1. Goals of Care in Palliative Medicine:- Managing Potential Conflicts in the Ghanaian Context
Setorme Tsikata, MBChB, MSc., CCFP.
Assistant Clinical Professor
Dept. of Family Medicine
University of Alberta, Canada
Medical Knowledge Fiesta, 13 Sept. 2016

2. Conflict of Interest
None to declare

3. Learning Objectives
Become familiar with a typical Goals of Care (GoC) designation model using a prototype by Alberta Health Services as a template for local adaptation
Discuss potential conflicts in (GoC) that may arise and possible resolution during palliation – Case examples.
To promote discussions about options for home versus hospice-type care based on available resources locally, at the end of life.

4. Case 1
56y/o female, First Nations (aboriginal), admitted to the acute care unit due to worsening pain, ascites and generalized swelling (anasarca). She was diagnosed with colon CA 5 years ago and had surgery and several cycles of chemotherapy till 8 months ago when liver metastasis was diagnosed. All recent treatments have been unsuccessful and the patient opted for palliative management and designated as C1 for her goals of care.
Current meds include
Morphine Sulphate 15mg i-ii tabs po q 4hrly, prn
Morphine Contin 30mg po bid
Citalopram 40mg po daily
Dexamethasone 4mg po tid
Senokot 2 tabs po qhs
Lax-A-Day 17g po daily (Polyethylene Glycol)
Marijuana oil – OTC from herbal store

5. Case 1 ctd. Physical exam:-
Slipping in and out of consciousness, nods at times
Generalized edema, very dyspneic due to worsening ascites
Enlarged Abdomen, full of metastatic tumors and hepatosplenomegaly
Patient in +++ pain, moaning and groaning
Not saying very much

6. Issues at stake Patient not taking pain meds
“morphine is not a good drug”
Prefers to use marijuana oil
Family heavily influencing patient’s compliance
History of close family member dying from cancer – “morphine killed him”
Family would like patient to be alert & “with it” and have no pain
Family request paracentesis – “googled procedure”

7. Questions What are your management priorities for this patient?
How will you handle family’s request to
Keep patient alert & “with it” and have no pain
Perform paracentesis (blindly)
Locally, how would you support the family if they request patient be discharged to die at home (eg. at Osu)?

8. Case 2
80y/o male with end-stage COPD, intubated, unconscious, in ICU with pneumonia and end-stage renal and hepatic failure. PMhx of chronic alcoholism.
Has advanced directive completed 10 years ago when he was fully functional and in good health, for life-sustaining measures or “full code”.
Healthcare team conflicted due to the poor prognosis if resuscitated in the event of a cardiac arrest, etc. – concerns with severe cognitive impairments, etc.
Wife would like some counselling since she’s his health care agent in his advanced directive. She wants to take the best decision in his interest but feels conflicted in his desire for full resuscitation.

9. Question
As the patient’s family physician, how do you counsel his wife to help her make the right decision in the best interest of this patient?
In the Ghanaian context, what are some of the potential conflicts that may require addressing in such a discussion/counselling session?

10. Importance of Goals of care/advanced care plans
Ensures that patients who are unlikely to benefit from treatment aimed at cure, receive care appropriate to their condition and are not subjected to futile treatments.
This becomes important for decisions regarding intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) or surgical intervention, among other procedures.
Sets a premise for a plan of management both for patients and their family/care-givers on one hand and their health care providers, on the other hand.

11. Being Proactive in Advance Care planning
Ideally, all geriatric patients and those critically ill need to have documentation of goals of their care to guide and inform treatment when they see a physician.
Should be prepared while the patient is competent and can make their own healthcare decisions or by a designated / substitute decision maker.
Patients who earlier on want to make their wishes known while they are healthy or prior to becoming incapacitated by illness.
The final decision ultimately remains clinical and ideally based on finding common- ground with patients/care-givers based on the circumstances.

12. Goals of Care Designation
A medical order used to describe and communicate the general aim or focus of care including the preferred location of that care.
Although advance care planning conversations don't always result in determining goal of care designation, they make sure your voice is heard when you cannot speak for yourself (1).

13. Previous goals of care designation
Full code
No code
?? Symptomatic Care
Rigid, not patient-centered

14. Goals of Care Designation – Alberta Health Services Model
Resuscitative Care
Focuses on prolonging or preserving life using medical or surgical interventions, including, if needed, resuscitation and intensive care.
Medical Care
Focuses on medical tests and interventions to cure or manage a person’s illness, but does not use resuscitative or life support measures.
Comfort Care
Focuses on providing comfort for people with life-limiting illness when medical treatment is no longer an option.

15. Resuscitation
R1 – Medical Care including ICU admission if required, WITH intubation AND chest compressions
- Patients who would benefit from, and are accepting of, any appropriate investigations and interventions that the health system can offer, including physiologic support in an ICU setting if required.
All appropriate supportive therapies are offered including intubation, chest compressions during resuscitation when clinically appropriate

16. Resuscitation
R2 – medical Care including ICU admission if required, with intubation but without chest compressions
- For patients who would benefit from, and are accepting of, any appropriate investigations and interventions that the health system can offer, including physiologic support in an ICU setting if required, but EXCLUDING chest compressions

17. Resuscitation
R3 – Medical Care including ICU admission if required, without intubation or chest compressions
- For patients who would benefit from, and are accepting of, any appropriate investigations and interventions that the health system can offer, including physiologic support in an ICU setting if required, but EXCLUDING intubation and chest compressions

18. Medical Care
M1 – Medical care with transfer to acute care when required and WITHOUT the option for ICU care
- For patients for whom all active medical and surgical interventions aimed at cure and control of conditions are considered, within the bounds of what is medically appropriate, and EXCLUDING the option of admission to an ICU

19. Medical Care
M2 – Medical care WITHOUT transfer to acute care and WITHOUT the option for ICU care
- For patients for whom all interventions that can be offered in the current location of care are considered. If a person deteriorates further and is no longer amenable to cure or control interventions in that location, the Goals of Care Designation should be changed to focus on comfort care primarily

20. Comfort Care C1 – Symptom Comfort Care
For patients for whom a diagnosis exists which is expected to cause eventual death. New illnesses are not generally treated unless control of symptoms is the goal

21. Comfort Care C2 – Terminal care
- For patients for whom a diagnosis exists which is expected to cause eventual death. Expert terminal care can be provided in any location

22. Can Goals of Care Designation be changed?
Yes, Goals of Care Designation can be changed at any time and should be reviewed if:
health condition changes
circumstances change (such as new understanding)
transfer or admission to another healthcare setting (eg. acute care to long-term care)

23. Definition of Palliative Care
WHO definition – an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual(2)

24. Goals of palliation
Palliation is defined by Webster as reducing the violence of a disease; to ease symptoms WITHOUT curing the underlying disease
Goals therefore are
- relieving suffering from pain and other symptoms
improving the quality of life of patients, throughout the illness and bereavement experience …..
Irrespective of prognosis, patients have a right to being afforded the best care possible as a basic human right (2); this ideally should be upheld.

25. Using a Patient-Centered Approach 1
Discuss diagnosis & prognosis with patients &/family/care-giver (s) – stage of disease, evidence
- Honesty and transparency
Address patients’ priorities (2), fears, ideas, feelings, expectations – allow ample time
Goals of Care at end of life – dependent on culture, values, belief system, FAITH, age, distal and proximal contexts
- Address religious, spiritual beliefs in a patient-centered fashion.
Discuss “trade offs” – risk of prolonging suffering versus benefits of added time; ie. buying time for the inevitable versus quality of life during that added time.

26. Using a Patient-Centered Approach 2
Patient’s wishes ultimately over-rides wishes of family/care-givers unless patients are unable to consent to treatment
Advanced directives
Enduring power of attorneys, substitute or alternate decision makers. etc.

27. Using a Patient-Centered Approach 3
Ethical implications when treatment is futile in resource-deficient settings (where healthcare is literally rationed and equity prevails)
Finding Common-Ground when patients’/family wishes are incongruent with standards of care at end of life

28. Case 1
56y/o female, First Nations (aboriginal), admitted to the acute care unit due to worsening pain, ascites and generalized swelling (anasarca). She was diagnosed with colon CA 5 years ago and had surgery and several cycles of chemotherapy till 8 months ago when liver metastasis was diagnosed. All recent treatments have been unsuccessful and the patient opted for palliative management and designated as C2 for her goals of care.
Current meds include
Morphine Sulphate 15mg i-ii tabs po q 4hrly, prn
Morphine Contin 30mg po bid
Citalopram 40mg po daily
Dexamethasone 4mg po tid
Senokot 2 tabs po qhs
Lax-A-Day 17g po daily (Polyethylene Glycol)
Marijuana oil – OTC from herbal store

29. Case 1 ctd. Physical exam:-
Slipping in and out of consciousness, nods at times
Generalized edema, very dyspneic due to worsening ascites
Enlarged Abdomen, full of metastatic tumors and hepatosplenomegaly
Patient in +++ pain, moaning and groaning
Not saying very much

30. Issues at stake Patient not taking pain meds
“morphine is not a good drug”
Prefers to use marijuana oil
Family heavily influencing patient’s compliance
History of close family member dying from cancer – “morphine killed him”
Family would like patient to be alert & “with it” and have no pain
Family request paracentesis – “googled procedure”

31. Questions What are your management priorities for this patient?
How will you handle family’s request to
Keep patient alert “with it” and have no pain
Perform paracentesis (blindly)
Locally, how would you support the family if they request patient be discharged to die at home (eg. at Osu)?

32. Case 2
80y/o male with end-stage COPD, intubated, unconscious, in ICU with pneumonia and end-stage renal and hepatic failure. PMhx of chronic alcoholism.
Has advanced directive completed 10 years ago when he was fully functional and in good health, for life-sustaining measures or “full code”.
Healthcare team conflicted due to the poor prognosis were he to ever recover – concerns with severe cognitive impairments, etc.
Wife would like some counselling since she’s his health care agent in his advanced directive. She wants to take the best decision in his interest but feels conflicted in his desire for full resuscitation.

33. Question
As the patient’s family physician, how do you counsel his wife to help her make the right decision in the best interest of this patient?
In the Ghanaian context, what are some of the potential conflicts that may require addressing in such a discussion/counselling session?

34. Conclusion
Goals of Care designations and their documentation can help reduce anxieties and conflicts that arise during palliation for patients.
Should be prepared while the patient is competent and can make their own healthcare decisions or by a designated substitute decision maker
Patients should have the option to die at home if they choose and be supported by available resources eg. Palliative Care team in conjunction with their FPs/GPs.

35. THANK YOU

36. References www.albertahealthservices.ca 2. World Health Organization
3. Gawande Atul, Being Mortal; Medicine and what matters in the end, 2014.