Goals of Care

What can I do

Establish specific and reasonable goals of care, these are medical and nonmedical. A person may initially establish a list of wishes; discussing goals of care and/or advance care planning are important steps in transforming these wishes into agreed, specific and reasonable goals.

Review the goals of care regularly with the person as his/her health changes.

Family meetings can be useful in developing goals of care and a care plan.

Suggest a comprehensive medication review that can be funded by Residential Medication Management Review (RMMR).  

Make yourself familiar with what Goals of Care document looks like. Primary Health Tasmania has a template Goals of Care Form.
 

What can I learn?

What can my organisation do

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 refer 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:
  • Establishing 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).