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Problem Vs Goal-Centered Approach To End Of Life Care

09/30/2013

Doctors treating seriously ill patients must shift from a problem-centered approach to a goal-centered approach to care, said Dr. Charles von Gunten, keynote speaker for the recent Hospice and Palliative Care Symposium at the Chicago Botanic Garden. “Some doctors look at the parts and some doctors look at the bigger picture,” said Von Gunten, an end of life care expert and editor-in chief of the Journal of Palliative Medicine.

Image: Von Gunten, The Institute For Palliative Medicine

Image: Von Gunten, The Institute For Palliative Medicine

“If the goal here is to win, and living is winning– and Americans hate losing, we use a fighting metaphor for health care– what really is winning?” Von Gunten asked. “As much as we would like to think that we are independent health care professionals, doing what is best for the patient in our judgement, we are influenced by the signals in our environment about what is winning.” The environment of health care actually favors short-term, problem-centered care, he added.

Von Gunten broke down the differences between problem-centered care and goal-centered care:

Problem

  • List Problems
  • Prepare A Plan To Resolve Each Problem
  • Reassess Each Day
  • When Problem Is Solved, Patient Is Better

Goal

  • Determine Overall Goal
  • Clarify Priorities Among Competing Goals
  • Choose Plan To Reach Goals

Patients receiving the problem approach may receive more unnecessary, painful and futile treatments (such as testing for cancers or insertion of feeding tubes) and accrue higher medical bills. There is usually little cohesion among treatments for such patients, and so the overall goal of care is lost.

On the other hand, patients experiencing goal-centered care know the best possible outcomes from their care, and may receive better symptom management and have short-term and long-term goals (like reaching a wedding anniversary or waiting for family). “We need to hope for the best and prepare for the worst. Human beings can live on both levels simultaneously,” Von Gunten said.

“Some doctors look at the parts and some doctors look at the bigger picture”

Physicians should also not characterize care for patients opting for goal-centered care as receiving less adequate care- but as the best possible care for their goals, Von Gunten said. “Words are like surgical tools, it takes time to practice them,” he said. Possible goals for seriously ill patients include: cure of disease, prolongation of life, relief of suffering, a good death and support for loved ones.

Von Gunten said initiating successful end of life conversations that address patients’ goals and fears are much more important than simply filling out advance directives. “It’s not a piece of paper, it’s the conversations that lead to the piece of paper, or the piece of paper generates the conversations,” he said.

“We have been taught to fight against the illness and that we win by keeping the patient alive,” said one doctor in the audience. “We need to take a step back. We need to change how we think.”

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