Goals Of Care, Family Meetings, And The 80/20 Rule

Surprisingly, in my past month in the intensive care unit (ICU), I spent more than half the time talking to family members about goals of care. In a previous post, my attending had a great quote about survival in the ICU. If one-third of your patients survive the ICU stay, you’re doing hall of fame work. So if only one-third of patients are surviving on a good day, then why am I spending most of my time speaking to families about goals of care? Shouldn’t I be spending more time treating the patients?



“20% of our efforts leads to 80% of our results.”


Thing is, most of the patients that come to the unit are already one foot out the door. The patients are usually connected to a breathing machine (respiratory system failure) and require medications to maintain blood pressure (cardiovascular system failure). That’s two organ systems. This well-known study showed that two organ system failure for more than one day had a 60% in hospital mortality rate. Three or more organ system failure has a greater than 90% mortality rate.

Not to sound harsh, but a majority of the care we do in the ICU is futile. There’s a 90% chance that the patient will die regardless of any intervention we do, and even if they do survive, the quality of life is very poor. The ones that survive are, for the most part, married to the hospital. Most have to enter a several week-long rehabilitation program, go to a dialysis center for 3-4 hours for 3 times a week, have intravenous antibiotics 1-2 hours a couple of times a day for several weeks at home, etc. If there was any brain injury, any return of baseline neurological status is nonexistent.

Don’t get me wrong, there are some miracle survivors. But that’s exactly what they are, miracles.

So back to the question – why do I spend most of my time talking to families of goals of care? Well, I can tell you that the answer is not because I gave up on my patients. The answer is actually far from it. I think my attending has us spend most of our time talking to them for this very reason – the 80/20 rule.unnamedIn 1906, an economist in Italy named Vilfredo Pareto noticed that 20% of the people owned 80% of the land in Italy. He then noticed something similar in his garden – 20% of the peapods produced 80% of the peas. This later came to be called Pareto’s principle, or the 80/20 rule, in which 20% of our efforts leads to 80% of our results.

The rule didn’t just apply to Italian land and peapods. In computers, Microsoft focused on the top 20% of software bugs to fix 80% of system errors. In business, 80% of a company’s profits come from 20% of its products. In hospitals, 80% of the most difficult clinical problems come from 20% of the patients. It’s a natural phenomenon.

So how does the 80/20 rule apply to the ICU?

If my patient has a 90% chance of dying regardless of what I do, what can I do to be more effective? I can talk to the family, educate them on the illness, share with them their grief, guide them through this scary period, and prepare them for what happens next. The family can tell me stories of how they were before the hospital: how kind they were, what jokes they used to say, where they were a year ago. We laugh and we cry. We sit in silence in the room. We listen to beeps from the monitor. We feel the ventilator blow gusts of air in and out of the patient.

If it’s the patient’s time, we can make the patient comfortable and let nature take its course. Or we can try to take a shot and be as aggressive as possible to win a miracle. Either way, it’s a win. It’s a win for myself, a win for the family, and most importantly, a win for the patient.

How to make the 80/20 rule work for you:

  1. Make a list of everything you do on a daily basis. By everything, I mean everything! (time on Facebook, cleaning the dishes, working on projects, etc.)
  2. Evaluate the list, and choose the top three things that will produce the most results.
  3. Focus on those top three things and make them your priority.

How did it work? Share your success below!




21 thoughts on “Goals Of Care, Family Meetings, And The 80/20 Rule

  1. Martha says:

    I really like your perspective here. As a healthcare provider sometimes it’s hard to remember that your patient had a life outside the hospital or even the ICU. I recently was on the other side of healthcare sitting with my mom in the hospital while she fought the manifestations of an autoimmune condition (pneumothorax r/t microscopic polyangiitis and Wegener’s granulomatosis). Being on the receiving end of care made me fully understand how important it is to treat the patient as a person no matter what state/condition they are in. Sounds pretty basic, but any healthcare provider knows that it’s not as easy as it sounds! Thanks for this great post.

    Liked by 1 person

    • doctormikesblog says:

      Totally agree! This may be out of topic, but FYI ICD-10 and I guess the rest of medicine can’t call it Wegener’s anymore. Do you know why? Apparently he was a Nazi doctor that did experiments on Jews in the concentration camps during World War 2. The politically correct term is microscopic polyangitis with granulomatosis. I know this cause I got chewed out on rounds one time for describing my patient with Wegener’s.

      Yes, it is really basic and I think it’s a great reminder to us as HCPs to remember that our patients are more than just patients. They’re people with their own lives, families, etc.

      Thanks for the comment!


  2. clearskies2016 says:

    I really liked this story! May 17, 2014 I suffered a massive heart attack. 100% LAD blockage and 85% on two other arteries. Heart stopped 3 times before they were able to place a stent in my LAD. Boy did the pain scare as well as HURT! Morphine, nothing even dented it. I was out in the ER for a good 10 or so minutes until they were able to revive me. During that 10 minutes or so- I was warm, sitting on a beach with beautiful light- I’ve never seen such beauty before! The sand I scooped up in my hands was amazing. I could see each grain of sand with such clarity. The smells, and sounds were wonderful! I felt warm and loved and never wanted to leave.

    That was when the helicopter medic shook me a lot to get me to come around. Boy was I mad at him!! Is there a Heaven- You bet!!

    I spent 3 days in ICU. The second day I suffered another heart attack! What a better place to be than in the ICU- Great nursing care, great doctors! After being stable the second time, a nurse came in to check my femoral site for the catheter access, to make sure it was not bleeding. I guess it was somewhat and she had to press on it hard- uncomfortable place if you know what I mean, and that is just when somewhere in the hospital, we had a FIRE!! The doors on the ICU room closed and we had our own little world. Poor nurse was stuck applying direct pressure while they figured things out.

    I will tell you this, I could not keep a dry eye when the catheter nurse came in the next day to check on me- here is someone who saved your life. How do you say thank you? No words were necessary- I think we both just teared up just like I’m doing now typing this.

    I went through 3 months of rehab and was back to work in 2 months. What caused the Heart Attack? I had a full work up 6 months prior and nothing. I routinely run the Wilmington Marathon and keep my self in shape. I’m 180 pounds. So I suppose its genetic.

    But your premise of a miracle- Yes you are right. I should have died, either in the house, ambulance or ER when my heart stopped. But the professionals never stopped and I’m here responding to this blog and enjoying life. I’ve changed my eating habits totally- no red meat, way low sodium diet. Kept it up for going on 2 years now. Certainly don’t want to waste the miracle and help of all those professionals.

    Thank you for the 20% effort, now its my turn to do my part and keep it going.

    PS- I went back after my rehab to give my nurses a hug and to say thank you. If you ever are in a similar situation- please take the time to say thank you afterwards.

    Thanks for another great post Dr. Mike!!

    Liked by 1 person

    • doctormikesblog says:

      Great comment! Wow, you had 100% occlusion of the LAD?! We nickname that condition the “Widowmaker.” It’s usually fatal, so I’m happy you survived it. I’m glad you took this chance to make the most of your live and live it, and I think that’s a great message we should share with everyone we meet.

      Liked by 1 person

  3. piezoradeon says:

    WordPress doesn’t even come in the top nine important things!
    Well, I will try it out today! Will see how it works out and will let you know tomorrow! 😀

    Liked by 1 person

    • doctormikesblog says:

      Thanks! Can’t wait to hear your results! Another caveat to this principle is to be consistent with it. Sometimes the best things in life don’t appear right away, but rather after the summation of small ripples we stir now.

      Liked by 1 person

      • piezoradeon says:

        Okay, it’s been a day and here is the report.
        1. I studied more than what I do usually
        2. I actually took a test for myself on what I studied the whole day ( I’ve been planning to do it for so long! The list made me do it) And I actually did better than what I expected.
        3. I wrote a new poem I’ve been thinking to write
        4. I well cleaned up my room which I always lose interest in after cleaning it awhile.
        That’s about it, the stuff I actually did and achieved today which I wouldn’t have done usually.
        Also, I realised that keeping a list reminds us of stuff we forget , like genuinely forget!
        And yeah, I ended up using wordpress more than I should’ve according to the list! We’ll I guess, posting something new wouldn’t count right?
        Well, I cant taste al success in a day! It will take time! And guess what? I made up the list for tomorrow too!

        Liked by 1 person

  4. deblewisarbonne says:

    I have worked in ICUs for many years. There are many survivors – now living normal lives because of the care they received. Every one of our efforts are worthwhile, whether is helps survival or peaceful death. I just remember – each survivor is a miracle and God gives us the strength and skills to play a part in those miracles.

    Liked by 1 person

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