ATA Guidelines Tools

5 Î Only imminently threatening disease elsewhere (e.g., brain or spine metastases or pulmonary hemorrhage) should prevent primary surgical management of neck disease if achievable. (S-L) Establishing Treatment Goals Î Physicians involved with the management decisions in the care of the patient should consult with multidisciplinary specialists who may be involved in the care of the patient, either at the present time or in the future, before having ''goals of care'' discussions with patients. (S-L) Î Patients must have decision-making capacity to consent to or make particular medical decisions. Concerns about diminished or impaired capacity may prompt a psychiatric consult or clinical ethics consult to assess barriers to capacity. (S-L) Î If patients require a surrogate (proxy) decision maker, the treating physician should ensure that one is appointed according to the patient's stated preferences if known (written or verbal) or in compliance with local jurisdiction laws surrounding surrogacy and guardianship in consultation with a hospital ethicist or attorney. (S-L) Î In consultation with a multidisciplinary team, a candid meeting with the patient should be scheduled in which there is full disclosure of the potential risks and benefits of various treatment options, including how such options will impact the patient's life. Treatment options discussed should include palliative care. Patient preferences should guide clinical management. (S-L) Î Patients should be encouraged to draft an advance directive in which they name a surrogate decision maker and list code status and other end-of-life preferences. Consider, in some cases, using ''allow natural death'' (AND) over ''do not resuscitate'' (DNR), which may be better understood by patients and families as an order that limits inappropriate aggressive care. Circumstances in which suspension of DNR or AND may occur must be discussed with the patient. (S-L) Locoregional Disease Î Resectability of ATC should be determined by routine preoperative imaging studies (ultrasound, CT, MRI, and/ or PET scan of the neck and chest). If locoregional disease is present and a grossly negative margin (R1 resection) can be achieved, surgical resection should be considered. In patients with systemic disease, resection of the primary tumor for palliation should be considered to avoid current or eventual airway or esophageal obstruction. (S-M) Î A total lobectomy or total or near-total thyroidectomy with a therapeutic lymph node dissection should be performed in patients with intrathyroidal ATC. (S-M)

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