Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 1: Goals of Care Conversation and Code Status
Clinical Image
Source: Wikimedia Commons - Doctor-Patient Communication - CC BY-SA 4.0
Case Presentation
A 78-year-old man with stage IV non-small cell lung cancer with brain and bone metastases is admitted for worsening dyspnea and pain. His oncologist confirms he has exhausted all systemic treatment options. His ECOG performance status has declined from 2 to 4 over the past month. He is alert and has decision-making capacity. The sub-intern is asked to lead a goals of care discussion with attending supervision. She begins by asking about his understanding of his illness ("What have the doctors told you about where things stand?"). He responds, "I know it's bad, but I'm hoping for a miracle." She gently asks what he hopes for and what he fears most. He expresses that he does not want to suffer and wants to be home with his family. She explores his values: "If we reach a point where your heart stops or you can't breathe on your own, would you want us to try to restart your heart with chest compressions or put you on a breathing machine?" She explains honestly that CPR in his situation has less than 5% chance of success, and if it did work, he would likely be in the ICU on machines. She asks what he would consider an acceptable outcome. He says, "I don't want to die in an ICU. I want to be comfortable and with my family." She makes a recommendation aligned with his values: "Based on what you've shared, I would recommend that we focus on keeping you comfortable and maximizing your time with family, rather than interventions like CPR that are unlikely to give you the outcome you want." He agrees to a DNR/DNI status and asks about hospice. A palliative care consult is placed, and he is discharged home with hospice services.
Key Learning Points
- Goals of care discussions should elicit patient values and fears before discussing specific interventions; ask "What are you hoping for?" and "What do you fear most?"
- CPR outcomes vary dramatically by clinical context; for metastatic cancer, survival to discharge is only 5-10%, with even lower rates of meaningful neurologic recovery
- Making a recommendation is appropriate and helpful when aligned with patient values; saying "I recommend we focus on comfort" is more supportive than asking "What do you want us to do?"
- POLST/MOLST forms translate patient preferences into actionable medical orders that travel across settings