POTD: Goals of Care Conversation and Prognostication
This is part 2 of the POTD covering patient communication over sensitive topics and my final POTD. Sorry this is a long one that probably could be two separate POTD. Given that it is my final POTD, I feel like prognostication should be mentioned as it is important for me internally so that I feel comfortable when recommending (yes, recommending) DNR/DNI. I am naturally pro Full Code as some of my co-residents can attest to (y’all better put me on ECMO and visit me at Palm Gardens), but the second part of this POTD will go over some research of prognosis after cardiac arrest and intubation. If this isn’t a mental hang up for you, the first half will go over the basics of a goals of care conversation.
Basics of a goals of care conversation
Ask what they know. – find out about what they know, allow the patient/family to express emotions
Hello, I am Dr. X. What have you heard about what has happened today to your loved one?
Break bad news
Warning shot: I am afraid I have serious news. Would it be OK if I share?
Headline: Your [mother] is not breathing well from COVID with her other health issues. I am worried she could become/is very sick and may even die.
Establish urgency. Align with patient/family.
We need to work together quickly to make the best decisions for her care.
I want to do what is best for the patient.
Baseline function
To decide which treatments might help your mother the most, I need to know more about her. What type of activities was she doing day-to-day before this illness?
Has he/she been able to feed himself/herself?
Is he/she bedbound?
Has the patient been coming in and out of the hospital?
Patient’s Values (select the appropriate question) – what is the acceptable quality of life
There are times when the pt’s values are clear. “I don’t want to be on life support. I would rather die.” But those times are rare. More often, family members are unsure and these values questions are often asked in a series. The last question is the hardest one. Work up to that one if the patient or family cannot give a clear answer.
Has she previously expressed wishes about the kinds of medical care she would or would not want?
If time is short, what is most important to her?
How much would she be willing to go through for the possibility of more time?
What abilities are so crucial to her that she would consider life not worth living if she lost them?
Are there states she would consider worse than dying?
Summarize – This creates higher alignment with patient/family. Ask Tell Ask.
What I hear is ____. Did I get that right?
What I heard you say is that you understand that the pneumonia is very severe today. Your father said that the minimum quality of life that he would want is to be able to read and have conversations with his family. Did I get that right?
Make Recommendations (We try not to be paternalistic, but patients and family do not understand prognosis, what the longer course after intubation is, what the trach and vent unit looks like. It is ok, if not our job to give a recommendation.)
Based on what you know about the patient’s baseline medical problems and current illness, make your best prediction about the patient’s prognosis. What is the likelihood that the patient that the patient will achieve his/her minimal quality of life?
Given that your father has no medical problems, and wants us to do everything to keep him alive, I would recommend intubation and chest compressions as needed. We will see if he improves on the ventilator, if not than we can revisit this conversation.
Given that your mother has significant medical co-morbidities with her current severity of illness, it’s very unlikely that doing invasive and traumatic procedures like placing her on the ventilator, central lines, or chest compressions is going benefit her. I would recommend giving her comfort care and provide pain medication as needed. We are still going to give her antibiotics and non-invasive interventions if that is her wish.
(If they ask, CPR can break ribs, damage internal organs; generally speaking I've been moving away from talking about the details of the procedures. Most of the times, they don't ask about the specifics; they just don't want anything traumatic happening to their loved one. Of course if they ask, being on the ventilator involves placing a breathing tube down their throat which is traumatic, and the patient can become dependent on the ventilator.)
This is the link to the great 30 min EMCRIT podcast that goes over this topic
https://emcrit.org/emcrit/rapid-code-status-conversations/
Prognostication
It’s hard to tell prognosis for young patients with serious underlying conditions like cerebral palsy requiring trach and peg. There is less variability in prognosis for older patient with medical co-morbidities. Generally, for goals of care, we are mostly concerned about two things, CPR and intubation, so we are going to take a look at both of these interventions and see how beneficial each is.
Cardiac Arrest
The prognosis of patients post cardiac arrest is extremely poor. Many studies of out of hospital arrest done over the world cite a 1-year mortality rate of ~88-92% (worsen in US ofc). Half of the survivors will have severe neurologic deficits123. The data on in-hospital arrest isn’t much better. The in-hospital survival rate is around 20%, dropping to ~10% by the 1-year mark4. I find it quite interesting that survival rates and neurologic outcomes are 15-20% lower for patients who arrested during nights or weekends (off-hours)…yikes5. One of the key prognostication factors seems to be your initial rhythm; if you have a shockable rhythm you are 2-3x more likely to survive.
Intubation
For patients > 65 who are intubated, there is a 33% in-hospital mortality rate, which doesn’t sound so bad. 24% of the survivors are discharged to home, and the rest to a skilled nursing facility or a long-term acute care facility (LTAC). This other study also done by the same author found that for the survivors, the median survival after discharge was only 163 days. The 1/5 year survival rates were 45% and 18% at LTAC. Surveys done at these facilities shows that most of these patients have terrible quality of life; to the credit of these facilities about 60% of the patients are discharged home. Also, in the Kei study, in which the patients was admitted with mild to moderate disability (walks with walker, dependent on some ADLS) 56% developed severe disability post intubation (bedbound, depending on all ADLs)67.This article found that for weaning the ventilator, age is not the dominant factor in predicting outcomes; having multiple co-morbidity burdens is a much better indicator8.
My takeaways from all this was that CPR was a lot less beneficial than I expected. Though the prognosis of intubation is poor, it does seem to convey significantly more benefit than CPR. I say this because at Maimo (I’m not sure for other hospitals), it seems like goals of care keeps these two as a package deal (especially in the ED). I think inpatient is more likely to be ok with having patient families accept one or the other. I feel like I am now more willing to accept intubation only, no CPR.
The other side of the coin is that intubation does run a much higher risk of keeping the patient alive in what some could consider a perpetual state with poor quality of life. The EMCRIT podcast goes over the idea that maybe the goal of treatment is a dignified life rather than a cure. If you are depending on others for all ADLs with barely any mental cognition, is that a dignified life? Of course, this has a lot to do with one’s beliefs, and it’s subjective. Just something to think about.
My last takeaway is that a significant portion ~5-10% of even elderly after CPR does recover with good neurologic function. You don’t want to condemn these people to death. It seems like age is not the best predictor for poor prognosis but rather medical comorbidities, low baseline function, and illness severity. My point is that if there is a 78F with just HTN and had perfect ADLs coming in for a modifiable illness like pneumonia, she has a great chance of returning to baseline function. Unless specified otherwise, I would recommend full code in that scenario. A 73M with CHF, DM, HTN, HLD, CAD w/ stents with baseline dementia (which is a lot of these patients) have a far worse prognosis. Depending on the wishes of the family and the patient, I am much more likely to recommend comfort care.
I want to give a special thank you to Dr. Turchiano for helping me with these last two POTDs. I also wanted to give a plug for his amazing palliative care selective that he ran last year for third years who are interested and second years who might be interested. If you are interested, please don’t hesitate to send him an email.
1. https://pubmed.ncbi.nlm.nih.gov/25399396/
2. https://pubmed.ncbi.nlm.nih.gov/25399397/
3. https://pubmed.ncbi.nlm.nih.gov/25355914/
4. https://www.resuscitationjournal.com/article/S0300-9572(18)30850-5/fulltext
6. https://emcrit.org/wp-content/uploads/2020/06/jgs.15361.pdf
7. https://www.jpsmjournal.com/article/S0885-3924(20)30436-X/fulltext?rss=yes#back-bib32
8. https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.12597
