Identify goals of care when the patient is admitted

Goals of care

  • The treating team works with the patient and family to identify goals of care
  • Goals of care inform medical decision-making and limitations of medical treatment (resuscitation plan).
  • Medical management aligns with the patient’s values and preferences from the point of admission.

Revisit goals of care when:

  • the patient is readmitted to hospital
  • there are significant changes in the patient’s condition or circumstances
  • the patient, substitute decision maker or family request it
  • the patient, substitute decision maker or family expresses concerns.

About goals of care

  • Active medical treatments and end of life care are not mutually exclusive - Palliative care from diagnosis to death (video).
  • Goals of care are reflected in the clinical treatment plan, limitations of medical treatment (resuscitation plan) and advance care planning.

Goals of care guide treatment at times of crisis 

Crises often occur after hours. Without documented goals of care, junior clinicians who don’t know the patient are forced to make decisions in the heat of the moment and without the input of the patient or substitute decision maker .3,4

Update: see Medical Treatment Planning and Decisions Act 2016

 The three-phase model of goals of care

Curative or restorative phase

'Beating it' - not considering death

Supportive and palliative care phase

'Living with disease, anticipating death'

Terminal phase

'Dying very soon'

Default position for most patients
Disease deemed to be incurable and progressive
Death seems to be imminent 

Goals of care guide medical decision-making:

  • All appropriate life-prolonging treatment deployed
  • Resuscitation: escalation unless otherwise specified

Goals of care guide medical decision-making:

  • Measured life-prolonging and stabilising treatments
  • Quality of life
  • Resuscitation: varied response depending on situation and advance care plan
  • Limitations of medical treatment (resuscitation plan)6  are in place

Goals of care guide decision-making:

  • Comfort, quality of life and dignity
  • Advance care plan activated
  • Site of care and death revisited
  • Limitations of medical treatment (resuscitation plan) in place and reviewed.  

 
 

End of life care considerations:

  • Advance care planning5
  • Symptom management (palliative care consultancy service may assist)
  • MET call/code blue - may prompt connection with palliative care consultancy service if deterioration or death are likely
 

End of life care considerations:

  • Ongoing advance care planning
  • Possible involvement of palliative care consultancy service for:
    • early referral and ongoing contacts in inpatient, outpatients, community
    • MET/Code blue
    • symptom management, goals of care, carer needs
 

End of life care considerations:

Adapted from Thomas R, Zubair M, Hayes B, Ashby M 2014.  Goals of care: a clinical framework for limitation of medical treatment, Medical Journal of Australia, 201: 452–455

See Therapeutic Guidelines Palliative Care 2016 Version 4 on the Clinicians Health Channel at your health service


Thomas R, Zubair M, Hayes B, Ashby M 2014.  Goals of care: a clinical framework for limitation of medical treatment, Medical Journal of Australia, 201: 452–455.

The term ‘substitute decision-maker’ is likely to change when the Medical Treatment Planning and Decisions Act comes into effect March 2018.

Advance care planning records the patient’s wishes for future health and personal care should they lose the capacity to make or communicate their own decisions.

Limitations of medical treatment (resuscitation plan) records the response required in the event of a cardiac arrest or other acute clinical deterioration.