Bates D. Moses, MD
In both inpatient and outpatient medical settings, the physician-patient communication process can become more difficult as a disease progresses. Conflicts due to a misunderstanding of therapeutic goals and/or a patient’s values can slowly arise over time among patients, their surrogates, and their health-care team. Adding to that challenge, there has been a profound shift from the historically paternalistic model of medicine, in which physicians unilaterally made all the decisions without regard to a patient’s goals and values, to one centered around patient autonomy, which has, at the other extreme, occasionally resulted in patients demanding treatments that fall outside the goals of medicine.
These conflicts have slowly increased as advances have blurred the distinction between being alive and “truly living.” Advance health-care directives and portable orders for life-sustaining treatment seemed to be the answer to extreme paternalism. However, conflicts continue to occur despite the completion of various documents.
A proposed solution, based on a model of shared decision-making, has been increasingly taught and practiced over the past decade. However, the primary focus has been on educating physicians and other health-care team members about eliciting and clarifying one side of this shared model—the patient’s goals of care. So much emphasis has been placed on understanding the patient’s goals that we seem to have forgotten that physicians also have a responsibility to understand and communicate the achievable goals of medicine.
This communication should begin at the very first visit and be a process of continual realignment to ensure that patients, surrogates, and health-care team members remain aligned with a shared medical goal and a shared understanding of a patient’s hopes and values.
Evolving Goals
Advance health-care directives and orders for life-sustaining treatment do well in documenting a patient’s values at the time they were completed. However, a snapshot in time cannot account for the reality that people are constantly adapting to illness, as individual clinical responses to various interventions will become evident. Accounting for this constant change can only be carried out by an ongoing discussion to understand the patient’s current goals and values and the physician incorporating the currently achievable goals of medicine.
Garrett and coauthors recommend that these discussions include the diagnosis, purpose, risks, benefits, alternatives, prognosis, as well as related costs. This information should be patient-specific, which requires that “the health-care professional really get to know the patient and determine what is important to him or her.”1 However, a robust informed-consent discussion also includes a physician’s recommendation using both the reviewed evidence and the patient’s elicited values. It is primarily the physician’s duty to balance the goals of medicine with the goals of care.
Patient’s Goals of Care
Important identified values of a patient experiencing a life-altering illness might include a goal for life prolongation, a cure, relief from suffering, regaining function, or not being a burden. Examples of more specific goals include reconciliation with a family member, attending a special event, completing a work assignment, or ensuring financial security. These goals routinely fluctuate over time, as one adjusts to the illness and as the prognosis changes.2
To fully understand patients’ values and goals in the context of illness, we need to ask reflective questions on how they have been doing since the last visit (or prior to the first visit), how they are doing now, and what concerns them about the future (physically, socially, mentally, and existentially). Assistance can be sought from others, such as social workers, with more expertise in eliciting this information. However, physicians should confirm their understanding of what is elicited and seek to develop skills in eliciting these responses on their own.
Goals of Medicine
Physicians share a firm scientific understanding of illness. However, delivering this information by itself is not adequate to be considered the physician’s part of the conversation. They must also address the goals of medicine in these discussions.
Garrett and colleagues have identified three goals of medicine: the prolongation of life, the alleviation of suffering, and “to optimize the patient’s chance for a happy and productive life.”3
From another perspective, it is worthwhile considering the goals of medicine first proposed by Hippocrates, which are “to do away with the sufferings of the sick; to lessen the violence of their diseases; and to refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.”4
In more recent times, a team of philosophers and ethicists identified four contemporary goals of medicine: (1) preventing disease and injury and promoting and maintaining health; (2) relieving pain and suffering caused by maladies; (3) caring for and curing those with a malady and caring for those who cannot be cured; and (4) avoiding premature death and pursuing a peaceful death.5
Note that while the prolongation of life is not included in these last two lists, the contemporary goals include the avoidance of premature death. These authors noted that “the struggle against death is an important goal … yet should always remain in a healthy tension with medicine’s duty to accept death as the destiny of all human beings.”5
Even more recently, Boorse proposed a seven-item list of the goals of medicine, divided into goals of benefit to the patient (eg, preventing pathologic conditions and reducing their severity) and knowledge goals (eg, discovering the diagnosis, etiology, and prognosis of the patient’s disease, including its response to various treatments).6
Simplified Goals
The goals of medicine can be varied, nuanced, and at times difficult to identify. However, if the physician does not incorporate the goals of medicine while offering interventions, he or she should not be surprised when a patient selects something the physician strongly believes is unreasonable or unachievable.
“Incorporating at every visit the currently achievable goal of medicine into the patient’s current goals of care can help guide both physicians and their patients in selecting an optimal course that is truly personalized, compassionate, and sensitive to the patient’s needs over time.”— Bates D. Moses, MD
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Despite the differences in the various goals of medicine reviewed, some core principles may be helpful for the front-line clinician. A simple model is one that is easily teachable, memorable, and useful for most illnesses and interventions that the average clinician will encounter. From this standpoint, the major goals of medicine are “to cure, to care, and to comfort” (adapted from Singh).7 This aligns well with the various types of medicine (preventive care, curative care, chronic care, and palliative care).
Most types of proposed medical interventions can incorporate these simplified goals to some degree. When a physician listens to a patient; understands his or her hopes, dreams, goals, and values; and then proposes options based on the goals of medicine (to cure, to care, and to comfort), one can expect a more informed and more personalized decision.
Practical Implications
Thus, a nephrologist, for example, should keep in mind the goals of medicine when discussing the purpose of hemodialysis. The proposed treatment could be utilized to care (to maintain functional capabilities), to comfort (to reduce dyspnea if dialysis was thought to be the best intervention for the circumstances), or to cure (to remove toxins while awaiting the return of renal function after an episode of acute renal failure). The discussion should also include mention of a time when hemodialysis might no longer be helpful in meeting the goals of medicine or care.
Similarly, an oncologist, when discussing palliative chemotherapy, might use these simplified medical goals to help conceptualize and identify the time when an intervention is no longer working to meet the goals of medicine (as opposed to looking at quantitative response rates alone). Sharing with a patient that a current treatment is no longer able to reduce symptoms or to improve function is difficult. However, making a clear recommendation on how best to achieve the goals of medicine helps reduce the burden that unguided decisions place on both patients and their loved ones.
After eliciting the goals of care and reviewing the goals of medicine, the physician’s recommendation might be for another line of chemotherapy, to consider a clinical trial, or to focus primarily on aggressive symptom management with opioids and other interventions with the assistance of specialty palliative care. Regardless, incorporating at every visit the currently achievable goal of medicine into the patient’s current goals of care can help guide both physicians and their patients in selecting an optimal course that is truly personalized, compassionate, and sensitive to the patient’s needs over time. ■
Dr. Moses is Regional Physician Director of Medical Bioethics for Kaiser Permanente Southern California, a palliative medicine physician with Kaiser Permanente in Riverside, California, Assistant Clinical Professor with the University of California at Riverside School of Medicine, and an MA in bioethics student at Loma Linda University.
Disclosure: Dr. Moses reported no conflicts of interest.
References
1. Garrett TM, Baillie HM, Garett RM: Principles of autonomy and informed consent, in Health Care Ethics: Principles and Problems, 5th ed, pp 38-39. Upper Saddle River, NJ; Pearson, 2010.
2. Lindenberger E, Kelley AS: Assessing goals of care, in Pantilat SZ, Anderson W, Gonzales M, et al (eds): Hospital-Based Palliative Medicine: A Practical, Evidence-Based Approach, p 121. Hoboken, NJ; Wiley-Blackwell, 2015.
3. Garrett TM, Baillie HM, Garett RM: The ethics of distribution, in Health Care Ethics: Principles and Problems, 5th ed, pp 83-87. Upper Saddle River, NJ; Pearson, 2010.
4. Baker R: The history of medical ethics, in Bynum WF, Porter R (eds): Companion Encyclopedia of the History of Medicine, 1st ed, vol 2, p 860. London, Routledge, 1993.
5. The goals of medicine: Setting new priorities. Hastings Cent Rep 26:S9-S14, 1996.
6. Boorse C: Goals of medicine, in Giroux E (ed): Naturalism in the Philosophy of Health, p 170. New York, Springer, 2016.
7. Singh A, Singh S: To cure sometimes, to comfort always, to hurt the least, to harm never. Mens Sana Monogr 4:8-9, 2006.
