A Goal-Concordant Prescribing Conceptual Framework: Implications for Practice and Measurement.

Abstract

Optimizing medication benefit and minimizing harm through effective and appropriate medication management is emerging as an important strategy in hospice and palliative care. This approach, however, often fails to align patient and family goals for remaining life with clinician priorities. Ascertaining patient and caregiver values and goals and aligning these goals with clinicians' priorities for care is a complex and iterative process. This process requires effective communication between all participants as a patient's illness trajectory moves toward death. The purpose of this article was to present a beginning conceptual framework for clinical consideration and use, as well as an example of a potential measurement framework envisioned from the conceptual framework for future research application. Both frameworks focus on goal-concordant prescribing among seriously ill older adults in home hospice. An environmental scan of existing deprescribing frameworks and approaches to goal ascertainment that inform hospice deprescribing was conducted. Feedback from practicing hospice clinicians engaged in a pilot project implementing a novel goal-concordant prescribing approach, as well as interprofessional clinicians and family caregivers from previous projects, were also used to identify theoretical and clinically relevant gaps in care as well as future research opportunities. The environmental scan and multiproject feedback served as the foundation for the development of the conceptual framework. The suggested communication frameworks for goal-concordant prescribing seek to bridge the gap between the preferences and priorities of the patient and family caregiver, and the risk-benefit considerations brought forth by clinicians.