Goals Of Care

Goals of Care is about a patient-centric approach that integrates the patient’s values, wishes, and goals in the context of medically appropriate treatment. WATCH VIDEO

Advance Care Planning Conversations: It provides resources for patients and their families to engage in advance care planning as early as possible in a patient’s course of care and/or treatment.

Standardizes the Process for Documentation of Advance Care Planning: It provides a standardized set of short-hand instructions where the Patient’s general care intentions, specific clinically indicated health interventions, transfer decisions, and locations of care are described.

Goals of Care will follow the Patient across the Continuum of Care: Goals of Care Designation Order will form part of the Patient’s health record and will follow the patient regardless of where the Patient lives or receives medical care.

Goals of Care Designation Tracking Record: Pertinent details of advance care planning and Goals of Care discussions are documented in the Patient’s health record and the Goals of Care Tracking Record and will be reviewed on a continuing basis.

Each patient takes an active role in their health care and/or treatment.

The patient’s wishes and goals are incorporated into the way decisions are made at each step of the Patient’s clinical treatment.

The Goals of Care Designation provides direction regarding specific health interventions, transfer decisions, locations of care, and limitations on interventions for a Patient as established after consultation with the Most Responsible Health Professional and Patient.

Goals of Care Designations R

Medical care and Interventions, including Resuscitation if required followed by Intensive Care Unit Admission

Goals of Care Designations M

Medical Care and Interventions, Excluding Resuscitation

M1: All clinically appropriate medical and surgical interventions directed at cure and control of condition(s) are considered, excluding the option of attempted life-saving resuscitation followed by ICU care.

M2: All clinically appropriate interventions that can be offered in the current non-hospital location of care are considered. If the patient does not respond to available treatments in this location of care, the discussion should occur to change the focus to comfort care. Life-saving resuscitation is not undertaken except in unusual circumstances (i.e. to prevent suffering).

Goals of Care Designation C

Medical Care Interventions, Focused on Comfort

C1: All care is directed at maximal symptom control and maintenance of function without cure and control of an underlying condition that is expected to cause eventual death. Treatment contemplated only after careful discussion with the patient about short-term goals.

C2: All care is directed at preparation for imminent death with maximal efforts directed at symptom control. 

Policy:

• Goals Of Care Policy
• Appendix A
• Appendix B

• Tracking Record Example
• GOCD Example

The purpose of the Tracking Record is to document the decisions/next steps/outcomes of discussions related to Advance Care Planning and Goals of Care Designations. The Tracking Record will be documented in the Patient’s Health Record. Goals of Care discussions, which may be initiated and/or participated by any member of the interdisciplinary team, are ongoing and may include any combination of 6 core elements:

1. Prognosis and anticipated outcomes of current treatment
2. Patient’s values and their understanding/expectation of treatment options
3. Life-sustaining measures/degree of benefit (e.g. enteral tube feeding, intravenous hydration, dialysis)
4. Comfort measures
5. Resources available (e.g. palliative care, spiritual care, social work)
6. Goals of Care Designations