Introduction to Difficult Decisions

Identifying Goals of Care

Throughout most of our lives, medical decisions are quite easy. If we get sick, we go to the doctor and get treated. We listen to the doctor and do what he suggests because it can only make us better. As one gets older, however, these decisions become less cut and dry. People are living longer and often with several long term illnesses. Treatments begin to offer only limited benefits and often come with painful or burdensome side effects. Now the benefits and burdens of treatments have to be weighed and decisions made based personal goals.

Adding to the difficulty of these decisions is the advancement of medical care. Ventilators, CPR, and feeding tubes have all helped people survive serious accidents and illnesses that wouldn’t have had a chance years ago. Because people with chronic disease or life-threatening illnesses have much less chance of benefiting from this technology, it is important for them to discuss life-prolonging treatments with their families and their doctor.

Goals of Care

The place to begin when considering life-prolonging treatments is to identify the intended goals of care. There are three possible goals for medical care:

1. Cure. This is the standard we are all used to. Nearly all health care is directed towards this goal. We get sick, we go to the doctor for treatment, and we are cured.
2. Stabilization. Sometimes we can’t be cured. Many diseases are incurable but can be stabilized with proper medical treatment. Diabetes is a good example of this. There is no known cure for diabetes but a diabetic patient can monitor blood sugars and take insulin injections and function very well. Someone with chronic lung disease may be on continuous oxygen therapy and take several medications to help them breathe but still maintain a level of functioning that is acceptable to them.
3. Comfort Only. This is the palliative care or hospice approach to care. This is usually the goal of care when a patient or their designated health care decision maker decides that treatment no longer offers them an acceptable quality of life. This is the beginning of preparing for a comfortable and dignified death.

Quality of life means something different for everyone. It is a very personal decision to make when treatments no longer contribute to quality of life but actually take away from it.

Sometimes these goals of care can coexist. A person who is on hospice care may still be treated to cure a urinary tract infection or pneumonia, for example.

Establishing a goal of care early on and reassessing that goal as things change is an important step as you prepare to face difficult choices that lie ahead. Unfortunately, even with a goal in mind, decisions are not made only with our logical minds. Our emotional and spiritual sides have a great impact on making difficult decisions. Difficult decisions are called that because that is exactly what they are….difficult.

We will address some of the most common difficult decisions you may be faced with: CPR, artificial feedings, mechanical ventilation, hospitalization, and more.