Establishing goals of care (GoC) is a way of ensuring a person’s goals, values and preferences remain central to current health care treatment decisions. While GoC are related to advance directives (AD) and advance care plans (ACP) they are different. Advance care planning involves anticipatory conversations that can occur at any age or stage of health and outline a person’s preferences about health and care outcomes for the future. Advance care planning may result in the production of an advance directive. Goals of care planning requires the person to have a clear understanding of their condition in order to have open, honest and realistic discussion around end-of-life care decisions. These goals should be reviewed if the person’s health changes.
You can play a key role in initiating and maintaining ongoing GoC discussions to establish specific and reasonable goals of care. These may be medical and nonmedical (e.g. reaching a milestone or participating in a family event).
Firstly, ensure the person has a clear understanding of their condition. Then encourage the person to express their personal values, preferences and wishes; discussing goals of care and/or advance care planning are important steps in transforming these wishes into agreed, specific and reasonable goals.
Consider using a decision or communication aid to help the person convey their preferences. Read the paper Bennett F, OʼConner-Von S. Communication Interventions to Improve Goal-Concordant Care of Seriously Ill Patients: An Integrative Review. J Hosp Palliat Nurs. 2020;22(1):40-8.
Recognise triggers such as a change in a person’s health condition that may require a review of the person’s goals of care.
Do not make assumptions about the level of involvement a person wants in decision-making. Clarify this with the person. Involve family members or carers where appropriate. Some cultural groups place great importance of family involvement in decision-making.
Suggest a comprehensive medication review that can be funded by Residential Medication Management Review (RMMR).
Make yourself familiar with what a Goals of Care document looks like. Primary Health Tasmania has a Medical Goals of Care Plan form as well as Guidance Notes and a Decision Making Flowchart to help you familiarise yourself with the process.
Family meetings can be useful in developing goals of care and a care plan.
Use the Australian Commission on Safety and Quality in Health Care guide on Identifying goals of care which includes a description of goal setting tools.
Consider including a Goals of Care Plan in each admission process as part of a defined management plan. The management plan should also include a plan for regular review of the goals of care, and the review under certain conditions (such as but not exclusively a hospital admission, notable functional decline or incomplete recovery from an infection or a fall…).
Encourage staff to:
Conducting a family meeting can be useful to provide information, to address the family's questions and concerns, and to establish goals of care. Use the series of palliAGED forms to organise a family meeting.
Read the information on how to conduct a family meeting in palliative care from the Therapeutic Guidelines (Palliative Care) (requires a subscription) in the section: Supporting families in palliative care.
Family meetings often require a skilled facilitator, consider that skill set in a recruitment process.
Page updated 07 July 2021