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Correspondence |

Goals of CareGoals of Care: Role of Physicians in the ICU FREE TO VIEW

Lakshmi P. Chelluri, MD, FCCP
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From the Department of Critical Care Medicine, University of Pittsburgh School of Medicine.

CORRESPONDENCE TO: Lakshmi P. Chelluri, MD, FCCP, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 641 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261; e-mail: chelluril@upmc.edu


Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.

CONFLICT OF INTEREST: None declared.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):e184. doi:10.1378/chest.15-1861
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To the Editor:

Experts seem to disagree about the meaning of the words “goals of care,” as indicated by the point/counterpoint editorial discussion in CHEST (June 2015).1-4 “Goals of care” may mean goals/values of patients to some, to others it is the treatments that achieve the goals, or to some others it means both. Physicians do not know the values/goals of the patients, particularly in the ICU, where the physician is interacting with patient/family for the first time. Physicians should not presume that they do know patients’ values/goals, although sometimes we do assume that a particular level of quality of life is not desirable and think that it is not desired by the patient. It may help if we separate discussion of “goals” from “care” that would achieve the goals and avoid the phrase “goals of care” to clarify the issue better. The distinction between values/goals and treatments that could achieve them should be emphasized, and these (ie, goals and treatments) need to be addressed separately because physicians, particularly trainees, focus on treatments (CPR/do not resuscitate, intubation/mechanical ventilation, and other life-sustaining therapies) rather than identifying goals and offering treatments that achieve the desired goals.

The difficulty in obtaining the goals and uncertainty about prognosis make these discussions difficult, particularly when the surrogate is the decision-maker. Discussions about death and dying are difficult for both patients/families and caregivers.5 A paradigm change with a focus on defining the goals/values, when it can be done, and then a focus on the treatments that could achieve the goals (short-term/long-term) is needed. These discussions need time and coordination between various health-care personnel, and an individual with a focus on coordinating the discussions could help facilitate the process. Finally, we need to reframe the question; we should ask “how do you want to live,” rather than “do you want to live,” which is the question we are actually asking when we discuss CPR and life-sustaining therapies.6

References

Hutchison PJ. Point: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? Yes. Chest. 2015;147(6):1453-1455. [CrossRef] [PubMed]
 
Veatch RM. Counterpoint: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? No. Chest. 2015;147(6):1455-1457. [CrossRef] [PubMed]
 
Hutchison PJ. Rebuttal from Dr Hutchison. Chest. 2015;147(6):1457-1458. [CrossRef] [PubMed]
 
Veatch RM. Rebuttal from Dr Veatch. Chest. 2015;147(6):1458-1459. [CrossRef] [PubMed]
 
Kalson S. We spend too much in dying. Pittsburgh Post-Gazette. April 7, 2013. http://www.post-gazette.com/stories/opinion/sally-kalson/we-spend-too-much-in-dying-682431/. Accessed July 15, 2015.
 
Kaminsky M. A doctor discovers an important question patients should be asked. Washington Post. March 9, 2015. http://wapo.st/1Mny00x. Accessed July 15, 2015.
 

Figures

Tables

References

Hutchison PJ. Point: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? Yes. Chest. 2015;147(6):1453-1455. [CrossRef] [PubMed]
 
Veatch RM. Counterpoint: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? No. Chest. 2015;147(6):1455-1457. [CrossRef] [PubMed]
 
Hutchison PJ. Rebuttal from Dr Hutchison. Chest. 2015;147(6):1457-1458. [CrossRef] [PubMed]
 
Veatch RM. Rebuttal from Dr Veatch. Chest. 2015;147(6):1458-1459. [CrossRef] [PubMed]
 
Kalson S. We spend too much in dying. Pittsburgh Post-Gazette. April 7, 2013. http://www.post-gazette.com/stories/opinion/sally-kalson/we-spend-too-much-in-dying-682431/. Accessed July 15, 2015.
 
Kaminsky M. A doctor discovers an important question patients should be asked. Washington Post. March 9, 2015. http://wapo.st/1Mny00x. Accessed July 15, 2015.
 
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