By Stacey Kusterbeck
Goals of care discussions are known to reduce invasive interventions and align patient care with patient values, but conversations often occur shortly before death.1 “Given the high morbidity and mortality associated with thoracic surgery, we sought to examine whether goals of care discussions were being utilized similarly for critically ill thoracic surgery patients,” says Christopher Towe, MD, associate professor of surgery at Case Western Reserve University.
Towe and colleagues conducted a study to understand how goals of care discussions were used and their timing in relation to patients’ time of death.2 The researchers conducted a retrospective chart review for 56 patients who underwent thoracic surgery. Patients discharged to hospice were more likely to have a palliative care consult and were less likely to be ventilator-dependent or comatose during the initial goals of care discussion than those who died in the hospital.
Multidisciplinary family meetings and palliative care consults were infrequent. While 93% of patients had goals of care discussions, many conversations occurred late in the patient’s hospital course. The majority of patients had their code status changed to comfort care on the day of death, and 77% died within 48 hours of their initial goals of care discussion. “This suggests a missed opportunity for earlier discussions,” says Towe.
Towe sees a broader ethical concern when goals of care conversations do not occur early enough. Without these discussions, patients may undergo aggressive interventions that are not in line with their wishes, prolonging suffering and reducing their quality of life. “Historically, there has been a tension between surgical care and palliative approaches,” notes Towe.
Surgeons often focus on interventions aimed at improving a patient’s condition, while palliative care emphasizes comfort. Bridging this gap requires a shift in perspective. “Surgeons must recognize the importance of comfort alongside recovery. And palliative care teams must understand that certain patients may still require complex interventions to address complications,” says Towe.
Ethicists in the hospital setting can advocate for the integration of palliative care early in the patient’s hospital course. This facilitates timely goals of care discussions, and ensures that both curative and comfort-oriented goals are considered. “Ethicists’ involvement can promote a more balanced approach to care that aligns with the values and needs of patients at all stages of illness,” concludes Towe.
References
- Bhangu JK, Young BT, Posillico S, et al. Goals of care discussions for the imminently dying trauma patient. J Surg Res. 2020;246:269-273.
- Alvarado CE, Worrell SG, Tipton AE, et al. The role of structured goals of care discussions in critically ill thoracic surgery patients. J Palliat Care. 2024;39(4):333-339.
