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second level
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/div>
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le
E
C
Module 7:=
Goals
of Care
© EPEC Project, 2003
Permission to reproduce for educational purposes granted
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![](3D"master07_background.gif")
![](3D"master07_image001.gif")
![](3D"master07_image002.gif")
E
P
E
C
P
E
C
=
Goals
of Care
Module=
7
![](3D"master06_background.gif")
![](3D"master06_image003.gif")
Objectives . . .
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.23%'>•Understand
the different goals and how they interrelate and change
=
•Understand how to use =
the
7-step protocol to negotiate goals of care
•Be able to communicate
prognosis and its uncertainty
•Understand how to tell=
the
truth and identify reasonable hope
. . .
Objectives
<=
span
style=3D'font-weight:normal'>•Be able to use language
effectively
•Be able to set limits =
on
unreasonable goals
•Be able to adjust care and communication
according to culture
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.44%'>•Understand
how to identify goals when patient lacks capacity
Introduction . . .
•E=
very
one has a personal sense of
who we are
what we like to do
control we like to have
goals for our lives
things we hope for
. . .
Introduction
•Hope,
goals, expectations change with illness
•Physician’s role =
to
clarify goals, treatment plan
Potential goals of care
<=
span
style=3D'font-weight:normal'>•Cure of disease
<=
/span>
•Avoidance of <=
span
style=3D'position:absolute;top:23.46%;left:9.84%;width:77.55%;height:8.66%=
'>premature
death
•Maintenance
or improvement in function
<=
span
style=3D'font-weight:normal'>•Prolongation of life&#=
13;
<=
span
style=3D'font-weight:normal;visibility:hidden'>•=
<=
span
style=3D'font-weight:normal'>•Relief of suffering=
3;
<=
span
style=3D'font-weight:normal'>•Quality of life
<=
/span>
<=
span
style=3D'font-weight:normal'>•Staying in control
=
;
<=
span
style=3D'font-weight:normal'>•A good death
•Support=
for
families and loved onesHistorically, a dichotomous
division of goals of care
![](3D"slide0036_image004.gif")
Relieve suffering (hospice)
![](3D"slide0036_image005.gif")
Curative /
life-prolonging therapy
![](3D"slide0036_image006.gif")
![](3D"slide0036_image007.gif")
Presentation<=
/b>
Death
Figure 1: A dichotomous intent
Multiple goals of care
•Multiple
goals often apply simultaneously
• Goals are often
contradictory
•Certain goals may take
priority over others
Goals may change
•S=
ome
take precedence over others
•T=
he
shift in focus of care
is gradual
is an expected part of the continuum of medical
care
![](3D"slide0039_image008.gif")
U=
sually
S=
ometimes
N=
ot
usually
Bereavement support
Y=
es
Y=
es
Y=
es
Advance care plann=
ing
Y=
es
Y=
es
Y=
es
Support for family=
P=
rimary
B=
alanced
S=
econdary
Symptom
prevention/relief=
P=
robably
N=
o
N=
o
Hospice candidate =
P=
robably
not
P=
robably
Y=
es
Preference for CPR=
“Accept”
“Fight”
“Win”
Psychological attitude
M=
inor-none
M=
ajor-moderate
M=
ajor
Acceptable
adverse efects=
A=
void
complications <=
span
style=3D'mso-bidi-font-family:Arial'>
A=
rrest
progression
E=
radicate
Impact on disease =
Symptomatic Palliative<=
/span>
Life-Prolonging Palliative<=
/span>
Curative
Aspect of Care
Primary Care Goal
Primary
Emphasis of Care for Those with Different
Goals
Related to Life-threatening Illness or Injury
Adapted f=
rom:
Institute of Medicine. Approaching Death:
Improving
Care at the End of Life. Washington, DC: National Academy Press; 1997:83.=
![](3D"slide0037_image009.gif")
![](3D"slide0037_image010.gif")
Curative /
life-prolonging therapy
Presentation<=
/b>
Death
![](3D"slide0037_image011.gif")
Relieve suffering (palliative care)
<=
span
style=3D'font-family:Arial;font-size:117%;text-shadow:auto;color:white;
mso-color-index:0'>Figure 2: The interrelationship of therapies with curative and palliative intent
Palliative care: expanding =
the
options . . .
. .
. Palliative care: expan=
ding
the options
7-step
protocol to
negotiate goals of care . . .=
negotiate goals of care . . .=
l1. Create the right setting
l2. Determine what the pa=
tient
and family know
l3. Explore what they are
expecting or hoping for
. . . 7-step protocol to
ne= gotiate goals of care
ne= gotiate goals of care
l4. Suggest realistic goals
l5. Respond empathically
l6. Make a plan and follow-through
l7. Review and revise
periodically, as appropriate
Communicating prognosis
•M=
arkedly
over-estimate prognosis
•He=
lps
patient / family cope, plan
increase access to hospice, other services
•Of=
fer
a range or average for life expectancy
Truth-telling and maintaining
hope
•False
hope may deflect from other important issues
•True clinical skill to
help find hope for realistic goals
Language with unintended consequences
•Do you want us to do everything possible?
therapy
<=
span
style=3D'font-size:97%;font-weight:normal'>•Will you agree to discontinue care?
<=
span
style=3D'font-size:97%;font-weight:normal'>•It’s time we talk about pulling back
•I think we should stop aggressive <=
span
style=3D'font-size:97%;font-weight:normal'>•I’m going to make it so he won’t suffe=
r
Language to describe
the goals of care . . .
the goals of care . . .
•I
want to give the best care possible until the day you die
=
=
•We will concentrate on
improving the quality of your child’s life
<=
span
style=3D'position:absolute;top:51.98%;left:4.7%;width:79.84%;height:9.74%'=
>•We want to help you li=
ve =
meaningfully
in the time that you have
Language
to describe
the goals of care . . .
the goals of care . . .
•I’ll
do everything I can to help you maintain your
independence
•I
want to ensure that your father receives the kind of
treatment he wants
•Your child’s comfort and dignity w=
ill be my
top priority
. . .
Language to describe
the goals of care
the goals of care
•I
will focus my efforts on treating your symptoms
=
•Let’s discuss wha=
t we
can do to fulfill your wish to stay at home
•Let’s discuss wh=
at
we can do to have your child die at home
Cultural differences
Determine specific priorities
•Based
on values, preferences, clinical circumstances
•Influenced by informat=
ion
from physician, team members
Reviewing goals,
treatment priorities
treatment priorities
•G=
oals
guide care
•A=
ssess
priorities to develop initial plan of care
<=
/div>
The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
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The Project to Educate Physicians on End-of-life Care Supported by =
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American Medical Association Robert Wood Johnson Foundation
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
• Any physician can
determine
• Capacity varies by
decision
•Other cognitive abilit=
ies
do not need to be intact
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
![](3D"slide0041_image013.gif")
Potential
goals of care
4. There are 2 overall aims of medical c=
are:
to cure disease and to rel=
ieve
suffering. More personal and specific goals also exist within <=
/span>=
these overall aims.
5. Many physicians have been trained to
focus on diagnosis and treatment=
of
the patient’s disease by using a medical problem-<=
span
style=3D'position:absolute;top:64.25%;left:8.42%;width:101.12%;height:4.5%=
'>oriented method. They have not been trained to pay
attention to relief of
symptoms and other issues that heighten patient
Potential pitfall: Thinking
that the “problem-oriented” approach is =
=
the
same as setting goals.
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
![](3D"slide0045_image014.gif")
The
interrelationship among goals of care
6. Many patients, families, and professionals are not
prepared to give up
therapies aimed at cure and/or life prolongation, and =
totally focus on relief of suffering.
Potential pitfall: Failure
to refer to hospice or palliative care programs.
The majority of Americans (80%) are never referred <=
span
style=3D'position:absolute;top:59.75%;left:9.36%;width:84.83%;height:4.5%'=
>to
hospice or palliative care programs.
7. Early access to symptom management and supportive
care may help patients and
families feel better, continue more of =
their normal lifestyle, and maintain more capacity to
fight their illness a=
nd
sustain treatment
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
![](3D"slide0043_image016.gif")
Identify
goals to hope for
19. When surveyed, most Americans (>80%) said they
would rather know the truth a=
bout
their illness.
Potential pitfall: Offering
a false sense of hope. The collusion =
of
a lie may only push patients and families apart.
Cultural
differences
20. Some cultures prefer that medical information,
particularly that of a
life-threatening prognosis, be given to the family and <=
span
style=3D'position:absolute;top:73.25%;left:9.36%;width:84.83%;height:4.5%'=
>not the patient.
Pearl: Ask early in the
relationship how the patient would like to =
handle
information sharing.
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
![](3D"slide0048_image017.gif")
Communicating
prognosis
Pearl: Always
expect hopefulness—the object of hope changes =
with
time.
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
![](3D"slide0047_image018.gif")
Clarify
goals and treatment priorities
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The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
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•R=
eview
with any change in
health status
advancing illness
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setting of care
treatment preferences
When
the physician cannot suppor=
t a
patient’s choices
•Typically
occurs when goals are unreasonable, illegal
•Set limits without
implying abandonment
• Make the conflict
explicit
<=
span
style=3D'font-weight:normal'>•Try to find an alterna=
te
solution
Reassess decision-making
capacity . . .
•I=
mplies
the ability to understand and make own decision
•P=
atient
must
understand information
use the information rationally
appreciate the consequences
come to a reasonable decision for him or
her
. .
. Reassess decision-making
capacity
When a patient lacks =
capacity
. . .
•P=
roxy
decision-maker
•S=
ources
of information
written advance directives
patient’s verbal statements
patient’s general values and beliefs
how patient lived his / her life
best interest determinations
=
. . .
When a patient lacks capaci=
ty
•W=
hy
turn to others
respects patient
builds trust
reduces guilt and decision regret
Key Clin=
ical
Considerations in Summary
1.
Everyone has a personal sense of what brings greatest meaning and value, and adds most to the quality of o=
ur
lives.
2. As we confront significant illness and
the possibility that we will
die, we will each make choices for care based on our diagnosis, prognosis, the potential benefits,
burdens,
and risks
association with various therapies, and our personal priorities.
3. Over time, our goals for care and treatment
priorities will change.&#=
13;
Giving
unwanted intervention. Most of us will become
angry and lose trust if things are done to us that we do not
want .
Potential pitfall: Failure
to discuss expectations.
Potential pitfall:
Key Clin=
ical
Considerations in Summary
Pearl: No one goal is inherent=
ly
more valid than another.
suffering as an explicit goal of medical care.
<=
/b>
Key Clin=
ical
Considerations in Summary
Key Clin=
ical
Considerations in Summary
8. Multiple goals may apply simultaneously.
=
9. Goals may appear to be contradictory.
10. Some goals take priority over others.
11. Goals may change near the end of life.
<=
/span>
Key Clin=
ical
Considerations in Summary
Key Clin=
ical
Considerations in Summary
21. Physicians tend to markedly overestimate prognos=
is.
&=
nbsp;
Consequently, they tend to refer patients to hospice much
=
&=
nbsp;
too late.
Potential pitfall: Excessively
optimistic estimates of prognosis .<=
/b>
Key Clin=
ical
Considerations in Summary
22. In addition to helping patients and families
establish
overall g=
oals
for care, assist them to clarify priorities for
treatment=
s and
care.
23. Review goals when patients have a significant ch=
ange
in
their hea=
lth
status, have limited life expectancy, change
their set=
ting
of care, or change their treatment preferences.
24. If the physician cannot support the patient̵=
7;s
choices, it is
generally=
more
useful to make the conflict explicit and then
offer to =
help
find an alternate solution.
E
P
E
C
P
E
C
End of Module 7:
Goals of Care
Review Fast Facts
Complete Module 7 Post Assessment
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‹#›
There are many possible goals of =
medical
care, from prevention, to cure, to prolongation of life, to achieving a go=
od
death. No one goal is inherently more valid than another, and multiple goa=
ls
may apply simultaneously. In general, attempts to reverse illness or resto=
re
health can be pursued at the same time as efforts to relieve suffering and
improve quality of life. Specific clinical skills are needed for negotiati=
ng care
goals. The physician must be able to identify what is reasonable for the
patient to hope for, to adjust according to the patient’s culture, to
convey prognosis even with all its uncertainty, to use appropriate languag=
e,
to set limits if necessary, and to manage care even when the patient lacks
decision-making capacity.
Every one of us has a sense of wh=
o we
are, what we try to do, how we determine and relate to events in our lives,
and what we hope for. Over time, we have developed a very personal sense of
what brings greatest meaning and value, and adds most to the quality of our
lives. The daily choices we make are based on our experiences and the goals
and expectations we have for our future. Over the course of our lives, the=
se change.
At
one time or another during our lives, most of us will confront significant
illness and the possibility that we will die. When this occurs, we will ma=
ke
choices for our care based on our diagnosis and prognosis, the potential
benefits and risks associated with various therapies, and our personal
priorities. In doing so, we will have a very personal sense of how aggress=
ive
we would like our physicians to be in addressing our illness, our prioriti=
es
for treatment, and what things we would like to do both in the outside wor=
ld
and personally.
Over time and in different circumstances, our goals for care, our treatment
priorities, and the things we would like to achieve will likely change. Mo=
st
of us will get upset if our expectations for treatment are not met. Most o=
f us
will become angry and lose trust if things are done to us that we do not
want.
Our patients and their families a=
lso have
very personal hopes and goals for their lives. As they confront
life-threatening illness, they may start by hoping that nothing is wrong, =
that
the diagnosis is not true. As they realize the full meaning of the illness=
, most
patients will hope for a cure and long life. As each patient realizes that=
the
illness will take his or her life, most will shift to hope for the absence=
of
suffering and a good death. As their hopes change, so will their goals for
care and their priorities for treatment. Each trajectory of changing goals=
in
unique.
Before developing or negotiating any plan of care, a physician
must clarify patient and family goals for care and current treatment
priorities. Regular review of these goals and priorities can help the pati=
ent,
family, physician, and health care team to strive for the same outcomes, a=
nd
avoid missing divergent expectations or providing unwanted therapies.
=
This
module presents an approach for eliciting a patient’s goals for care=
(or
parents’ goals when the patient is a child) and clarifying his or her
treatment priorities. While it focuses on patients who are nearing the end=
of
their lives, the process can be used at any time during a person’s
illness.
Since the beginning of medicine, =
there
have been 2 overall aims of care: to cure disease and to relieve suffering.
Within these are numerous possible goals for health care, including comple=
te
cure, avoidance of premature death, maintenance or improvement in function,
prolongation of life, relief of various types of suffering, improvement of
quality of life, preservation of control, a good death, and support for fa=
milies
and loved ones. No
one goal is inherently more valid than another; all=
are
legitimate goals of medicine and each will be applied differently by the
individual in his or her particular circumstances.
While the primary goal of medicin=
e in the
last century was to provide comfort, in the latter half of the 20th century
there have been significant developments in science and technology. In the
fight against illness and death, modern medicine has focused primarily on
curing illness and prolonging life as it has fought aggressively against d=
eath.
In the process, less attention has been paid to the management of symptoms,
the relief of suffering or care of the dying.
In the 1960s and 1970s, =
the
hospice and palliative care movements were born in the United Kingdom, the
United States, and Canada to fill a growing void and provide care for the
dying. Historically, hospice in the United States has been primarily restr=
icted
by the Medicare hospice benefit to the last 6 months of a person’s l=
ife,
and programs have tended to serve only patients with cancer when cure was =
no
longer possible. More recently,
hospice and palliative care programs h=
ave
been evolving into medical practices and programs that focus on relieving
suffering and improving quality of life for patients with a broader range =
of
prognoses.
Figure 1 shows the division betwe=
en goals
of care if medical decision making occurs in a dichotomous way where the f=
ocus
is first on therapies with a curative intent, and only when they are no lo=
nger
effective does the intent shift to relief of suffering.
This figure is
representative of the current situation driven by the Medicare hospice ben=
efit
where prognosis must be six months or less and patients must agree to fore=
go any
therapy with a curative intent before they can avail themselves of this
benefit. However, many patients, families, and professionals are not prepa=
red
to give up therapies aimed at cure and life-prolongation in order to focus
totally on relief of suffering. Consequently,
an unintended consequenc=
e of
the original legislation is that the majority of dying Americans are never
referred to hospice programs.
Moreover, studies show that patients with
life-threatening illnesses, and their families, will experience multiple
symptoms and have ongoing needs for psychological, social, spiritual, and
practical support throughout their illness.
Why should the relief of
suffering not be pursued at the same time as cure and life prolongation? Do
not wait to focus on the relief of suffering until all attempts at cure ha=
ve
been exhausted or the patient and family plead for such efforts to stop. W=
ith earlier
access to symptom management and supportive care, patients and families ma=
y feel
better, continue more of their normal lifestyle, and maintain more capacit=
y to
fight their illness and sustain treatment.
As patients and families experien=
ce
life-threatening illness, several aspects become apparent
to the observant clinician:
Multiple goals apply simultaneously. Although goals may seem to str=
etch
along a continuum in a linear fashion, in fact the patient and physician m=
ay
seek both disease control and symptom palliation together. They may not
consider a therapeutic intervention (eg, chemotherapy), unless it addresses
both goals. In clinical practice this is more the rule than the
exception.
Goals may be contradictory. A patient may want
prolongation of life as the overriding goal but also insist that nothing
should be done that increases discomfort. The physician knows, however, th=
at
treatments aimed at curing disease, such as a surgical operation or
chemotherapy, may unintentionally cause temporary or permanent functional
deterioration and suffering. It is the physician’s role to help the =
patient
and family understand the balance between the benefits and burdens of a pa=
rticular
treatment.
For a particular patient, some goals take priority over
others. Over the course of a lifetime, or the course of an illness, the
relative weight given to each goal may change in response to numerous fact=
ors.
It is only in the context of an individual’s life that an adequate
balance of goals can be achieved. Clinical decisions routinely require pri=
oritization
among potentially contradictory goals. Such tradeoffs are an inevitable pa=
rt
of medical
care.
As patients approach the end of t=
heir
lives, goals of care and treatment priorities frequently
When
the dying patient is a child. It is often particularly hard for the
parents and family to shift away from their hopes for cure. The realization
that the disease will take their child’s life may come quite late for
many parents. Consequently, the pattern for changing goals of care can be
somewhat different than when the patient is an adult. To help parents prep=
are,
the physician will want to explicitly include a goal of comfort along with
the
goal of cure from the beginning of treatment planning. In other wo=
rds,
curative and palliative treatments can coexist from the time of presentati=
on.
When curative goals are no longer appropriate, this strategy permits some
aspects of the treatment plan to continue until death, rather than
necessitating a change from one goal to another with its implications for
abandonment and “giving up hope.”
change:
Some goals take precedence over others. As a patient’s progno=
sis
and health status worsen, the goals of prevention, cure, or avoidance of d=
eath
may become less important as they become less possible. At the same time, =
the
goals of maintaining function, relieving suffering, and optimizing quality=
of
life may become the focus of care.
Ideally, this shift in focus of =
care
is gradual. It is usually negotiated over time. An abrupt transition f=
rom
primarily curative care to primarily palliative care is rarely appropriate=
.
The
shift in goals is an expected part of the continuum of medical care. C=
hanges
occur throughout the patient’s life and illness. The physician plays=
a
key role during all phases of the continuum. In all situations, the nature=
and
course of the illness, and the patient’s and family’s goals for
care, should determine the relative emphasis on cure vs palliation.
The concurrent integration of go=
als of
care (rather than a dichotomous approach) can be particularly important for
progressive illnesses that will be predictably fatal. Medical treatment for
most illnesses will only change the natural course of the disease and prol=
ong
life, but not provide a cure (eg, for most cancers, AIDS, chronic obstruct=
ive
pulmonary disease, congestive heart failure, diabetes, renal failure,
etc).
In contrast to the previous dichotomous model of care, Figure 2
below shows how the relief of suffering can integrate into the continuum of
care desired and needed by the patient and family during an illness.
Initially, more focus may be on t=
herapies
intended to cure the illness or prolong life. Later, the relief of sufferi=
ng
may become increasingly important or even the total focus of care. But
therapies with a palliative intent are not an alternative, to or an abrupt
change from, the preceding care plan.
To redress the tendency to dichot=
omize
curative and palliative care, many palliative care programs are striving to
expand the availability of services. By doing so, the interdisciplinary ca=
re
focused on symptom control and supportive care so well provided by hospice
programs can be available to all patients with any life-threatening diagno=
sis,
at any time during their illness when they have symptom control or support=
ive
care needs, and are prepared to accept such care.
For many physicians, negotiating =
goals of
care with patients and families who are facing the end of the patient̵=
7;s
life can be difficult, particularly when there is a conflict between
aspirations and what is medically likely or possible. To have a greater ch=
ance
of achieving a successful outcome, physicians might use the following
modification of the 6-step protocol for communicating bad news.
1. Create the right setting. Sit down. Ensure privacy and
time.
2. First, determine what the patient/family know. Clarify the curre=
nt
situation and the context in which decisions about goals of care should be
made. For example, if the patient thinks he or she has indigestion and the
physician thinks it is life-threatening myocardial infarction, the
determination of goals of care will have to wait until there is agreement =
on
the clinical situation.
3. Explore what they are expecting or hoping
for. Focus on what you will do to achieve those expectations and hopes=
. As
appropriate, identify those things that you cannot do, perhaps because they
will not help achieve the goals or because they are not possible.
4. Suggest realistic goals. As the
physician brings a wealth of scientific knowledge about the patient’s
illness, its natural course, the experience of patients in similar circums=
tances,
and the effects that contemporary health care may have, this must be share=
d to
assist with decision making. After sharing this information, suggest reali=
stic
goals (eg, comfort, peace, closure, loving care, withdrawal of interventio=
ns,
etc) and how they can be achieved. Work through unreasonable or unrealistic
expectations.
5. Respond empathically to the emotions that may arise.
6. Make a plan and follow through.
7. Review and revise periodically, as appropriate.
As part of the decision-making pr=
ocess to
determine the goals for their care, patients and families rely on physicia=
ns
for answers to 2 fundamental questions: “What is wrong with me?̶=
1;
and “What will happen to me?” In the case where the patient is=
a child,
parents want to know: “What is wrong with my child?” and
“What will happen to my child?”
The issue of prognosis is
crucial to patients and families for several reasons. Most importantly, an
understanding of what might happen helps them to cope, respond, and plan f=
or
their future. Without reasonable information about what the future is like=
ly
to bring, patients and families may choose treatments they would otherwise
decline, and miss important opportunities for growth and life closure.
Secondarily, knowing that life is likely to be short may open opportunities
for increased support from the health care system (eg, they may be eligible
for the Medicare hospice benefit if the patient’s prognosis is less =
than
6 months).
Prognostication is never easy. Studies suggest that
evidence-based prognostication does not explain customary medical practice.
Even when physicians refer patients for hospice care, they seem to markedly
overestimate prognosis in that patients live for only days or weeks once
referred to home hospice care, rather than the months of life that the
physician thought remained. In the SUPPORT study, physicians tended to make
significant errors in both directions (overestimates and underestimates) w=
hen predicting
the lifespan for patients in the ICU.
A number of ways of communicating
prognosis have been developed.
Consider offering a range that encompasses average life expectancy =
(eg,
hours to days, days to weeks, weeks to months, or months to years).
Alternatively, consider offering averages: “People with your illness
circumstances can live for a long or a short time. About half live for abo=
ut 3
months. There is a lot variation for the other half. Some find it is best =
to
plan for little time, and hope for more time.”
One of the chief obstacles to neg=
otiating
goals of care in the face of life-threatening illness and poor prognosis is
the issue of hope (the feeling that what is wanted will happen).
Hippo=
crates
stated, and Osler continued to advocate for the medical convention that ph=
ysicians
should express hope to the patient and family that the patient will enjoy =
a full
recovery from the current illness, even if it is not true. This principle =
has
been mistakenly taken so far as to administer treatments that are known to=
be
ineffective, all in the service of maintaining hope.
However, when
surveyed, most Americans said they would rather know the truth about their
illness. Unfortunately, a false sense of hope may deflect the patient and =
family
from finding final meaning and value, and closing their lives together. At=
a time
when people most need closeness, the collusion of a lie may serve to push =
them
apart.
Physicians agree that a positive attitude and a sense of
hopefulness should be maintained throughout the course of an illness. To
achieve this end, some find it useful to frame discussions
using words like:
· we can hope for the best, but we also need to plan for the
worst
Whatever approach, the true skill of the physician is in his or her abilit=
y to
help patients and families find hope for realistic goals, which can change
with time.
In any physician-patient communic=
ation,
well intentioned physicians may say things that will have unintended
consequences. What the listeners understand may be quite different from wh=
at
the physician intended. Some examples that may be significantly misinterpr=
eted
by patients include:
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Content-Transfer-Encoding: quoted-printable
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InitHLinkArray()
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function _RSW()
{
if( !g_supportsPPTHTML || IsNts() ||
( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) )
return
var padding=3D0;
if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6
cltWidth=3Ddocument.body.clientWidth-padding
cltHeight=3Ddocument.body.clientHeight-padding
factor=3D(1.0*cltWidth)/g_origW
if( cltHeight < g_origH*factor )
factor=3D(1.0*cltHeight)/g_origH
newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
s=3DSlideObj.style
s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
}
}function DocumentOnClick()
{
if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames=
Mode() ) ||
(event && event.keyCode=3D=3D32) ) {
=09
if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex=
t )
return;
parent.GoToNextSld();
}
}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
, g_bgSound=3D"",
g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
=3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1;
var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va=
r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
es", gIsEndShow=3D0, NUM_VIS_SLDS=3D38, SCRIPT_HREF=3D"script.js", FULLSCR_=
HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0022.htm",1,-1,1),new hrefList(=
"slide0002.htm",1,-1,1),new hrefList("slide0024.htm",1,-1,1),new hrefList("=
slide0003.htm",1,-1,1),new hrefList("slide0025.htm",1,-1,1),new hrefList("s=
lide0026.htm",1,-1,1),new hrefList("slide0005.htm",1,-1,1),new hrefList("sl=
ide0036.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("sli=
de0010.htm",1,-1,1),new hrefList("slide0039.htm",1,-1,1),new hrefList("slid=
e0037.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("slide=
0027.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slide0=
031.htm",1,-1,1),new hrefList("slide0014.htm",1,-1,1),new hrefList("slide00=
12.htm",1,-1,1),new hrefList("slide0015.htm",1,-1,1),new hrefList("slide001=
6.htm",1,-1,1),new hrefList("slide0033.htm",1,-1,1),new hrefList("slide0032=
.htm",1,-1,1),new hrefList("slide0013.htm",1,-1,1),new hrefList("slide0018.=
htm",1,-1,1),new hrefList("slide0017.htm",1,-1,1),new hrefList("slide0019.h=
tm",1,-1,1),new hrefList("slide0020.htm",1,-1,1),new hrefList("slide0034.ht=
m",1,-1,1),new hrefList("slide0021.htm",1,-1,1),new hrefList("slide0035.htm=
",1,-1,1),new hrefList("slide0040.htm",1,-1,1),new hrefList("slide0041.htm"=
,1,-1,1),new hrefList("slide0045.htm",1,-1,1),new hrefList("slide0044.htm",=
1,-1,1),new hrefList("slide0043.htm",1,-1,1),new hrefList("slide0048.htm",1=
,-1,1),new hrefList("slide0047.htm",1,-1,1),new hrefList("slide0023.htm",1,=
-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
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------=_NextPart_01C7D4E2.48ECE2D0
Content-Location: file:///C:/8E7312A5/Module7GoalsofCare_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
The Project to Educate Physicians on End-of-life Care Supported by =
the=20
American Medical Association Robert Wood Johnson Foundation
------=_NextPart_01C7D4E2.48ECE2D0--
· Do you want us to do everything possible?
· Will you agree to discontinue care?
· We’ll refrain from extraordinary measures.
· It’s time we talk about pulling back.
· I think we should stop aggressive therapy.
· I’m going to make it so he won’t suffer.
From each of these statements, the patient and family may interpret the
unintended message that they are about to be abandoned. As a result, they =
may
see only a stark choice between aggressive curative care and giving up.=
3;
In order to prevent unintended
consequences, it is useful to develop facility with language that reinforc=
es
the goals of appropriate medical care for someone with advanced progressive
illness and a life-threatening prognosis. Some examples include:
· I want to give the best care possible until the day your chi=
ld
dies.
· We will concentrate on improving the quality of your life.&#=
13;
· We want to help you live meaningfully in the time that you
have.
· I’ll do everything I can to help you maintain your
independence.
· I want to ensure that your father receives the kind of treat=
ment
he wants.
· Your child’s comfort and dignity will be my top
priority.
· I will focus my efforts on treating your child’s
symptoms.
· Let’s discuss what we can do to fulfill your wish to s=
tay
at home.
· Let’s discuss what we can do to have your child die at
home.
Cultural differences may require=
the
physician to modify his or her approach to determining goals for care. Some
cultures prefer that medical information, particularly that of a
life-threatening prognosis, be given to the family and not the patient. Fa=
milies
may insist on this. Among other cultures (eg, some Navajos), it is not goo=
d to
raise a negative prospect at all. Moving the conversation to the third per=
son
may circumvent this: “If you were hearing a story about someone who =
was
facing an illness that could not be cured, how would you want that story to
describe the best way to help?” As cultural generalizations often do=
not
apply to given individuals, it may be a useful approach to ask the patient
early on in the relationship how he or she would like information to be
handled, and who should be making decisions. It may be useful for this
conversation to take place in the context of a family meeting so that all =
can
hear the patient’s disposition.
Once overall goals have been det=
ermined,
the physician can help the patient, proxy, or parent to discuss the priori=
ties
for specific treatment and care approaches. Priorities should be based on
individual patient values and preferences as guided by specific clinical
circumstances. Priorities will be influenced by information from the physi=
cian
and other health care professionals. The physician will want to describe t=
he
possible priorities
and be open to the feasibility of
others. Values and preferences will be elicited and clarified through
physician-patient discussions.
Here are some examples of questions th=
at
can be used to elicit patients’ values and goals
for medical care at the end of life:
· What are you expecting?
· What do you most want to accomplish?
· What is most important in your life right now?
· What are you hoping for?
· What do you hope to avoid?
· What do you think will happen?
· What are you afraid will happen?
· What do you expect the end to be like?
Examples of values and preferences that may be expressed by patients
include:
· No matter what happens, I want us to stay at home. No more
hospitals.
· I’m worried what all of this will cost my family.
=
· What I fear most is pain.
· I would like to be alert and aware as long as possible.
=
· I just hope I have time to finish my memoirs.
· If I live to see my daughter married, I’ll die happy.&=
#13;
· When death comes, I want my family around me.
· I don’t want my wife to have to quit her job to take c=
are
of me.
· My wish is never to be hooked up to machines.
· It’s important to me to live as long as possible, and =
to
go out fighting.
· It is important to me to try everything there is to cure my
child.
· I don’t want my child hooked up to machines.
Whenever the patient’s, proxy’s, or parent’s goals are
uncertain or might be expected to change, goals and treatment priorities
should again be clarified.
Review is recommended at several types of juncture:
· when patients have a significant change in their health status (e=
g,
additional diagnosis,
worsening prognosis or unexpected recovery)
· when a patient realizes they have a limited life expectancy (eg,
advanced age or serious
life-threatening illness)
· with a change in the setting of care (eg, from hospital to
nursing home or vice versa)
· with a change in the patient’s treatment preferences (eg,
decide to discontinue dialysis
or other therapies).
If the prognosis allows you to delay this conversation, give the patient t=
ime
to acclimatize
to his or her new circumstances. With a little time to settle, patien=
ts
are more likely to
again stabilize their goals and priorities.
Occasionally, the physician will=
be
confronted with a situation where the patient, proxy, or parent has goals =
and
treatment priorities that the physician cannot support. Typically, this oc=
curs
when goals are unreasonable or illegal. The challenge for the physician is=
to
set limits on what he or she will do, without implying abandonment or dest=
roying
the relationship of trust and loyalty that has developed.
If this
situation occurs, it is generally more useful to make the conflict explicit
and then offer to help find a solution. For example, “I understand t=
hat
your first priority is to live as long as possible by having a heart
transplant. Unfortunately, I’m not able to do that because of your o=
ther
health problems. Is there an alternative way that I can help you achieve y=
our
goal of living as long as possible?” or “I understand your goa=
l is
not to be a burden to your family and you would like me to assist you to d=
ie. Unfortunately,
I cannot do that. Is there an alternative way that I can help you so that =
you
will not be a burden?”
More intractable differences are addressed elsewhere
Occasionally, choices that are
unsupportable suggest that the patient is losing decisionmaking
capacity. Reassess your patient if this seems possible.
Decision-making capacity implies the ability to understand and make medica=
l decisions
for oneself. It can usually be determined by any physician. It does not re=
quire
a psychiatrist or a court ruling. For a patient to have decision-making
capacity, he or she must be able to understand the information, use it in
rational ways to come to a decision, appreciate the consequences of the
decision, and have that be a reasonable decision for him or her. For examp=
le,
consider a man who refuses an amputation of a gangrenous leg. He needs to
demonstrate that he understands the information about the condition and the
options for care, that he could die if it is not amputated, and that this =
is a
rational decision for him. The patient can meet criteria for decision-maki=
ng
capacity for a particular treatment (decision-specific capacity), and yet =
not
be competent to handle his or her practical, financial, and legal affairs.
Further, decision-making capacity may vary depending on the treatment
decision
When patients lack the capacity =
to
express their own values and preferences for medical care, goals must be
determined by others. For patients who lack decision-making capacity, a pr=
oxy
decision maker should be sought to help clarify the patient’s goals =
and
consent to specific care plans.
Generally, the appropriate proxy is a
person selected in advance for this role by the patient (see Module 1: Adv=
ance
Care Planning), or a person who has knowledge of the patient’s values
and preferences and is willing and able to serve in this capacity. For
children, this role almost always falls to the parents. For adults, when t=
he
patient has not preselected a proxy decision maker, this usually falls to =
the
next of kin. Legal criteria for proxy selection vary from state to state.&=
#13;The
physician should guide the proxy/decision maker to understand his or her r=
ole
in determining what the patient would have wanted based on available
information. Where information is lacking, it becomes necessary to try to
determine what would be in the best interest of the patient. This is often,
but not always, the same conclusion and often errs more toward life
prolongation.
To the extent that they are know=
n, the
patient’s values and preferences should be used to determine the goa=
ls
of care. Written advance directives, the patient’s verbal statements,
his or her general values and beliefs, and how the patient lived his or he=
r life
can all be useful. Together they allow an assessment of what the patient w=
ould
have judged (ie, a substituted judgment). Fundamentally, the process
demonstrates respect for the patient, and builds trust that the physician =
and
the health care team are acting in the interests of the patient. Further, =
by
focusing on the wishes of the patient, there is reduced guilt or decision
regret for the proxy, family members, the physician, and the health care
team.
Here are some practical ways to elicit patient values and
preferences in discussions with
proxy decision makers:
· Help me to understand what your husband was like before he g=
ot
sick. What was
most important to him?
· Has he ever said anything about how he would want to be trea=
ted
if he could no
longer make decisions for himself?
· What would he say in this situation?
· Do you have any other family members or friends who have experien=
ced
serious illness?
Did he or she express how he or she would want to be treated in that
situation?
· Based on everything you know about him, what do you think he
would have wanted
in this situation?
Many of the approaches that work for an advance care planning discussion a=
lso
work for establishing immediate goals of care, whether working with the
patient or a proxy. In particular, it can help to go through a worksheet
again, using predrafted scenarios, goals, and treatment options, prior to
returning to the situation at hand. Often clarity and perspective return w=
ith
this exercise for getting a broad perspective and allow a comfortable sett=
ling
into current goals.
' + ENDSHOW_MESG + '
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