Can goal-based advance planning guide medical care in the nursing home?

OBJECTIVE To determine whether a goal-based system of advance planning, which allows patients to choose among five "pathways of care" (longevous, ameliorative/comprehensive, ameliorative/basic, palliative/comfort, or palliative/hospice), enables physicians to select treatment options in specified clinical situations. DESIGN A pencil and paper test was administered in which clinicians were presented five common clinical scenarios and were asked which of four possible treatment options they would recommend, given a predetermined "pathway of care." SETTING A 725-bed teaching nursing home and affiliated continuing care retirement community. MEASUREMENTS The proportion of correct answers was measured for each clinician, for each clinical scenario, and for each pathway. RESULTS Of the test answers, 78% coincided with the reference answers. The greatest rate of correct answers was found for the ameliorative/comprehensive pathway and the palliative/hospice pathway. CONCLUSION Establishing pathways of care by asking nursing home residents to prioritize their goals of care may help clinicians narrow the range of appropriate options when facing an acute medical problem. Key Words: Advance planning; goals of care; treatment limitations