A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers

Abstract

BackgroundGoal setting is a recommended approach in clinical care that can help individuals with multi-morbidities and their caregivers manage chronic conditions. In this paper, the types of goals that were important for older persons with multi-morbidities were explored from the perspectives of patients, their caregivers and physicians. Comparisons of goals were made across each patient, caregiver and physician triad to determine alignment.MethodsThe study was a qualitative descriptive study facilitated through semi-structured one-on-one interviews. The study took place between May and October 2012 at a Family Health Team located in Ontario, Canada. The sample included 28 family medicine patients, their informal caregivers and family physicians. Socio-demographic data were analyzed via descriptive statistics in SPSS Version 17. Open ended questions pertaining to patient goals of care were analyzed thematically using NVivo9. Themes were derived on patient care goals for each of the participant groups (patients, caregivers and family physicians). Following this, alignment of goals across each of the triads was examined. Goal alignment was defined as concurrence on at least one goal by all three parties in a particular triad (i.e., patient, caregiver and family physician).ResultsJust over half of the patients were male (56%); they had an average age of 82.3 years and 4.61 health conditions. Most of the caregivers were female (82%); and 61% were a spouse of the care recipient. At the aggregate level, common goals expressed among patients, caregivers and family physicians were the maintenance of functional independence of patients and the management of their symptoms or functional challenges. Despite these common goals at the aggregate level, little alignment of goals was found when looking across patient-caregiver and physician triads. Lack of alignment tended to occur when patients had unstable or declining functional or cognitive health; when safety threats were noted; and when enhanced care services were required.ConclusionsThe data suggest that goal divergence tends to occur when patients are less medically stable. While goal divergence may be expected due to the different roles and responsibilities of each of the players involved, these perspectives should be illuminated when building care plans. Further research is required to observe the extent to which goal setting occurs in family practice as well as how it can be embedded as a standard of practice.

Understanding Clinical Complexity the Hard Way: A Primary Care Journey

“…If we wish to be truly patient-centred, uncertainty needs to be acknowledged. It is often the case, as a study by Kuluski and colleagues demonstrates, that patients, their caregivers and clinicians do not often share the same treatment goals (Kuluski et al 2013). Aligning treatment goals is important to successful care planning, but often patients and families are unclear themselves about care goals or defer to healthcare professionals who are similarly confused and may devolve to acting on clinical imperatives, which may drive utilization needlessly.…”

Do Clinical Guidelines Still Make Sense? No

“…I also suggest seeking alignment of treatment goals among patients, care givers, and clinicians as an important priority. 8 There is also great lack of clarity about the outcomes being pursued with the vast armamentarium of diagnostic and therapeutic power at physicians' disposal. Clarity on desired outcomes in this context is urgently needed.…”

Is Australian primary care practice equipped to provide multimorbidity care?

“…Looking to simplify the complexity of managing multiple chronic conditions and the resulting treatment burdens, patients must frequently prioritise conditions, goals, medications and/or outcomes (28,73,93,133,135,189,196,206,(217)(218)(219)(220)(221)(222)(223).…”

“…A critical challenge to emerge from the multimorbidity literature is the need to acknowledge and incorporate patient preferences for care, particularly in relation to determining treatment and management priorities (28,73,93,133,135,189,196,(217)(218)(219)(220)(221)(222)(223). Individuals with multiple conditions are tasked with managing complex treatment regimens, complicated by conflicting conditions, medications, treatments and outcomes (201).…”

“…The discussion has identified that patients and GPs experience numerous barriers associated with the management of multiple chronic conditions, but at the patient level, the process of prioritising and re-prioritising emerges as a potential response to address some of these barriers. As the gatekeeps of care, GPs appear best placed to work with patients to set priorities, but the goals and priorities established through the clinical consultion may not always align (21,70,135,219,220):…”