Goals of care: Decision-making at end of life

We have introduced a new process and documentation system in our health service (Southern Tasmania Area Health Service/Royal Hobart Hospital) to improve care and decision-making at the end of life. It is based on a policy/protocol to urge clinicians to assess goals of care into one of three categories: curative, palliative and terminal1. Limitation of medical treatment is then discussed with the patient or substitute decision maker, and documented on the form. This Goals of Care form replaces the existing ‘NFR’ form.

The form is intended to be completed for ALL admitted patients, even if no limitation of treatment is to be considered. Clinical teams are asked to review patients regularly, and change the goals category and limitations as needed. Patients who are allocated to the ‘terminal’ category are then recommended for a ‘Liverpool Care Pathway’ approach for imminent dying. The form is based on one developed at the Austin Hospital (theirs does not have the three-goal categories), and also bears many resemblances to the POLST instruments widely found in the USA2. A Goals of Care form is not an advance directive, it is a medical order form. It can be endorsed for transfer journeys by ambulance to new locations of care, and can be validated for up to 90 days at a new facility, or in the home. This approach has been popular with nursing, medical and ambulance staff, and although uptake is as variable as ‘NFR’ documentation, it is now a well-accepted way of generating clarity about managing acute medical deterioration, and differentiating between reasonable attempts to prolong life, as opposed to prolonging the dying process. This work is being undertaken as part of a broader initiative on advance care directives and ‘Healthy Dying’.3

1.http://www.gpnw.com.au/AAWeb%20Pages/Events/GCLTRPv2_BW_101209.pdf
2.http://www.ohsu.edu/polst/
3.https://clinicalnetworks.dhhs.tas.gov.au/pages/viewpage.action?pageId=11337953