Understanding Goals of Care Statements and Preferences among Patients and Their Surrogates in the Medical ICU.

BACKGROUND: Treatment decisions should be based on patients' goals of care to provide an ethical, patient-centered framework for decision-making. OBJECTIVES: The purpose of this study is to improve our understanding about how patients' and surrogates' goals of care are communicated and interpreted in an MICU. METHODS: One hundred patients admitted to an MICU, or their surrogates, responded to an open-ended question about goals of care for their hospitalization followed by a closed-ended question regarding their most important goal of care. Investigators interpreted participants' open-ended responses and compared these interpretations with participants' closed-ended, most-important-goal selections. RESULTS: Investigators' interpretations of participants' open-ended goals of care responses matched participants' closed-ended most important goal of care in only 28 of 100 cases. However, there was good inter-rater reliability between investigators in their interpretation of participants' open-ended responses, with agreement in 78 of 100 cases. CONCLUSIONS: Clinicians should be cautious in interpreting patients' or surrogates' responses to open-ended questions about goals of care. A shared understanding of goals of care may be facilitated by alternating open-ended and closed-ended questions to clarify patients' or surrogates' responses.

Code status orders and goals of care in the medical ICU.

BACKGROUND: Decisions about CPR in the medical ICU (MICU) are important. However, discussions about CPR (code status discussions) can be challenging and may be incomplete if they do not address goals of care. METHODS: We interviewed 100 patients, or their surrogates, and their physicians in an MICU. We queried the patients/surrogates on their knowledge of CPR, code status preferences, and goals of care; we queried MICU physicians about goals of care and treatment plans. Medical records were reviewed for clinical information and code status orders. RESULTS: Fifty patients/surrogates recalled discussing CPR preferences with a physician, and 51 recalled discussing goals of care. Eighty-three patients/surrogates preferred full code status, but only four could identify the three main components of in-hospital CPR (defibrillation, chest compressions, intubation). There were 16 discrepancies between code status preferences expressed during the interview and code status orders in the medical record. Respondents' average prediction of survival following in-hospital cardiac arrest with CPR was 71.8%, and the higher the prediction of survival, the greater the frequency of preference for full code status (P = .012). Of six possible goals of care, approximately five were affirmed by each patient/surrogate and physician, but 67.7% of patients/surrogates differed with their physicians about the most important goal of care. CONCLUSIONS: Patients in the MICU and their surrogates have inadequate knowledge about in-hospital CPR and its likelihood of success, patients' code status preferences may not always be reflected in code status orders, and assessments may differ between patients/surrogates and physicians about what goal of care is most important.