Goals Of Care

Goals Of Care Overview
Goals Of Care Resources and Information
Goals Of Care FAQ's
Goals Of Care Contact Us

 

OVERVIEW

Goals of Care is a standard process for the documentation of a patient’s values, wishes, and goals in the context of medically appropriate treatment in advance care planning.

Goals of Care is about a Patient centric approach that integrates patient’s values, wishes and goals in the context of medically appropriate treatment. It encourages each patient to takes an active role in his or her healthcare 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.

Why Goals of Care?

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

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.

 

RESOURCES AND INFORMATION

Designations

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


R1: Patient is expected to benefit from and is accepting of any appropriate investigations/interventions that can be offered including attempted resuscitation and ICU care

R2: Patient is expected to benefit from and is accepting of any appropriate investigations/interventions that can be offered including attempted resuscitation, intubation and ICU care, but not chest compression.

R3: Patient is expected to benefit from and is accepting of any appropriate investigations/interventions that can be offered including attempted resuscitation and ICU care, but not intubation and chest compression.

 

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 Patient does not respond to available treatments in this location of care, 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 Patient about short-term goals.

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

Documents

Advance Care Planning Tracking Record

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

 

FAQ's

How will this impact my care?

Goals of Care is a communication tool between healthcare providers used to respect your values and wishes regarding the treatment you receive

Is this only for when I am in the Hospital?

Goals of Care will follow you as a patient and be part of your permanent health record; these discussions can take place both in the hospital and in the community.

When will this conversation take place?

Conversations regarding goals of care will take place as early as possible within your treatment or course of care.

Who will have this conversation?

Goals of care conversation will take place with you and the healthcare team, any member of the healthcare team can start this conversation. The most responsible health practitioner will be ultimately responsible for discussing, establishing, and documenting your Goals of Care wishes.

What if I am not capable of having this conversation?

Goals of Care will be discussed with your substitute decision maker if you are not capable of making health care decisions.

I already have an advanced directive do we need Goals of Care?

An advance directive does not replace Goals of Care designation; the advance directive will help shape your designation but must still be documented.

What if I want to change my Goals of Care designation?

Goals of care designation can be reviewed at your request with your most responsible health care practitioner at any time. It will also be reviewed if there is a significant change in your condition or circumstances which affect your choice.

I am healthy; do I need to have the Goals of Care conversation?

We understand these topics are difficult for some to discuss but you cannot predict how or when something will happen. You can change your plan at any time and as many times as you would like. It is important to start having this conversation as early as possible as it will help determine your care later on.

 

CONTACT US

Robin Williams 
Patient Representative
Email: Robin.Williams@wrh.on.ca
Phone: (519) 254-5577 ext. 52317
Cell: (519) 995-2063

Angela D'Alessandro
Patient Representative
Email: Angela.DAlessandro@wrh.on.ca
Phone: (519) 254-5577 ext 34404
Cell: (519) 995-2899