The Goals of Patient Care project: implementing a proactive approach to patient-centred decision-making

Abstract

Background: Patients in the later stages of their lives risk being harmed by futile or unwanted interventions if realistic care goals and patient values are not recognised. Doctors have difficulty discussing and informing patients' healthcare goals.

Aims: To review implementation of a Goals of Patient Care (GOPC) summary in medical inpatients and its applicability in emergency medical response (EMR) situations.

Methods: Single-centre cross-sectional study of adult medical inpatients and adult inpatients requiring EMR at a Victorian general hospital.

Measures: presence and content of GOPC summary, secondary review of decision-making and discussion documentation, patient characteristics; EMR precipitants and outcomes.

Results: GOPC were documented for 82 of 101 patients. One had an existing advance directive, and six had records of a patient-appointed substitute decision-maker. For patients with GOPC, 80 had life-prolonging treatment aims, with a varying degree of treatment limitation in 48. Discussion with patient or substitute decision-maker was evident in 43 cases. GOPC were documented prior to nine of 23 EMR. The EMR triggered a GOPC modification in three instances.

Conclusions: Introduction of a routine GOPC summary encourages consideration of goals of care for most medical inpatients. Few have pre-existing records of their wishes, and there are opportunities for improvement in this regard. Doctors may still have difficulty determining goals of care, and discussion of GOPC with patients and families may not be clearly documented. Most patients requiring EMR do not have prior GOPC review, and the role of the summary in these situations remains unclear.

Keywords: advance care planning; communication; decision-making; futility; resuscitation orders.