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Making Difficult Decisions

Identifying Goals of Care

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Updated October 05, 2010

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 hopefully 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 him.
  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 aggressive treatment no longer has any lasting benefit. Quality of life trumps quantity and the focus becomes comfort rather than cure. This is the beginning of preparing for a comfortable and dignified death.

Sometimes these goals of care can coexist. The life-limiting illness may be incurable but another illness can arise which can be easily treated. A person who is on hospice care for incurable cancer may still be treated to cure a urinary tract infection or pneumonia, for example.

Quality of Life

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. Some people are willing to sacrifice their comfort and enjoyment for the chance to live a few more months, even if that time is spent in the hospital. Others may decided to spend their final months at home with their loved ones, even if it means they may die a bit sooner. There is no "right answer" for everyone, only a "right" answer for you.

Plan Ahead, and Again, and Again

Establishing a goal of care early on and making your choices known is important. You can use an Advance Directive and appoint a Durable Power of Attorney for Health Care to make decisions for you if you become unable to. Equally important is reassessing that goal as things change. Early on in a serious illness, your goal may be to do everything possible to find a cure. As your illness progresses, that goal may change and you may want to modify any legal documents to reflect those changes.

Unfortunately, even with a clear goal in mind, decisions are rarely cut and dry. Difficult health care decisions are not made only with our logical minds. Our emotional and spiritual sides have a great impact on making difficult decisions as well, which can sometimes muddle an otherwise clear choice. Difficult decisions are so called because that is exactly what they are -- difficult.

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