Prioritizing What Matters in Healthcare: A Comprehensive Approach
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Focusing on What
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atters
Most means looking at the goals
of our care, coordinating advance care planning, and making sure priorities
and preferences that are important to us individually become part of our
treatment plans.What Matters
•
Focusing on
M
edications
means raising awareness about
potential side effects while also working to reduce the number of
medications we take whenever we can.Medications
•
is the term for being able to move freely on our own or with
help.
M
obility
is linked to staying physically fit and being able to live on our
own for as long as possible, which makes it one of the most important “Ms”
of geriatrics for our health, safety, and independence. Focusing
on
M
obility
means maintaining our ability to walk or stay balanced while also
avoiding falls and other types of common injuries.Mobility
•
Staying mentally sharp and managing mental health can help us
live longer and hopefully healthier lives. That’s why expert attention to
the
M
ind
—one of the “Ms” of geriatrics and age-friendly care—is such an
important part of our well-being. Focusing on the
M
ind
means supporting
our brain health and managing unique conditions like dementia, delirium,
and depression, which can affect our ability to think clearly and make
decisions.Mentation
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Rebecca Sudore et al
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Advance Care Planning
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Tinetti, Blaum, Naik, et al
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Priority setting in multimorbidity, good for
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ACP entails
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Identification of surrogates
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Elicitation of What Matters
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40 yo woman is an elementary school art teacher
with hyperlipidemia and hypothyroidism.
•
Recently remarried, she has an 8-month old son
and 5-year-old daughter.
•
A chest film incidentally discovers a 2-cm RUL
mass; pathology shows adenocarcinoma.
•
What are your next steps in her care?
M
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85 yo woman is a retired elementary school art
teacher with advanced parkinson disease, related
dementia, HFrEF (last EF 20%), frailty.
•
Widowed, her son and daughter reside out of
state with their families. Resides in an ALF.
•
A chest film incidentally discovers a 2-cm RUL
mass; pathology shows adenocarcinoma.
•
What are your next steps in her care?
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Be of uncertain benefit
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Few older adults in RCT’s
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Those who are don’t look like Mildred
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These persons have less benefit from
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•
Be burdensome
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Inflict unintended harm
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Be frustrating
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Involves
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Reflection
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Sharing
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Choosing a surrogate
•
Articulating What Matters Most
•
(Maybe) Clarifying strong views about medical
interventions
•
CPR
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Intubation
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Dialysis
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Artificial nutrition and hydration
•
Etc.
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Thinking in advance – hope for the best, prepare
for the worst
•
Benefit for patient and family
•
No decisions necessary today, but…
•
Is this OK?
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•
(Not always necessary)
•
What is your understanding now of where we are
with your illness?
•
“I know we doctors may not always do the best
job of communicating about these things”
•
Calibrate their understanding as needed
P
R
O
G
N
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I
S
•
(Not always necessary)
•
(May provide rationale for: Why now?)
•
Share prognosis as a range, tailored to
information preferences
•
How to estimate?
•
Experience
•
Contact consultant if a prominent disease
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Can’t expect the process or document to cover
every possible situation or decision
•
Better to spend time clarifying desired (vs
undesired) way of living than…
•
Checking a selection of boxes on menu of
possible interventions
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Can understand and represent patient’s particular
goals, values, preferences…
•
…Even if they don’t agree with them!
•
Can make decisions in difficult moments
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Can’t just pick one – need to have a heart-to-
heart talk
•
Patient should think about and clarify how much
flexibility (if any) to grant the surrogate
W
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M
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T
T
E
R
S
:
G
O
A
L
S
•
What things are most important in your life?
•
Examples:
•
Function and independence – living on your
own, caring for yourself
•
Longevity
•
Social connection – friends, family, religion
•
Symptom relief
•
Have you changed your mind about what matters
in your life? (Say more…)
G
O
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L
S
,
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t
.
•
What would you be doing more of if your [ailment]
were not so burdensome?
•
(Probably better for current multimorbid
management than for ACP)
•
What activities are particularly important or
meaningful?
G
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S
,
c
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t
.
•
Describe what a good day would look like
•
Which relationships or connections are most
important to you?
•
What brings you the most enjoyment or pleasure?
•
What do you hope your health care can do for
you?
W
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A
T
M
A
T
T
E
R
S
:
B
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D
E
N
S
•
Are these aspects of your health care making it
difficult to meet your goals
•
Medicines (pills, shots, drops, inhalers)
•
Self-care tasks (diet, FSBG checks…)
•
Blood tests and x-rays, etc.
•
Medical visits
•
Dialysis…
•
What are you willing/able to do, and what NOT?
W
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A
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S
:
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S
A
N
D
W
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R
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S
•
What are your biggest fears and worries about
the future with your health?
•
What experience have you had with serious
illness?
•
What went well? What didn’t? Why?
•
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,
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.
•
Can you imagine anything that would be worse
than death? Or,
•
Can you think of any health situations that would
be hard on your quality of life?
•
Some people might say
•
Not being able to live w/o machines
•
Not being able to think for oneself
•
Not being able to live on one’s own
•
Constant pain…
S
C
E
N
A
R
I
O
T
O
C
O
N
S
I
D
E
R
•
Sudden event has left you unable to
communicate
•
You’re receiving all care needed to keep you alive
•
Doctors believe little chance you’ll recover ability
to know who you are or who you’re with
•
Would you want
•
Medical treatment to keep you alive, or
•
To stop the medical treatment
•
(You’d be kept comfortable in any case)
W
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A
T
M
A
T
T
E
R
S
:
F
U
N
C
T
I
O
N
•
What abilities are so critical to your life that you
can’t imaging living without them?
W
H
A
T
M
A
T
T
E
R
S
:
T
R
A
D
E
-
O
F
F
S
•
If you became sicker, how much are you willing to
go through for the possibility of gaining more
time?
•
“I’ve had some patients who have told me, “Doc, I
want you to do anything you can to have me live
as long as possible – surgery, breathing
machines, you name it….”
•
“And I’ve had other patients….”
Focusing on what truly matters in healthcare involves aligning care goals, optimizing medications, maintaining mobility, promoting mental acuity, and fostering collaboration. Advance care planning, identifying patient priorities, and eliciting what matters are crucial components for enhancing patient-centered care and managing complex health needs effectively.
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Presentation Transcript
What Matters Bill Lyons, MD February 25, 2021
This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $751,695.00 with 0% financed with non- governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
What Matters Focusing on What Matters Most means looking at the goals of our care, coordinating advance care planning, and making sure priorities and preferences that are important to us individually become part of our treatment plans. Medications Focusing on Medications means raising awareness about potential side effects while also working to reduce the number of medications we take whenever we can. Mobility is the term for being able to move freely on our own or with help. Mobility is linked to staying physically fit and being able to live on our own for as long as possible, which makes it one of the most important Ms of geriatrics for our health, safety, and independence. Focusing on Mobility means maintaining our ability to walk or stay balanced while also avoiding falls and other types of common injuries. Mentation Staying mentally sharp and managing mental health can help us live longer and hopefully healthier lives. That s why expert attention to the Mind one of the Ms of geriatrics and age-friendly care is such an important part of our well-being. Focusing on the Mind means supporting our brain health and managing unique conditions like dementia, delirium, and depression, which can affect our ability to think clearly and make decisions.
Collaboration helps us all achieve more Methods to collaborate: Attend, Participate, Provide Feedback Please note your attendance in the CHAT by entering Name, Role, E-mail address During discussion: Please unmute yourself to contribute and ask questions. Following each session, complete surveys and provide feedback
COUPLE OF GREAT RESOURCES prepareforyourcare.org Rebecca Sudore et al Advance Care Planning patientprioritiescare.org Tinetti, Blaum, Naik, et al Priority setting in multimorbidity, good for ACP as well
ACP AND ELICITING WHAT MATTERS Similar and related activities ACP, by definition, is about planning for the future ACP entails Identification of surrogates Elicitation of What Matters Yet eliciting What Matters is helpful in the here and now of managing multimorbid patients
MEET RENEE 40 yo woman is an elementary school art teacher with hyperlipidemia and hypothyroidism. Recently remarried, she has an 8-month old son and 5-year-old daughter. A chest film incidentally discovers a 2-cm RUL mass; pathology shows adenocarcinoma. What are your next steps in her care?
MEET MILDRED 85 yo woman is a retired elementary school art teacher with advanced parkinson disease, related dementia, HFrEF (last EF 20%), frailty. Widowed, her son and daughter reside out of state with their families. Resides in an ALF. A chest film incidentally discovers a 2-cm RUL mass; pathology shows adenocarcinoma. What are your next steps in her care?
CARE FOR MANY OLDER ADULTS WITH MULTIPLE CONDITIONS MAY Be of uncertain benefit Few older adults in RCT s Those who are don t look like Mildred These persons have less benefit from treatment than those in the studies Be burdensome Inflict unintended harm Be frustrating Hence the need for determining What Matters
ADVANCE CARE PLANNING Is a process, not just a form or document Involves Reflection Sharing
KEY DECISIONS INVOLVED IN ACP Choosing a surrogate Articulating What Matters Most (Maybe) Clarifying strong views about medical interventions CPR Intubation Dialysis Artificial nutrition and hydration Etc.
SET UP THE CONVERSATION Thinking in advance hope for the best, prepare for the worst Benefit for patient and family No decisions necessary today, but Is this OK?
CHECK THEIR UNDERSTANDING (Not always necessary) What is your understanding now of where we are with your illness? I know we doctors may not always do the best job of communicating about these things Calibrate their understanding as needed
PROGNOSIS (Not always necessary) (May provide rationale for: Why now?) Share prognosis as a range, tailored to information preferences How to estimate? Experience Contact consultant if a prominent disease eprognosis.ucsf.edu
REALISTIC EXPECTATIONS OF ACP Can t expect the process or document to cover every possible situation or decision Better to spend time clarifying desired (vs undesired) way of living than Checking a selection of boxes on menu of possible interventions
CHARACTERISTICS OF A GOOD SURROGATE Reasonably available Can understand and represent patient s particular goals, values, preferences Even if they don t agree with them! Can make decisions in difficult moments
CHOOSING THE SURROGATE Can t just pick one need to have a heart-to- heart talk Patient should think about and clarify how much flexibility (if any) to grant the surrogate
WHAT MATTERS: GOALS What things are most important in your life? Examples: Function and independence living on your own, caring for yourself Longevity Social connection friends, family, religion Symptom relief Have you changed your mind about what matters in your life? (Say more )
GOALS, cont. What would you be doing more of if your [ailment] were not so burdensome? (Probably better for current multimorbid management than for ACP) What activities are particularly important or meaningful?
GOALS, cont. Describe what a good day would look like Which relationships or connections are most important to you? What brings you the most enjoyment or pleasure? What do you hope your health care can do for you?
WHAT MATTERS: BURDENS Are these aspects of your health care making it difficult to meet your goals Medicines (pills, shots, drops, inhalers) Self-care tasks (diet, FSBG checks ) Blood tests and x-rays, etc. Medical visits Dialysis What are you willing/able to do, and what NOT?
WHAT MATTERS: FEARS AND WORRIES What are your biggest fears and worries about the future with your health? What experience have you had with serious illness? What went well? What didn t? Why? In the same situation, what would you want?
FEARS AND WORRIES, cont. Can you imagine anything that would be worse than death? Or, Can you think of any health situations that would be hard on your quality of life? Some people might say Not being able to live w/o machines Not being able to think for oneself Not being able to live on one s own Constant pain
SCENARIO TO CONSIDER Sudden event has left you unable to communicate You re receiving all care needed to keep you alive Doctors believe little chance you ll recover ability to know who you are or who you re with Would you want Medical treatment to keep you alive, or To stop the medical treatment (You d be kept comfortable in any case)
WHAT MATTERS: FUNCTION What abilities are so critical to your life that you can t imaging living without them?
WHAT MATTERS: TRADE-OFFS If you became sicker, how much are you willing to go through for the possibility of gaining more time? I ve had some patients who have told me, Doc, I want you to do anything you can to have me live as long as possible surgery, breathing machines, you name it . And I ve had other patients .
