A 71-year-old woman with metastatic non-small cell lung cancer is admitted to the intensive care unit for malignant airway obstruction with post-obstructive pneumonia and sepsis. Her oncologist calls the admitting physician to provide sign out, saying, "Her disease has been progressing. Our plan was to start a third-line chemotherapy regimen next week." Despite receiving antibiotics and supportive care, she has rapid deterioration of her respiratory status with a very high likelihood of dying in the intensive care unit. When the physician discusses the patient's condition, the patient and family say, "Whatever might have a chance of working, we want everything to be done." Which of the following is the most appropriate response?
When patients & families request that "everything" be done | |
Understand what "everything" means |
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Communicate prognosis |
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Propose a philosophy of treatment |
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Support emotional response |
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Negotiate disagreements |
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This gravely ill patient has acute respiratory failure due to refractory metastatic lung cancer. Because the patient is rapidly deteriorating, discussions regarding goals of care are time-sensitive, as she may soon be incapacitated (eg, urgently intubated) and unable to participate in her own decision-making (Choice E).
The patient and her family request that "everything" be done, a frequently voiced sentiment during care discussions. In the outpatient oncology setting, "everything" meant exhausting multiple chemotherapy regimens to achieve a disease response. Unfortunately, the patient has become unstable and is very likely to die during her acute hospitalization. Predefined preferences should therefore be revisited regularly, including whenever there is a major change in clinical status. The physician cannot presume that a patient's past preferences can be directly extrapolated to a new situation.
Patients can be unsure of how to express evolving preferences without an open invitation to a discussion. Therefore, clarifying the patient's current concept of "everything" is the first step toward developing a shared plan of care. "Everything" has fluid meanings, shifting across both a patient's life span and different clinical situations. Due to this wide variability, it is critical to guide and support patients as they weigh the acceptability of potentially harmful interventions with a low likelihood of benefit.
(Choice B) The patient and her oncologist may have previously discussed long-term goals of care. However, her current preferences need to be revisited in light of her acute deterioration, with specific clarification about the meaning of "everything."
(Choices C and D) Some patients request "everything to keep me alive at all costs." Radiation and airway stenting can temporarily improve pulmonary function and extend this patient's life by days to weeks. However, her personal beliefs, values, and concept of "everything" should be openly discussed and reevaluated prior to offering treatments that may ultimately prolong the inevitable dying process with no meaningful benefit.
Educational objective:
When approaching goals of care, the specific meaning of a patient or family's request that "everything be done" should be explored and revisited regularly, including whenever there is a major change in clinical status.