palmer JL, et al. Supportive versus palliative care: what’s in a name? A survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer. 2009;1159:2013-2021 [CrossRef] [PubMed]
 
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;3638:733-742 [CrossRef] [PubMed]
 
Kelley AS, Meier DE. Palliative care—a shifting paradigm. N Engl J Med. 2010;3638:781-782 [CrossRef] [PubMed]
 
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