Why are goals of care discussions important?
Goals of care discussions (GOCD) are important because treatment and care decisions:
- can be complex, with no obvious one right decision and therefore require input of a person's values, goals or priorities
- happen in all health care settings
- can be supported by all healthcare practitioners
- will happen many times over the course of an illness as different treatments decisions come up
- require skillful communications: listening to understand, speaking to be understood and responding to emotions
Why are goals of care discussions challenging?
Clinicians often say they:
- lack training to support people through what often are emotional conversations
- worry about removing hope or causing distress
- worry about managing uncertainty, especially about prognosis
- do not feel they have time required for these discussions
We also know:
- it is hard to witness suffering and these conversations often involve difficult choices
- clinicians feel that they have failed if they don't have treatments to reverse or treat an illness
But with knowledge and skill, these conversations will allow you to make recommendations and plans that best align with your patient's goals and values.
With skill, you will also learn to support your patients when if their goals are not medically achievable.
Outcomes of goals of care discussions
Goals of care discussions aim to align treatment and care decisions with a person's goals and values while supporting them if their goals and values cannot be achieved.
Three outcomes of GOCD are:
- People and their SDMs improve their understanding of the illness including what to expect in the future.
- Treatment and/or care options are explained and goals and values are explored.
- Treatment and/or care recommendations take into consideration people's goals, values and wishes.
There are many values-sensitive decisions that result from goals of care discussions, for example:
- starting, continuing or stopping chemotherapy;
- deactivating an ICD;
- starting or stopping dialysis;
- being cared for in a palliative care unit or at home.
A person's Code Status is not their Goals of Care
A person's code status is not a "goal of care" -- it is just one treatment decision among many that can be the outcome of a goals of care discussion.
A treatment plan (or plan of treatment) provides the capable person (or if incapable, the SDM) an opportunity to consent to a group of treatments, some of which may occur in the future. This is not an “advance consent”, as it is consent related to a current state of health. A plan of treatment may be an outcome of a goals of care discussion.
A “plan of treatment” means a plan for care of a patient that,
- is developed by one or more health practitioners,
- deals with one or more of the health problems that a patient has,
- may deal with one or more of the health problems that the patient is likely to have in the future given the patient’s current health condition, and
- provides for the administration to the patient of various treatments or courses of treatment and may, in addition, provide for the withholding or withdrawal of treatment in light of the patient’s current health condition,
- it requires all the same components as informed consent.
In other words, If making a treatment plan for a future situation, the patient (or SDM) has the information necessary to make an informed and contextualized decision that is related to the current condition.
Examples include: a person can consent to multiple cycles of chemotherapy; a person can consent to recurrent blood transfusions; a person can consent to on-going dialysis; an SDM can consent to a community treatment orders.
Reference: Health Care Consent s.13
How goals and values inform decision-making?
Deciding on a treatment and/or care plan involves knowing the potential outcomes, risks and benefits.
But often, to choose among options requires knowing what a person is aiming for -- what are their goals, hopes and fears.
In these situations, the input of a person's goals is the missing piece in determining the right treatment decision.
For example, consider a third line chemotherapy treatment that:
- May give someone more time (months)
- Requires visits to hospital and treatment
- Will cause fatigue and some other side effects.
This person's goals include spending as much time at home as possible and avoiding time in hospital and away from family. His goals don't include adding additional quantity of time. His worries include: worsening fatigued and worsening nausea. These symptoms make it hard for him to spend quality time with his family.
Based on these values and goals, Person B is likely to decide against chemotherapy
For Person B her goals include living until her son graduates in a few months. She wishes to have any treatment that might add enough time.
Based on her goals, she may decide to accept chemotherapy if it has a chance of meeting that goal.
It is the same illness, the same illness trajectory and the same treatment options.
Person A has different goals and values from person B.
A person's goals and values are essential ingredients in helping them make treatment decisions.
So in our case above we see different treatment choices, as the decision hinges on their goals and values.
When we focus on goals and values, treatment decisions become clearer. People care about how the outcomes of treatments meet their goals and values. They don't focus on the treatments themselves. Yet, health care practitioners often talk just about the treatments, not about the outcomes.
It isn't what treatment the person wants -- it is what they are hoping to achieve and what matters to them -- not the specific treatment.
The role of inter-professionals
All health care practitioners have a role in supporting people in a goals of care discussion.
- Even if you aren't the clinician proposing treatment, you can explore someone's need for better illness understanding.
- You can assist in helping someone get the information they need.
- You can listen what people express about their worries, questions, goals and priorities. Just being open to listening to people will provide a lot of information that supports people when they need to have a goals of care discussion.
Improve your goals of care discussions
It takes knowledge, skill and practice to improve discussions about treatments and/or care decisions that are patient-centred and values-based. Most important is to listen to your patient rather than impose your own values and goals. With good listening and openness, you will align with your patient and find solutions together.
- Learn the principles underlying an effective goals of care discussion
- Use a conversation guide
- Practice a set of skills to engage in good conversations
- Use reflective practice to improve
- Watch an E learning Module for more information about having these discussions.
To enquire about Training Workshops, email email@example.com
Document Goals of Care Discussions
Documentation of a goals of care discussion helps ensure clarity and consistent care.
- Even partial discussions can and should be documented. Other clinicians can pick up and continue the conversation if it is well documented.
- Document in the patient's own words as much as possible.
There are four components to document.
- Illness understanding
- Information given
- Treatment recommendations