‘Goals of Patient Care’:
Proactive shared decision-making to establish medical treatment goals & treatment limitations
Dr Barbara Hayes - Palliative Care Physician Clinical Lead – Advance Care Planning
Member - Accreditation Standard 9 Committee
Managing the Deteriorating Patient Conference 2014
© B. Hayes.2014
Acknowledgement
Prof Michael Ashby and Dr Robyn Thomas from Royal Hobart Hospital & Southern Tasmania Area Health Service
Developed original Goals of Care model on which Northern Health’s approach is based.
© B. Hayes.2014
Brings together….
Person Centred Care
Advance Care Planning
Raising awareness
Capturing & implementing prior planning
Shared decision-making for potential deterioration
Medical Treatment Goals
Emergency Treatment Escalation (CPR/MET)
CPR/NFR decision-making
Community Endorsement of Medical Orders
© B. Hayes.2014
Rapid Response Teams
Initially developed to rescue deteriorating patients
- but dying patients progress through same trajectories
New role for RRTs
Diagnosing and managing EoL / dying
- up to one third of RRTs
(Jones D et al. 2013)
© B. Hayes.2014
Goals of Patient Care Summary
Doctor directed
In consultation with the patient
and/or Medical Substitute Decision-maker & family
Planning for urgent situations
or for when treating clinicians
are not around
© B. Hayes.2014
Advance Care Planning
Patient directed
In consultation with the clinicians
Planning for when the
patient can’t speak for
themselves
© B. Hayes.2014
‘ACP in 3-Steps’ © Northern Health 2009
© B. Hayes.2014
Goals of Patient Care Summary
• Routinely at the front of adult admissions to Northern Health - - All Medical Admissions
- Selected Surgical Patients (Emergency > 65yrs)
• Aim to complete within first 24-48 hours of admission
• Decisions to limit treatment must be discussed with treating Consultant (or their delegate)
© B. Hayes.2014
First of three sections:
Documents:
Substitute Medical Decision-maker Prior Advance Care Planning
© B. Hayes.2014
Second of three sections:
Documents: Medical treatment goals
© B. Hayes.2014
© B. Hayes.2014
Medical treatment goals
A quickly accessible summary of the agreed medical goals of care
Pro-active decision:
• general guidance about the ‘big-picture’ and medical treatment that is appropriate
• specific instructions about CPR and Code Blue / MET Calls etc
Identifies who has been involved in the decision
© B. Hayes.2014
Medical treatment goals
THREE treatment aims Curative or restorative
Primarily non-burdensome treatment & symptom management
Dying (Ashby MA, Stoffell B. 1997)
→ → FOUR patient medical goal categories
© B. Hayes.2014
Medical treatment goals
THREE treatment aims
→ → FOUR patient goal categories
A. Curative or restorative - no treatment limitations
B. Curative or restorative - some treatment limitations
C. Primarily non-burdensome treatment & symptom management
D. Terminal care (Ashby MA et al. 2014)
© B. Hayes.2014
Medical treatment goals based on -
…then within those constraints
…leading to
(i) A medical assessment & a medical decision about
treatment & what is possible
(ii) A shared decision-making discussion between clinician
and patient and/or substitute decision-maker
An agreed medical treatment plan including:
- Overall medical treatment goals &
- Specific emergency medical treatments / limitations
© B. Hayes.2014
Medical treatment goals
A. Curative or restorative - no treatment limitations
B. Curative or restorative - some treatment limitations
C. Primarily non-burdensome treatment & symptom management
D. Terminal care – all treatment is aimed at comfort during dying
(Ashby MA et al. 2014)
Default
© B. Hayes.2014
© B. Hayes.2014
Third of three sections:
Endorsement
• The medical orders can be endorsed after Consultant review to continue in the community or at another health service such as Residential Aged Care
should NOT come as a surprise after discharge
© B. Hayes.2014
Northern Health audit
August 2013 – Implementation
Point prevalence audit of medical admissions (Nov 2013)
• 101 files audited
82 (81%) forms completed
(Brimblecome C et al. 2014)
© B. Hayes.2014
Goals of Patient Care Summary
Systematically identifies patient’s Substitute Medical Decision-maker
Systematically captures prior ACP
Pro-actively identifies medical treatment goals and limitations to treatment escalation
Hand-over of Medical treatment orders for use in the community
© B. Hayes.2014
Goals of Patient Care Summary
Treating team know patient/family best – best placed to complete GOPC
Aim to complete at a time when discussions are more easily undertaken
Aim to avoid MET / Code Blue teams making these decisions, in a crisis, for an unknown patient
© B. Hayes.2014
References
• Ashby MA, Stoffell B. Therapeutic ratio and defined phases: proposal of an ethical framework for palliative care. BMJ 1991, 302:1322-24.
• Jones D et al. The rapid response system and end-of-life care. Current Opinion Critical Care. 2013; 19(6);616-623.
• Ashby M et al. Goals of Care: a clinical framework for limitation of medical treatment. (accepted for publication)
• Brimblecombe C et al. The Goals of Patient Care project: implementing a proactive approach to patient-centred decision making. Internal Medicine Journal. 2014; DOI: 10.1111/imj.12511
• Hayes B. Clinical model for ethical cardiopulmonary resuscitation decision-making. Internal Medicine Journal. 2013; 43:77
© B. Hayes.2014
Dr Barbara Hayes [email protected]
Managing the Deteriorating Patient Conference 2014
‘Goals of Patient Care’
© B. Hayes.2014
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