What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients.

BACKGROUND: Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS: At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS: A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS: Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.

Anticoagulation in a patient with antiphospholipid syndrome and a mechanical heart valve: a case study.

: A case report of a patient with antiphospholipid syndrome (APS) with positive lupus anticoagulant and a mechanical mitral valve replacement (MVR) who presented with a thrombosis and difficult-to-control INRs. Current literature on anticoagulation options for patients who present with these conditions as well as alternate laboratory assays are reviewed. APS can present a unique complexity and challenge to appropriate anticoagulation on warfarin. Although there are emerging data regarding the use of novel oral anticoagulants to treat this condition, they do not justify their use in a patient with APS and an MVR because of a current lack of evidence. CFX testing may be used to calibrate INRs when there is a concern for false readings because of lupus anticoagulant interaction with INR assays.