8 - Goals of Care in Late-Stage Disease

Summary

When prolonging life with acceptable quality of life becomes difficult, goals of care discussion are necessary. For clinicians and patients, the discontinuation of disease-modifying therapy can feel like a failure. This can lead clinicians to offer treatments we don’t believe are good options or offering treatment on the condition that our patients make an improbable recovery. The roadmap for late stage goals of care discussions is REMAP. Reframe why the status quo isn’t working, expect emotion and respond with empathy, map big picture values, align with the patient’s values, and finally plan medical treatments based on what’s important to your patient. Some things to note: Mapping thoroughly will help you make sure you don’t miss something important. A useful shift in thinking for many clinicians is first talking about what you will do before talking about what should be stopped or you won’t offer. And, clearly linking your recommendations to the patient’s values will help your proposed plan be more acceptable. By grounding ourselves in what is medically possible and using the patient’s values to guide our next steps, we can cocreate a plan that is both possible and meaningful.