Psychiatric Goals of Care at the End of Life: A Qualitative Analysis of Medical Records at a Geriatric Psychiatric Outpatient Clinic.

Abstract

Objectives: Person-centered care emphasizes patient choice and autonomy and is considered an important means for improving the quality of care and quality of life for older adults with multiple chronic conditions and functional limitations. In implementing person-centered care, goals of care based on the patient's preferences are considered fundamental. Psychiatry is generally practiced in a curative paradigm, and little is known about the goals of care in geriatric psychiatric settings. In this study, goals of care as documented in care plans and medical records in geriatric psychiatric outpatient care have been explored, with a special focus on the end of life. Methods: This study was based on a descriptive qualitative content analysis of medical records of patients enrolled at an outpatient clinic for geriatric psychiatry at the time of death. It was complemented by a basic quantitative analysis of patient characteristics. Results: A total of 66 medical records were included, with a male/female ratio of 41/59% and a mean age of 83 years (66-104 years). Among psychiatric diagnoses, depression predominated. The dataset was generally limited, and clearly defined goals of care were sparsely presented. Therefore, the included medical records were analyzed twice: first regarding goals of care and second regarding patient wishes and requests. In both cases, the highest level of abstraction in terms of themes was achieved. Analysis of goals of care resulted in the themes patient well-being and care arrangements. Analysis of patient wishes resulted in the themes active patienthood and living and being. Conclusion: Goals of care were often disease-oriented, focusing on recovery or symptom management, whereas analysis of patients' wishes revealed personal goals other than remission, including outspoken existential needs. The results call for further research on the interplay between person-centered care and the goal-planning process and point to the potential of a palliative approach in geriatric psychiatric care involving patients with complex comorbidities and multilevel needs.