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Invited Commentary
April 2015

Goals of Care DiscussionHow Hard It Can Be

Author Affiliations
  • 1Cardiovascular Division, Department of Medicine, University of Pennsylvania, Philadelphia
  • 2Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
JAMA Intern Med. 2015;175(4):557-558. doi:10.1001/jamainternmed.2014.7740

Mechanical ventilation. Internal cardioverter defibrillators. Hemodialysis. Extracorporeal membrane oxygenation. Cardiopulmonary resuscitation. Percutaneous gastrostomy feeding tubes. Multidrug chemotherapy. Dying used to be less complicated when unaccompanied by decisions about high-tech interventions. We forestall mortality but at the cost of increasing end-of-life complexity. Clinicians help patients manage this complexity with open communication about prognosis, patients’ values and goals, and the impact of life-sustaining therapies. Since the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment1 of the mid-1990s, however, we have known that seriously ill patients rarely communicate end-of-life preferences to physicians. Recent studies show that more patients fill out advance directives and consider end-of-life care options, but few report having discussions with their clinicians.2,3 Yet evidence is mounting that goals of care discussions lead to better outcomes, particularly improved quality of life near the end of life and reduced costs. There is now an evidence base to support best practice recommendations.4 How can we make goals of care communication easier? Perhaps, following the lead of You and colleagues5 in this issue of JAMA Internal Medicine, we must first determine what makes it so hard.

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