Module 2: Direct Comprehensive Primary Care in the LTC Setting

36 2.4.4 Goals of Care & Serious Illness Conversations

A serious illness is a condition that carries a high risk of death, substantially reduces quality of life and can impose a significant burden on the patient’s caregiver[1]

Serious Illness conversation is not just:

  • Code status conversations
  • Conversations to share prognosis, life expectancy and recovery statistics
  • Conversations to make immediate medical decisions

Challenges for Serious Illness conversations:

  • Time pressures and complex life-saving procedures requiring acute decision-making
  • Continuity of care[2][3][4][5]

Benefits of early Serious Illness conversations:

  • Increased goal-concordant care
  • Increased patient and family satisfaction with care
  • Better preparation for making treatment decisions, even in challenging and time-sensitive situations
  • Improved patient quality of life
  • Reduction in the use of non-beneficial, intensive treatments
  • Cost savings by avoiding unnecessary treatments
  • Enhanced healthcare provider-patient relationships

Clinician identified barriers to GOC discussions in LTC settings:

  • Caregiver reactions and treatment understanding
  • Lack of time for conversations
  • Residents not having advance care planning
  • Inadequate documentation of previous GoC conversations[6][7][8][9][10]

  1. Jacobsen et al., 2022 ↵
  2. Harris et al., 2021 ↵
  3. Cameron & Laupacis, 2019 ↵
  4. Vancouver Coastal Health, n.d. ↵
  5. Baxter et al., 2023 ↵
  6. Choosing Wisely Canada, n.d. ↵
  7. Jacobsen et al., 2022 ↵
  8. Clarke et al., 2023 ↵
  9. Siu et al., 2020a ↵
  10. Nova Scotia Health, 2023 ↵

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Nurse Practitioners Delivering Primary Care in the Long Term Care Setting Copyright © 2024 by Erin Ziegler, Carrie Heer and Adhiba Nilormi is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License, except where otherwise noted.

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