The Goals of Care Plan is a key component of the Healthy Dying Initiative. It has been implemented at the Royal Hobart Hospital, and is under consideration by other Tasmanian hospitals.
A less formal version has been created for use in the community and in aged care facilities. It may be modified as needed. Goals of Care Plan template.
Information here is a summary only. Authorised users should access the detailed documentation available on the DHHS Intranet site.
The aim of the Goals of Care Plan is to ensure that patients who are unlikely to benefit from medical treatment aimed at cure, receive care appropriate to their condition and are not subjected to burdensome or futile treatments. In particular this concerns cardiopulmonary resuscitation and Medical Emergency Team (MET) calls, which may otherwise occur if the patient's condition deteriorates. A set of Principles - Goals of Care (GOC) Plan underlines this aim.
The Goals of Care Plan is an assessment tool which should be completed for all patients being admitted to the hospital. Day admissions for low risk procedures on otherwise healthy people may be exempted at the discretion of the admitting Consultant. Where possible the goal of care should be informed by discussion with the patient, or their Person Responsible, or by an Advance Care Directive. However the final decision about care is always a clinical one.
The Consultant or Specialist responsible for the patient's care, or their designated delegate, (Registrar or RMO) is responsible for completing and signing the Goals of Care Plan form, authorising any changes, contacting the patient's GP, and endorsing the form for out-of-hospital use.
View a flowchart of decision-making involved in implementing the Goals of Care Plan.
Decision-making is based on determining the appropriate phase of care according to a realistic assessment of the probable outcomes of medical treatment at this stage of their illness. The phases are: curative, palliative and terminal. Patients may move from one phase to another. For some patients cure is never an option even at presentation, while other patients only present in the terminal phase.
A step by step Guidance Notes - Completion of Goals of Care Plan for the completion of a Goals of Care Plan provides key clinical questions which may be asked when assessing a patients' presentation and outlook.
Endorsement of Goals of Care Plan for Out of Hospital Care
If the patient is to be transferred or discharged, the goals of care should be reviewed and documented in the discharge summary.
The Goals of Care Plan may be endorsed by the Consultant or Specialist responsible (or delegate) as active, and presented to ambulance crews to accompany a patient who is being transferred for palliative or terminal care at home or in another facility such as a Nursing Home or Palliative Care Unit.
If the Goals of Care Plan is being endorsed for ambulance transfer, or continuation of the Plan at home, or in a residential care facility, the patient's GP should be informed of the discussions and a copy of the Plan should be faxed or emailed to the GP for follow up in the community.
View the Goals of Care Plan form (example only, as used at Royal Hobart Hospital).