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Lauris C. Kaldjian, MD, PhD; Thomas G. Gehlbach, MD; Karl W. Thomas, MD, FCCP; Gregory A. Schmidt, MD, FCCP
Author and Funding Information

From the Program in Bioethics and Humanities (Dr Kaldjian), Division of General Internal Medicine (Dr Kaldjian), Division of Pulmonary Diseases, Critical Care, and Occupational Medicine (Drs Thomas and Schmidt), University of Iowa Carver College of Medicine; and the Dean Clinic (Dr Gehlbach), Madison, WI.

Correspondence to: Lauris C. Kaldjian, MD, PhD, Program in Bioethics and Humanities, 1-106 MEB, University of Iowa Carver College of Medicine, 500 Newton Rd, Iowa City, IA 52242; e-mail: lauris-kaldjian@uiowa.edu


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):1126-1127. doi:10.1378/chest.11-3186
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To the Editor:

We thank Mr Allen and Dr Jesus for their efforts to engage some of the issues raised by our study.1 One concern pertains to whether differences between a patient’s code status preference and a surrogate’s understanding of that preference might account for some discrepancies between their expressions of the patient’s preferences and their actual code status orders. First, we agree that surrogate decision making for previously capable adults is expected to follow a standard of substituted judgment so that surrogates represent their loved one’s preferences, not their own. Second, it is important to emphasize that when a surrogate served as a participant in our study it was because he/she was the patient’s legally authorized decision maker. Whether surrogates’ expressions of patients’ preferences were accurate, those expressions would in fact serve as the basis for decision making unless a patient’s physician had independent knowledge of a patient’s previously expressed wishes or had reason to question the validity of a surrogate’s decision making.

Regarding the literature-based goals of care we used,2 we agree that their interrelationships caution against overinterpretation of differences between goals of care identified as most important by physicians as opposed to patients/surrogates. In terms of impact on clinical decision making, there may not be, for instance, a clinically meaningful difference between wanting to achieve a specific life goal vs simply wanting to live longer (though personal significance for patients may vary when a highly valued life goal is at stake).

Last, we agree that different goals of care often are and should be pursued simultaneously. Early in the course of a disease trajectory it is common to pursue cure, longer life, increased function, and comfort. Even in incurable conditions, it is common (at least for some time) to pursue longer life, increased function, and comfort. However, it is also true that sometimes some goals of care are mutually incompatible and need to be prioritized,3,4 such as when a patient has to choose between comfort (resulting in an earlier death) and cure (resulting in a more burdened life) or between being alert (resulting in the ability to communicate with loved ones) and sedated (resulting in greater comfort and the ability to sleep). Since patients must at times choose between multiple preferred goals, we believe it is sometimes clinically necessary to engage patients in dialogue to learn which goal is most important to them.

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]
 
Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Care. 2008;256:501-511 [CrossRef] [PubMed]
 
Gillick M, Berkman S, Cullen L. A patient-centered approach to advance medical planning in the nursing home. J Am Geriatr Soc. 1999;472:227-230 [PubMed]
 
Bradley EH, Bogardus ST Jr, Tinetti ME, Inouye SK. Goal-setting in clinical medicine. Soc Sci Med. 1999;492:267-278 [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]
 
Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Care. 2008;256:501-511 [CrossRef] [PubMed]
 
Gillick M, Berkman S, Cullen L. A patient-centered approach to advance medical planning in the nursing home. J Am Geriatr Soc. 1999;472:227-230 [PubMed]
 
Bradley EH, Bogardus ST Jr, Tinetti ME, Inouye SK. Goal-setting in clinical medicine. Soc Sci Med. 1999;492:267-278 [CrossRef] [PubMed]
 
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