I'd like to take a moment now to review goals of care. We spent a lot of time in palliative care talking about goals of care, and I think that goals of care are one of the foundational components of what we do in a palliative care interaction. As a reminder, goals of care actually has a couple of different components. Goals of care include, conversations and documentation. So a goals of care conversation is often an open-ended dialogue between a clinician, and the patient, and their family about their goals and their priorities. It's an opportunity to explore a patient's values and what's most important to them. You might learn that they really want to be able to continue to volunteer in their kid's classroom, or they might want to get to a wedding. Or they really feel that it's super important that they are able to maintain their cognitive level as high as possible to work on research, or they enjoy playing the guitar and they need to maintain good function of their hands. Advance care planning is the opportunity to take those goals and values and to put them on paper. So, if you know that they want to attend this wedding, or they want to maintain their cognition, or they want to maintain their function, you take those values and you use that to inform formal documentation in the form of something like an advanced directive. Or in some states, a physician order for life-sustaining treatment or a POLST and so,we recognize that these will constantly change, this is a living document. And so our hope is that if you're going to provide goal concordant care, that with transitions in care, with transitions in disease, with transitions in the family, you are having a new goals of care conversation, you're assessing how goals and priorities are changing over time, and you're creating new documents that reflect these changes. So, very simply, have a conversation, use that conversation to inform your documentation, and have the discussion again. If priorities have shifted, or if disease, or care has shifted, so that you can reinvoke those goals, make sure that you're providing care that's concordant with those goals, and make sure that the documentation reflects those goals and changes over time. Is this easy? Sometimes, I would say that there are many families that are really ready to talk about goals of care, but they're also families that feel like this is an encroachment on their ability to stay positive, and an invitation for a bad outcome. Common worries and fears, you see our lovely patient saying, I'm just not ready, I want to stay positive, my future is in God's hands. These are very common emotions that a patient has when a provider wants to talk about goals of care. And the provider is also thinking about how to approach this, and wondering maybe there are some ways that I can help my patient get through and have this conversation. She might be thinking or asking, tell me a little bit about why you're hesitating. are there folks that would be helpful to you in making these difficult decisions? It's common to have an advanced directive and we have all of our patients do an advance directive. Is there a person that you trust on the team that you'd like to have this conversation with? I think that there are many approaches to try to overcome resistance. I would say that if you are feeling like you've given it a good go, and the patient and family just don't feel comfortable, it's okay to step back. And it's okay to say, I've done my best to today, and maybe ask for some help from either a colleague or a palliative care specialist.
