Module 2: Direct Comprehensive Primary Care in the LTC Setting
26 2.2.8 Goals of Care
Goals of Care (GOC) discussions are important in the context of serious, life-limiting illnesses. The focus of GOC discussions is to:
- Ensure that individuals and/or their SDMs have a strong understanding of the nature of their illness
- Ensure that healthcare providers understand the patient’s values and care goals
- Align care with patient’s values, needs, and priorities[1][2][3][4]
Goals of Care:
- Curing the disease
- Prolonging and preserving life
- Relieving suffering
- Optimizing quality of life
- Maintaining control
- Achieving a peaceful and dignified death
- Providing support for family and loved ones
- Decisions that can result from GOC discussions:
- Resuscitation/DNR orders
- Starting, continuing or stopping chemotherapy
- Location of care
- Initiating or discontinuing dialysis
- Limits to treatment[5][6]
Steps to GOC Discussions:
- Explore illness understanding
- Inform
- Elicit values and define goals
- Plan and document
- Document Goals of Care
- Revisit
Outcomes of GOC discussions:
Improved understanding of illness, what to expect, care options, goals and values
actively participate in making informed decisions about their care
Enhanced patient-centered care
- Improving GOC discussions:
- Practice good communication skills
- Use a conversation guide:
- JUST ASK
- REMAP: Reframe, Expect emotion, Map out goals, Align with goals, Propose a plan
- SUPER: Setup, Understanding, Priorities, Explain, Review & Recommend