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/Communication

Part 1: Stepwise Approach to Discussing GOK/LOMT
Part 2: Template For Goals of Care Discussion, Written in the positive:
Part 3: Spiels for Patients Who Have Significant Limitations

TL;DR - Always start with the positives when discussing goals of care. Decision regarding CPR is a medical, and should not be offered if clinically inappropriate. In the grey areas, make a shared decision after framing the discussion into context. CPR is usually the last thing discussed. NFR simply means not for CPR - it is often more important to document if a patient is a candidate for ICU level supports (NIV / CVC / IAL / Dialysis).

“Would you like to be resuscitated?” …is a phrase that should probably be avoided in the Emergency Department. Yet I do hear it mentioned every now and again. This article aims to help frame things in a more practical and useful manner.

Part 1: Stepwise Approach to Discussing GOK/LOMT

Step 1: Break the topic of goals of care
“There is a form that I need to fill for the admission”
“It exists to protect patients from harmful interventions that can cause pain and suffering without any meaningful outcome”

Step 2: Outline Levels of Medical Treatment
“There are levels of treatment that can be offered by hospitals. Medications can be given orally, under the skin, through muscles (like a vaccine), or through a drip/cannula into a small vein in the arm or leg. There is alot we can do without having to use invasive and uncomfortable procedures.”
“Many patients tell us that they do not want significantly invasive procedures done, especially after having the unfortunate experience of requiring intensive care – they tell us that they do not want to have a big drip in the neck or groin; the ones that get stitched into skin.”

Step 3: Discuss Breathing Supports
“For breathing, we can give oxygen by various means: nasal prongs, a mask, or even warmed oxygen through a special high flow mask. However, many patients tell us that they do not want a high pressure mask – like a fighter pilots mask – that is strapped on to the face to force air into the lungs. It is called BIPAP or CPAP, and is the next level of breathing support. You cannot eat or drink while using the mask. The most invasive form of breathing support is called an endotracheal tube, also known as a breathing tube – it requires an induced coma.”

Step 4: Discuss Actual CPR.
[PATIENT IS A CANDIDATE FOR CPR – see part 3 if pt is not a candidate]
“CPR involves two things; chest compressions and electric shocks. If your heart goes into an abnormal rhythm, we can use electricity to try and reset the heart – this is called Defibrillation. It is a painful procedure, but you will likely be unconscious at the time it is performed. Chest compressions can be performed if your heart stops working to move blood around your body while we try to restart it. It involves compressing the chest by about 1/3rd of the way and will involve breaking the ribs and bruising the lungs.”
“Do you have any strong feelings or thoughts regarding CPR?”

Part 2: Template For Goals of Care Discussion, Written in the positive:

Patient Consents To The Following Treatment:

Ward Level Care:
– [YES] Medications/fluids via the following routes: Oral/NG, subcutaneous, intramuscular.
– [YES] Oxygen via Nasal prongs / Hudson Mask / Non rebreather Hudson Mask / High flow nasal prongs (warmed oxygen)

ICU/HDU Level Care:
– [YES] Medications via a central line
– [YES] Invasive monitoring: arterial blood pressure monitoring
– [YES] Breathing support via a Non-Invasive Ventilation (CPAP/BIPAP) device
– [YES] Breathing support via an endotracheal tube

Resuscitation
– [YES] Defibrillation and Chest Compressions discussed.
– [YES] Patient consents for ACLS and CPR per protocol.

Part 3: Spiels for Patients Who Have Significant Limitations

• No CPR, but for everything else. eg. The independant 85yo from home, with some comorbidities but a reversible condition like pneumonia]
• End-stage COPD / Chronic Lung Disease
• Ward Based Care Only. eg. 90yo from a high level care nursing home with dementia

[No CPR, but for everything else. eg. The independant 85yo from home, with some comorbidities but a reversible condition like pneumonia]
“We will provide the maximum treatment possible without causing harm, pain and suffering for no reasonably good outcome. This means IV antibiotics, steroids, fluids, and powerful drugs via big drips in the neck or groin. We will also give oxygen via a high pressure mask or breathing tube if required. However, we would not perform chest compressions as it is brutal and will almost certainly be fatal – in the best case situation it will cause prolonged suffering with no reasonable outcome.”

[End-stage COPD / Chronic Lung Disease] “We will be using a high pressure mask to give you the best chance of recovery, but rest assured we will not torture you or cause any severe distress. If it is not tolerated for any reason, we will not force it on you, and remove it. We will also ensure it will not be used for a prolonged period – hours, not days. Does that sound reasonable to you?” “Your comfort remains our priority. We wont perform procedures that would certainly cause pain with no positive outcome – this includes chest compressions that will break ribs and bruise the lungs, which is very painful and not survivable.” >> document: “Trial of NIV for ‘hours not days’, and only as tolerated. Not for CPR”

[Ward Based Care Only. eg. 90yo from a high level care nursing home with dementia]
Discuss positives with NOK then document: “The patient’s family consents for medications and fluids to be given orally, subcutaneously, or intramuscularly. They agree that pt’s comfort should be a priority, and that a peripheral cannula should be used only if tolerated, and in the short term if possible. No significantly invasive procedures such as drips that require stitching on to the skin (central lines / arterial lines) are to be performed as they will cause more distress without any meaningful long term outcome. Oxygen can be given with nasal prongs or a reservoir (non rebreather) hudson mask as required for comfort, and only if tolerated, with comfort as a focus of care.” By documenting this, you are effectively stating that the patient is for ward level care, while reassuring the family that there are a lot of treatments that can be provided without invasive / hurtful / futile procedures.