 Our next speaker will be Dan Bronner. Dan is an associate professor of medicine, the director of the geriatrics fellowship program, and a faculty member at the McLean Center. Dan and Tracy Kugler co-direct our ethics consultation service. Dan's academic interests have focused on interdisciplinary approaches to medical and ethical issues, primarily as they affect older people. Research interests include the history of cardiac resuscitation, cardiac arrest and DNR, language and medicine, cognitive impairment, and dementia. Today, Dan will talk to us about whose goals of care and historical linguistic analysis. Join me in welcoming Dan Bronner. Thank you very much, Mark. It's always a pleasure to speak here. I really appreciate the opportunity. In this brief paper, I will discuss the notion of the goals of care and comfort as a manifestation of the cardiac arrest paradigm, an intellectual and institutional framework that has shaped the practice of medicine for the past 50 years. Following the trend of presenting an illness narrative of a friend, not a patient, I will begin with a case that happened about a year ago. Eileen, an elderly close family friend, like an aunt to my wife, asked me to be her durable power of attorney as all her friends had either died or left town and she had never married and had no kids. She had a significant tremor that was a bit better on Parkinson's meds. She had always been a petite person and a picky eater, but a blade had developed significant weight loss from eating even less, related to nausea and decreased appetite. This became so severe that she was admitted to an affiliated hospital on the north side. Several scopes and scans later, no answer to her predicament was forthcoming. I was wondering if it was related to the Parkinson's drugs and pushed for lowering the dose and seeing the effect. One night towards the end of her now lengthy hospitalization, Eileen called me to report that two very friendly women had just come to her room and were asking her about her goals of care. And wouldn't she like to be comfortable? Although Eileen didn't understand the full implications of the question, I did and asked her if she was ready to give up the ghosts, cash in her chips, buy the farm, exit this mortal coil, pass away, bite the dust, kick the bucket, in other words, die. Eileen answered, no. I just wanna feel better and get out of the hospital. Where did these notions of goals of care and being comfortable as currently used by physicians, nurses, social workers and others come from? From where did the script for enrolling patients in hospice arise? What are the origins of these current meanings? The origins are intimately related to the cardiac arrest paradigm. Many of the underlying principles of the paradigm were already established in the mid 20th century when resuscitation still involved cutting open the body and squeezing the heart, open cardiac massage and started moving out of the operating room onto the wards of the hospital. But the paradigm clicked into existence after closed chest compressions and CPR became the norm in the 1960s. This was the moment when a constellation of forces made resuscitation the default therapy for every patient whose heart stopped in the hospital, regardless of its expected efficacy and cardiac arrest became the clinical condition we recognize today. This development marks a pivotal transformation in the history of medicine. Not because it signaled the discovery of a new revitalizing technology, resuscitation had been practiced in various overlapping ways since the late 18th century. Instead, CPR and its indication, cardiac arrest, helped usher in what I'm calling the cardiac arrest paradigm and help establish a model of care that persists today. An important manifestation of the paradigm was the intensification of therapies, particularly at the end of life. Whether or not such interventions were expected to help the patient. The paradigm also tended to narrow the physician's gaze to single organ systems at the expense of more holistically oriented goals. The canonical interpretation of the default application of CPR involved the need for fire drill-like action. Despite the early appreciation that is shown in this order early editorial from 1962, most people who experienced sudden stoppage or disruption of the heart, cardiac arrest, cannot be saved even under ideal circumstances in a hospital. However, it was more complicated than that. Here's a partial list of some of the forces that compelled the cardiac arrest paradigm forward. And just take a look at that list, which I'm not gonna talk about today. I'm talking about the consequences. But because it's interesting, and I've just gotten into this lately, the first edition of the current procedural terminology published by the AMA in Chicago in 1966 created billing codes for therapies or procedures for the new government programs of Medicare and Medicaid. It did not contain CPR or cardiac arrest and was comprised of mostly surgical interventions in various levels of patient visits. The second edition, however, published four short years later in 1970 and now 60 to 70% larger did. So here we see cardiac arrest along with a few other medical therapies like chemotherapy. Here we see an example of the first billing form reporting professional services to Medicare found in the back of the second edition of the CPT. The example features Gladys E. Albert for fractured femur and closed reduction. If the surgery had gone badly and Ms. Albert did poorly and she developed cardiac arrest requiring resuscitation, the bill would have looked like this. Another influence on the paradigm. Early on they're developed a struggle, a burning question for caring and considerate doctors and ethicists. How to practice compassionate and logical care under the cardiac arrest paradigm. The 1970s saw a few important forays of early attempts to navigate the care that I will quickly gloss. The ONTR or DNR was officially codified in the 1974 standards for CPR. It unwittingly sealed the default by requiring orders to opt out. This then inspired the federal folder all associated with DNRs specifically and most notable with the court cases involving Shirley Dinerstein which did acknowledge that CPR was not always life-saving therapy. In 1974, one month after the standards containing the first order not to resuscitate were published, TAG AOL proposed a theoretical system for classifying patients according to levels of therapy based on prognosis and defining quote overall therapeutic goals. This is a very early use of the phrase overall therapeutic goals which was likely motivated by how the paradigm had reconfigured therapeutic goals by standardizing certain treatments. It changed the essential question from what is best for the patient at this moment to what does the protocol or guideline tell me to do now. The default application of CPR and the standards developing in the new ICUs forced the issue of therapeutic goals which before this were presumably to provide therapies that were expected to help the patient. The report of an actual application of this classification system awaited a dramatic change in the openness of discourse concerning withholding and stopping treatment. This occurred immediately after the Quinlan decision two years later with this paper. It accompanied an editorial titled Coming Out of the Closet. Mitchell Rapkin's call for patient family involvement in DNR and Sisley Bach's call for living wills. This paper described the classification system and the six month experience with 209 patients at the MGH. We see here AM, here it is. We see here AMB described business as usual. But C, oh I shoulda looked there, but C is where the real substance of the classification lies. All therapies including resuscitation are now to be considered for their effectiveness. Finally with D we see an early usage of comfort presumably for the hopelessly ill patients that aligns it with discontinuing all therapy. It is unclear how many ICUs use this system. I know from personal conversations at Henry Ford Hospital did, but none persisted very long or at least wrote about it to my knowledge. In 1980 an updated standards for CPR was again published in JAMA. This time the order not to resuscitate was several paragraphs long and housed in a special section on medical legal aspects of CPR and ACLS. This required repeating at the dawn of the 1980s because for the most part DNR orders were not happening much. The 1980s saw ongoing and more widespread attempts at limiting inefficacious dare I say futile therapy. The question of how worthless a therapy has to be before it's deemed futile is only partially a semiotic question. CPR was the archetypal master signifier of such therapies and the one that attracted most of the attention of ethicists in the 1980s and I would say persisting until today. And early perhaps the first use of comfort as in comfort measures in relation to DNR can be found in a paper published in 1982 by the parapetetic Father John Parris. The Michael P. Walsh Professor of Bioethics at Boston College and a visiting scholar at the McLean Center among other places shown here who is here today. In this paper, Father Parris encourages physician to ask patients and families whether they wanted comfort measures only instead of asking about resuscitation. The paper is important for several reasons. It formulated many of the DNR arguments that are still repeated to the present day in the vast DNR literature. It also makes evident the use of DNR as a marker for patients who are expected to die soon and in whom aggressive medical therapy was not expected to help. Here we see the choice of comfort, the implied goal being presented perhaps for the first time as an alternative to default CPR, thereby acknowledging approaching death. In a paper published one month later in May 1982, Stephen Miles also affiliated with the McLean Center situates the question of resuscitation in a discussion of quote the patient's total medical care and prognosis and returns to the theme of goals as in setting reasonable goals in relation to their present, to their illness and prognosis. In the next year, 1983, Bernard Lowe and Robert Steinbreck, writing in the Archives of Internal Medicine in a paper titled Deciding Whether to Resuscitate present two very dire patient scenarios. We see here an early use of the term fertility as regards CPR, but not that CPR is futile. Instead, they propose that a DNR order is appropriate when further treatment, that is other treatments are futile. The DNR order signifies that no other therapeutic treatments are available and that perhaps you are dying. Again, CPR is not itself futile. We could keep you alive longer, that is prolong your dying at least. In their concluding paragraph, Lowe and Steinbreck make an off-repeated claim about the meaning of DNR that flies in the face of its just-stated use to mark futility. But this meaning of DNR, that it only means no resuscitation, pertains only when further care may not be futile and that treatment of reversible medical conditions may be appropriate, exemplifying the difference and sometimes confusing meanings of DNR that is dependent on its motivations. That Brody and all would address later in the 1980s. In the next sentence, we again see the function of DNR, of the DNR decision being a moment for evaluating the goals of care, echoing miles. Lowe, this time with Lori Dorbrand, hits the goals of care trope again in a paper published in New England Journal of Medicine one year later in 1984, but in a different way. This time, Lowe and Dorbrand expand the therapy in question from CPR to feeding tubes in a patient with advanced dementia. In this paper, we see an example of the goals of care being intrinsic aspects of a given therapy. The therapy defines the potential goals of prolonging life, delivering calories or providing comfort. We see from these examples how the cardiac arrest paradigm and specifically DNR, the DNR order, has helped usher in the goals of care conversation and just as there are different reasons and meanings for choosing DNR, there are different reasons and meanings that have evolved for the goals of care. A common practice for raising questions about goals of care is exemplified by the discussion with my friend Eileen, signaling the lack of all but futile diagnostic and therapeutic interventions and offering comfort. The palliative care team is often called upon to address goals of care with patients in whom no apparent therapies are available to heal their problems. Comfort is held out as the goal the patient should choose now. The script echoes Father Paris's proposal back in 1982 for reformulating the choice of DNR to comfort measures only, where DNR meant all other care is futile. We can see that this has actually become the standard procedure for informing patients that they've run out of therapeutic options. We've got nothing left in our current procedural terminology besides comfort measures that will actually help you. They can choose to move to the hospice benefit. There are obvious problems with this approach. One is that it obscures what is really going on. Also, even if we have nothing left to help at this moment, doesn't necessarily mean A, that the patient will necessarily die soon. Eileen is still kicking. And B, that in the future, there may not be moments where there are things that we can do that may make her better. Once one chooses comfort, a palliative care, using goals of care as guiding forces can lead to a set of somewhat difficult, sometimes absurd questions for physicians ultimately triggered by the vagaries of the Medicare benefit. The question of is this really a palliative therapy or is it a therapeutic therapy? That is, does it make the patient feel better or is it just what the standard of care would call for if one was taking care of a regular patient? The cardiac arrest paradigm forces us to ask this question, but is not necessarily a bad question to the extent that it makes us question the standard, its risks and benefits in a thoughtful manner. It is perhaps a good question to ask of all our therapies, especially in patients with multiple comorbidities. However, when it pushes us to stop thinking about the possibilities for helping because the patient no longer qualifies for that type of care, it becomes problematic. The use of goals of care can be confused with those that may be intrinsic to various types of therapy, a la Lo and Dorban 1984, and that asks real questions that need to incorporate values because they engender real potential different outcomes from real choices. But this can also be discussed by a presentation of options and risks and benefits without resorting to the notion of goals of care. Finally, patients need to understand what they are really being asked when we ask about their goals of care. Eileen's goal is to feel better and get out of the hospital and sure, be comfortable. I would posit that the goals of care are always the same, to provide the options of diagnostic and therapeutic interventions based on the values of our patients that may actually help them. And to honestly disclose, when we don't have any options left and to relieve suffering, of course, using straightforward and honest language. Thank you. Thanks for Dr. Bronner. Do you go back two slides? This one? Yeah, that one. It looked to the upper left-hand corner of that slide. You see the words, clinical ethics. That was a section that we started in the Archives of Internal Medicine in 1978. I didn't realize that the Loe Steinberg paper, I had forgotten that, was published as part of that section. That was the second time the word clinical ethics was used in the literature. The first was when Ann Dudley-Goldblatt, some of you were here yesterday, and I wrote that grant to H.E.W. called clinical ethics. Do you see that way up in the left-hand corner? I see it, I put it there. Yeah. So, are there any questions for Dan? Yeah. So, the idea is that goals of care is a term that has been back there for about 30 years. Where's Father Paris? Is he still there? John, and that John helped introducing the literature? Well, I think John was the first person to actually equate the choice of DNR as to reformulate it as the choice for comfort. And I think that came out of some of the earlier work in the 60s, which sort of classified patients to those that would only receive comfort care. After the sort of cardiac arrest and CPR had become the norms. Because I think it was important at that time to sort of define what the goals of care were because I think in the 60s and 70s, there was this sort of lapse of what are we actually doing here with these patients? And I think we've sort of been left with those same questions and the language has persisted today. Lainey, thank you. No, Dan, thank you. That was lovely. So, I have a question, a follow-up of your aunt, because one thing, do you think they came in to do goals of care, meaning palliative care because she was old or because she really had a life-limiting treatment? So was there any type of age discrimination going on here? And number two, can you give a follow-up? What happened after she got discharged? I think there were several reasons why they came in. I think partly because she was old, partly because the diagnostic workup was not revealing so there was really nothing they could think of offing her. And the third thing was she had been in the hospital for a really long time and they didn't know what to do with her. And people need a dispo. They need to have some plan in place. And so I think they thought about switching her goals of care to comfort and putting her in hospice. You know, she got out of the hospital and she moved to a place with more people around and she started eating again and she's doing okay now. So, yeah. Thank you so much. All right.