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Goals of Care
Goals of care evolve during the course of a serious illness. Patients, families,
and medical staff must recognize that these goals can, and do, change -- often
rapidly. Information and open lines of communication are essential if the goals
are to be understood by everyone involved in the patient's care.
For a patient in the earlier stages of a life-threatening illness, treatments
might have the goal of curing the disease. When a cure is not possible, treatment
still could be aimed at prolonging the patient's life while managing symptoms.
At times during the course of the disease, the major goal might be to restore
or maintain function. At other times, particularly toward the end of life, the
treatment may focus completely on comfort for the patient and family.
Medical Treatment
The dying patient requires medical care for a variety of physical
symptoms and needs. Medical treatment is now focused on making the patient as
comfortable as possible. This treatment includes managing pain, fatigue, shortness
of breath, and nausea and vomiting. The medical team should monitor the patient's
treatment plan closely and review it to make sure that it is in the patient's
best interests and in line with the goals of the treatment plan. This process
may involve revising the drug regimen and discontinuing any unnecessary medications,
deciding whether to continue nutrition, determining whether hydration (giving
fluids) is appropriate, and providing comfort without artificial ventilation.
The patient should be monitored by a nurse who can help to make him/her more
comfortable by treating pressure sores (bedsores), bladder and bowel needs,
immobility, and secretions. In some cases, when symptoms are unbearable and
cannot be relieved, sedation may be offered to ease patient suffering.
There are a few ways to ensure the best possible medical care for dying patients.
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First, it is important to find a skilled doctor who can meet the unique
needs of dying patients. Patients should expect doctors to take their medical
problems seriously and provide adequate relief for their physical symptoms. |
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Second, patients should look for a compassionate doctor who listens to
and addresses their concerns. A good doctor-patient relationship can have
a healing effect in that it shows concern, respect, and the value of patients
as individuals. |
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Finally, medical staff should acquaint themselves with the patient's family
members, speak openly with them, and include them in the course of the patient's
dying process. The family is a great source of support, affirmation, and
comfort at the end of life, and their involvement fosters a sense of continuity
and well-being for the patient. |
Practical Considerations
For most patients it is very difficult to hear that treatment is not going to
offer a cure for their illnesses. At this time, patients should be assured that
their physical symptoms can be addressed through a therapeutic treatment plan.
Such a plan identifies patient problems and available treatment options. Once
a care plan has been established and agreed upon, it is necessary to decide where
patients will live out their remaining days.
Choices for dying patients include being cared for at home, in the hospital, or
in an inpatient hospice care facility. Regarding home care, it is necessary to
determine if there are resources available, such as family members and home care
attendants. In addition, family members must consider the physical and emotional
factors involved in caring for a loved one. When deciding on inpatient hospice
or hospital care, it is important to try to insure that the special needs of a
dying patient will be met in each setting, including extended visiting hours and
private rooms that are large enough to accommodate visitors.
Psychological/Spiritual Treatment
Psychological and spiritual distress in dying patients commonly presents as anxiety,
depression, hopelessness, and remorse. If these feelings persist and interfere
with the patient's functioning, they can severely affect his/her quality of life.
Treatment is offered in an effort to restore a level of psychological and spiritual
well-being.
For psychiatric conditions, such as anxiety and depression, treatment includes
supportive psychotherapy and the use of antidepressant or anti-anxiety drugs.
Psychotherapy may include relaxation training, imagery, distraction, coping training,
and restructuring negative thoughts.
Spiritual distress may be confronted with curative approaches that address feelings
of disappointment, remorse, and loss of personal identity. Some patients receive
comfort from talking to a chaplain or minister about such topics as religion,
death, and afterlife.
American Academy of Hospice and
Palliative Medicine
American Board of Hospice and
Palliative Medicine
Continuum Hospice
Care
End-of-Life Physician Education
Resource Center
European Association for Palliative
Care
Growth House, Inc.
Hospice Cares
International Hospice Institute
& College
National
Hospice and Palliative Care Organization
U.S. Dept. of
Health and Human Services: A Clinical Guide on Supportive and Palliative Care
for People with HIV/AIDS, 2003
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