Wednesday, September 5, 2012

Goals Based Decision Making

We face decisions every day;  minute things, like which cereal to eat in the morning, to the extremely complex, like is it time to encourage our parents to move into an assisted living facility? Depending on the ramifications of our choices, the amount of stress these decisions carry certainly varies.

One way to reduce angst associated with decision making is to step back and use a technique called goals based decision making. This term has become associated with hospice and palliative medicine because it runs countercultural to the way modern medicine tends to make decisions.

The idea is simple; instead of focusing on the immediate crisis, think ahead to what the objective is. We actually do this all the time.  Do we have a lot of activities today and our goal is to have energy? Then we choose a breakfast with more protein than simple sugars.  Are we meeting a new client that we hope to sign a contract with at work? Then we choose our more professional vs. casual clothes.  Those choices all involve a quick determination of goals. 

We do this for big decisions as well. When we decide where we’ll rent or buy a house, we don’t just consider the immediate crisis of needing a place to live, we think of the future and the purpose of this living structure. Does it need a certain number of bedrooms? Is the location important? How much work do we want to put into fixing it up? All of these are questions about where we’re headed.

It seems so simple, and yet when we enter the complex world of healthcare things change.  A specialist says you need to be on a medicine for your heart, because your numbers are high. Unfortunately this medicine also causes you to be in the bathroom 10x every morning, so you avoid leaving your house and are now napping more in the afternoons.  No one thought to ask about the goals. Is it more important to you to have those good numbers for your heart? Or is your goal to have energy and be out interacting with your community?  In medicine the default is to fix the problem, not to find out what you’re hoping for.

The issue with only focusing on the disease is the narrowness of that vision.  When I meet patients who are on 30 different medicines, with timers and schedules, pill boxes and post-it notes, I find they are lost in the regimen.  Life has become about managing the pills, which in turn makes the numbers look good.  These patients don’t say to me, “My goal in life is to have the best blood pressure and best cholesterol of anyone I know.”   Usually their goal is living life with quality, meaning and minimal burden. 

When you have goals the decisions become easy. If the most important thing for you is to live independently, and you are diagnosed with something that makes that goal impossible, then the choices about medications and procedures that would place you in a nursing home should be denied.  Unfortunately it’s up to you to speak out. The healthcare system is designed to fix diseases and avoid death, period. As to where you’re headed, that’s up to you. 

No comments:

Post a Comment