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Robert M. Veatch, PhD
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From the Kennedy Institute of Ethics, Georgetown University.

CORRESPONDENCE TO: Robert M. Veatch, PhD, Kennedy Institute of Ethics, Georgetown University, Healy Hall, 4th Floor, Washington, DC 20057; e-mail: veatchr@georgetown.edu


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-e185. doi:10.1378/chest.15-2029
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To the Editor:

In her discussion of my counterpoint editorial and rebuttal in CHEST,1,2 Prof Chelluri points out that the words “goals of care” can be confusing. Her problem may be with the word “care.” In normal discourse, it refers to a virtue, a disposition to be a concerned, engaged, compassionate person. But in medicine, it is also a synonym for “treatment.” Hence, a “health-care delivery system” may not always feature “caring.”

If “care” refers to “treatment,” it should be easy to distinguish a treatment from its goals. If that is the meaning of the terms, then I agree with Prof Chelluri that the distinction between a treatment and the goal of the intervention is important. The former is a matter of medical fact; the latter is in the realm of values. Prof Chelluri makes a key point: Physicians should not be expected to know the patient’s goals. Hence, physicians are going beyond their expertise in offering advice about the goals of medical intervention.

There is a complication, however. Once patients have stated their goals, it is reasonable for the physician to suggest treatments consistent with those goals. Both patients and physicians may mistakenly believe that the physician is the expert on picking the treatment appropriate for achieving the patient’s goals. Typically, however, more than one treatment may, with varying degrees of probability, be expected to achieve various elements of the stated goal. The physician may have to negotiate with the patient to clarify and state the goal more precisely. The patient who says he or she wishes to live at all costs probably does not really mean that. The physician could consider various treatment options, including those, for example, that are extremely expensive, painful, inconvenient, and unaesthetic. In such a case, physicians need to ask patients to formulate their goals more precisely; this makes advising patients problematic.

Prof Chelluri points out that this is made more complicated by the fact that patients are often not competent to respond contemporaneously to such probes. Surrogates may be necessary. We have well-worked-out standards for surrogate decisions. We rely first on the patient’s own previously expressed views (as in an advance directive), then on surrogate estimates of what the patient would have wanted based on his or her own values, and finally, on surrogate judgment of what is best for the patient. In any case, there is no reason to assume that physicians’ judgments of the proper goals for the patient should be relied on.

References

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]
 
Veatch RM. Rebuttal from Dr Veatch. Chest. 2015;147(6):1458-1459. [CrossRef] [PubMed]
 

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References

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]
 
Veatch RM. Rebuttal from Dr Veatch. Chest. 2015;147(6):1458-1459. [CrossRef] [PubMed]
 
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