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Palliative Care Perspectives : Chapter 7: Communication : The GOOD Acronym

The GOOD Acronym: 'Its Good to Incorporate Patient and Family Preferences into Decision Making.'

Fortunately, in most cases there is a middle ground between these extremes of consumerism and physician paternalism. Most patients and families will willingly enter into a collaborative decision-making process if offered the chance.

The GOOD acronym (goals, options, opinion, document) provides a construct for communicating with patients and others involved in making such difficult decisions. GOOD decision making for such problems is a cooperative venture that involves input from patients, families, and health care providers. The acronym provides only a crude structure for engaging in such conversations. Flexibility and practice are required if communication skills are to improve.

G: Goals

What are the "big picture" goals for patients, families, and care providers? Understanding the big picture is critical to good decision making and facilitates the identification of explicit treatment goals. Often, these goals are not clearly stated by participants and may not even be clearly conceptualized. Identifying and clarifying such goals makes consideration of specific options much easier. Sometimes goals can be obvious. A patient who shows up at an emergency room with a cut on the finger probably wants it sewn up. We can assume this is a goal we share with the patient. Rarely are goals so clear-cut toward the end of life. Patients and their families may have very different goals relating to how they wish to live and die. Often, we are simply unaware of patient and family goals because such goals arise from long and complex life stories about which we are understandably ignorant. We will not understand their goals unless we ask. In terms of storytelling, goals represent possible story endpoints.

Steps in considering goals include:

Palliative Care Note
"What is your understanding of..." is one of the most important questions you can ask regarding an episode of illness.

O: Options

Palliative Care Note
Clinicians who would never think about addressing a therapy "outside their area of expertise," such as what chemotherapy agent to use for a particular tumor, often seem not to hesitate to bring up such issues and offer options regarding end-of-life decisions about which they are at least as ignorant. Perhaps this is because they do not recognize that a body of knowledge also exists in this area.

O: Opinion

Palliative Care Note
Although the boundary between the personal and the "medical" in such decisions is indeed difficult to demarcate, I do not believe such issues are so outside the medical realm that opinion should not be offered. The choices involve clinicians, and their medical knowledge and experience should help people make more intelligent choices.

D: Document

A quick survey of many hospital and clinic charts will reveal that documentation of important discussions is often lacking. This is not only ill advised clinically, but also medically and legally. Imagine a patient with whom you have discussed code status who agrees to a DNR status. She then dies. A relative subsequently states that the patient had always wanted "everything done." The first source of information would be the medical record. A (common) note stating simply "DNR" would not document that the patient had been involved in the decision. You might be sued. Conversely, if you wrote only "Full Code" or nothing at all and the patient arrested and was resuscitated with serious neurologic sequelae, you might be accused of resuscitating a patient against her wishes. The family might refuse to pay the bill. What you should document in your note should include:

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.