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Goals of Care

What we know

Goals of care are a way of describing what medical treatments a person will receive. It is different to an advance directive which provides the person's preferences. Preferences are often not expressed as treatment options. Goals of care should where reasonable incorporate the wishes and preferences of the person. There should be open, honest and realistic discussion around end of life care to inform the goals of care. These goals should be reviewed if things change.

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?

Watch: Establishing goals of care, a PCC4U Module.

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.

Read: Discussing goals of care in palliative care. In Therapeutic Guidelines – Palliative Care (requires a subscription).
 

 

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

Conducting a family meeting can be useful to provide information, to address the family's questions and concerns, and to establish goals of care. Information on how to conduct a family meeting in palliative care is available from the Therapeutic Guidelines (Palliative Care)  (with 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 25 May 2017