Goals of Care

What can I do?

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.

What can I learn?

Check out 

• Module 4 Activity 3: Goals of Care from Palliative Care Curriculum for Undergraduates (PCC4U)
• Victoria Health's three-phase model of goals of care

Read: 

• Thomas RL, Zubair MY, Hayes B, Ashby MA. Goals of care: a clinical framework for limitation of medical treatment. Med J Aust. 2014 Oct 20;201(8):452-5.
• Discussing goals of care in palliative care. In Therapeutic Guidelines – Palliative Care (requires a subscription)

What can my organisation do?

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:

• use the suite of information and resources such as a decision or action flow chart, guidance notes, resources for GPs and templates for forms available at Medical Goals of Care Plan
• learn about goals of care:
  • Goals of care via a learning module from The Palliative Care Curriculum for Undergraduates (PCC4U) (free of charge)
  • Discussing goals of care in palliative care (Therapeutic Guidelines – Palliative Care) (requires a subscription).

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.