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.