Use of a goals of care plan as a limitation of medical treatment instrument

Background: In March 2011, the Royal Hobart Hospital (RHH) in Tasmania implemented a new limitation of medical treatment instrument, the 'Goals of Care Plan' (GOCP) to facilitate considered and appropriate limitations of treatment for individual patients and establish goals of care for each admission to the RHH. Patients are assigned to one of four categories: curative with no limitations (A) curative with limitations (B) palliative (C) and terminal (imminently dying) (D). An audit of compliance with the GOCP prior to inpatient death at the RHH was done 2 years after introduction of the GOCP.

Aims: To audit compliance with and report outcomes following use of a limitation of medical treatment instrument entitled 'Goals of Care Plan' (GOCP) over the course of a final admission. The secondary outcome was to assess its role in the recognition of dying.

Methods: Retrospective analysis of the Digital Medical Record (DMRl of all deceased patients in the Tasmanian Health Service-South (THO-S) over the six-month period 1/1/13 - 30/6/13.

Results: There were 352 deaths over the six months. 328 at the RHH and 24 at the five MPC's 290 (82.4%) patients had a completed GOCP and 62 (17.6%) did not. After exclusion of sudden unexpected deaths and the rural MPC deaths, the compliance rate for GOCP completion was 94,5%. 74% of forms were completed on the day of admission and 83.5% within 48 hours. Final GOCP category was either C or D for 86% of the deceased patients studied. 78% of patients assigned to category D died within 72 hours reflecting expectation of dying within hours to days. Of the 62 patients without a GOCP, 45(73%) died within 72 hours of admission. Many were sudden, unexpected deaths with 27 (44%) dying within 24 hours of admission - 12 patients died in the rural MPCs where the GOCP was not formally in use.

Conclusions: Compliance with completion of the GOCP at the RHH 2 years after its introduction was very high at 94.5% adjusted and done in a timely manner (83.5% within 48 hours). There was timely recognition of the imminently dying patient and the GOCP framework prompted appropriate limitations to medical treatment escalation and deployment of necessary and appropriate palliative and terminal care. The clinical decisions  made are medical and patients and families should not feel inadvertently burdened with the thought that they are being asked to personally make what they may see as life-ending decisions. Skilled communication is critical whilst discussing goals of care and can be taught.

Research Implications: Priority issues for future study include patient and family reactions and experiences with evaluation of concordance with patient wishes.

Practical Implications: Documentation of medical treatment limitations is essential to protect patients from burdensome and futile treatment at the end of life and ensure that their wishes and directives are followed. GOCP described here is a tried and tested procedure and trial replication at other sentries is recommended if none exists.

Final Goals of Care (2.79MB pdf)