Utilizing the OODA Loop to uphold a patient's wishes and values

Through the process of developing My Gift of Grace we have learned a lot about the kinds of conversations people have (and don’t have) about end-of-life care. We have seen just how challenging it can be to get clear about one’s values and goals of care, and how important it is to make one’s wishes known.

Reflecting on playing My Gift of Grace and numerous conversations with leaders working in late life and end-of-life care, it has also struck me that there is another critical need. Just having and communicating a well thought-out set of final wishes is not enough; a patient and her caregivers need to be better prepared to make decisions in the midst of the complex, and often chaotic experience of aging, illness and dying.

In order to make sound and timely decisions, we must each have clear roles and responsibilities within an effective decision-making framework.

In a recent study titled Redefining the “planning” in advance care planning: preparing for end-of-life decision making the authors focus on the importance of preparation for “in the moment decision-making.” This focus helps us view end-of-life care through a new framework. This framework puts the emphasis on roles and decisions to advance a patient’s wishes rather than focusing on the wishes themselves. This framework seems very similar to an approach that is core to our methodology at the Action Mill. And we learned this approach from an unlikely source: the US military. While working with US veterans from 2006 to 2008 we learned a great deal about John Boyd and the OODA Loop.

The OODA Loop, developed by Boyd, a US Air Force fighter pilot, is is a framework for working in contexts where there is a high level of complexity and, at times, chaos. What better describes the actual experience that patients, their families and medical professionals face everyday in our health system?

An OODA Loop consists of a series of steps (Observe, Orient, Decide and Act) that enable a person or team to take meaningful action in a rapidly-changing environment. The Loop divides decision-making into clear steps that take into account both the overall goals and the changing situation on the ground.

In the military, decisions are guided by a commander’s intent for the mission. At the same time there is support for in-the-moment decision-making by sub-commanders and soldiers. Viewing a patient’s goals of care as commander’s intent and providing support, structures and training for caregivers to interpret and meaningfully carry through on that intent is a necessary step toward improving the quality of care for patients and their families.

In end-of-life care decision-making, the patient’s goals of care can be thought of as the mission of the patient and her caregivers. The OODA Loop provides a structure that supports patients, families and healthcare staff to make good decisions and take effective action within the complex and changing situations that they will encounter.