Goals of Patient Care

The need to develop a clear, consistent and effective approach to establish the goals of medical care for patients admitted into West Australian hospitals, has resulted in the development of a statewide Goals of Patient Care Form. This document prompts and facilitates proactive shared decision making between treating clinicians, patients and their families.

These conversations are essential to plan medical treatment which would be applied in the event of clinical deterioration. Use of this clinical document aims to improve the delivery of medically appropriate care, congruent with patient preferences, needs and values. Goals of Patient Care will change over time, particularly at points of transition, such as during advancing illness, at the diagnosis of life limiting illness and at entry to the end-of-life and terminal phase of illness.

This care planning process captures and documents the patients preferences for care during clinical deterioration including any limitations to treatment for the current admission or during planned extended use (beyond the admission). The use of this clinical document will compliment and support the take up of Advance Health Directives.

Current Interim Resources for Goals of Patient Care

This section is intended for clinicians seeking information on how to complete Goals of Patient Care clinical documents.

The information provided is not meant to replace clinical judgement or specialist consultation; rather it is intended to clarify and strengthen clinical care planning/management and supported/shared decision making for all patients, families and clinicians.

Three types of these documents are used across Western Australia:

• Goals of Patient Care BOSSnet eForm (eform submitted sample (PDF 207KB) exclusively available to BOSSnet sites and completed via the Digital Medical Record.
• Goals of Patient Care Form MROOH.1 (PDF 324KB), a paper version of the statewide clinical document currently used by the majority of public/private/metropolitan and rural health services.

 
Image: Goals of Patient Care iCM (Non-BOSSnet) eForm

• Residential Goals of Care RC00H.1 (PDF 156KB), a print on site form suitable for in both public and private residential aged care facilities. For private facilities that wish to make adjustments specific to their context, contact WACHS.FormsManagement@health.wa.gov.au for assistance.

Clinicians new to Goals of Patient Care are advised to familiarise themselves with the below resources:

• Goals of Patient Care video – Using the iCM (Non-BOSSnet) eForm (external site) (log-in required)
• Goals of Patient Care video – Using the BOSSnet eForm (external site)
• Goals of Patient Care eForm frequently asked questions (external site) (log-in required)
• Goals of Patient Care video – Clinical framework (external site)
• Goals of Patient Care – A clinician's guide With thanks to Dr Nicholas Waldron, Consultant Geriatrician, together with the clinicians and ward staff at Armadale Health Service)

This section is intended for clinicians seeking information on how to conduct Goals of Patient Care conversations.

• Goals of Patient Care – discussion tips (PDF 1MB)
  Reproduced with permission from Dr Ioana Vlad, Consultant Emergency, Sir Charles Gairdner Hospital, Perth.
• End of life essentials (external site)

Reproduced with permission from Dr Ioana Vlad, Consultant Emergency, Sir Charles Gairdner Hospital, Perth.

Increasingly, health consumers, clinicians and systems are considering the importance of patient centred treatment decisions. This is especially true when undertaking anticipatory care planning for deterioration. Clinicians have a responsibility to provide honest information that assist patients and families to understand treatment options. This should be done in light of their values, changing health/illness and real options for future care.

This process relies on clinician recognition of patients who may be at risk of clinical deterioration, and those that may be approaching end-of-life or transitioning to the terminal phase. Failure to identify these patients can reduce their quality of care through delays in timely comfort care and prolonged exposure to non-beneficial treatment.

Clinical Indicators can be used to identify when to initiate a Goals of Patient Care process. Clinical Indicators are screening tools designed to support hospital teams to recognise patients at risk of deteriorating and/or dying. Once such tool SPICT.

SPICT aims to reduce the impact of prognostic ambiguity and improve clinician confidence in identifying these patients earlier in the course of the hospital admission, or earlier in the course of illness. 

Supportive and Palliative Indicators Tool (SPICT^TM)  

It is used to identify people with deteriorating health due to one or more advanced conditions. It guides holistic assessment and care planning.

SPICT for health professionals

• SPICT^TM 2019 (PDF 165KB)  
• Guide to using SPICT^TM  (PDF 385KB)

SPICT for patients, family and professional carers

• Guide to Using SPICT-4ALL (PDF 155KB)
• SPICT-4ALL Individual Record Sheet (PDF 144KB)

Additional resources 

The SPICT™ tool is available as a free app on iOS for iPhone and iPad, and as an app for Android.

The latest version of the SPICT^TM app includes information about the SPICT^TM, advice on how to assess and plan care for people identified with it, and tips on effective communication:

• SPICT^TM app for iOS (external site)
• SPICT^TM  app for Android (external site)

Note: all users are responsible for ensuring that they use the current version of SPICT-App and for any use they make of SPICT™ and SPICT™ website resources.

Visit Clinical resources for End-of-Life and Palliative Care in the COVID-19 environment for symptom management flowcharts.

Conversations and communications tips

• Società Italiana di cure palliative (SICP) COVID19 communication toolkit (Word 446KB)
• COVID-ready communication skills: a playbook of VitalTalk tips (external site)
• Vital Talk (external site)
• Guidelines for institutional ethics services responding to COVID-19 managing uncertainty, safeguarding communities, guiding practice Hastings Center COVID-19 Framework, 16 March 2020 (PDF 315KB).

The workshops were facilitated by Dr Simon Towler, Intensivist, Fiona Stanley Hospital and WA Cancer and Palliative Care Network Clinical Lead (End-of-Life Care) and Valerie Colgan, Staff Development Educator, Clinical Implementation Unit, WA Cancer and Palliative Care Network.

Attendees identified useful clinical resources and current health service planning for training in this environment. The Workshops provide an opportunity for collective thinking and sharing to improve clinical training during COVID-19 management.

Dr Simon Towler’s presentations

• Goals of Patient Care and end-of-life in the COVID-19 environment introduction 
• Goals of Patient Care

• WA Health – Advance Care Planning – training and resources
• WA Health – Advance Care Planning (HealthyWA)
• Advance Care Planning Australia (external site)

Ethical challenges in health care are common even under normal conditions because health care responds to human suffering. To act ethically should be integral to professionalism in health care. However, professionals often experience uncertainty or distress about how to proceed during public health emergencies.

More information see the Hastings Canter website (external site).

The Department of Health, WA has been working in association with the Australian Digital Health Agency on the National Goals of Care Collaborative. The Collaborative aims to increase the use of Advance Care Planning (ACP) documents and Goals of Patient Care (GoPC) clinical documents in the My Health Record (MHR) system for record sharing and to improve the availability of these documents at point of care.

As part of the Collaborative, selected WA Health hospitals are now uploading both the BOSSnet GoPC and the Non-BOSSnet iCM GoPC eForm to My Health Record. These documents can only be uploaded to My Health Record with the patient’s consent. Storing GoPC clinical documents in MHR allows other health care professionals (including General Practitioners and private providers) to understand the types of discussions that have occurred between the patient and their healthcare team about their goals of care and treatment preferences. This can then be used to prompt discussions with other people involved in their care.

Additional hospitals in WA will be able to upload GoPC clinical documents to My Health Record in the second half of 2021.

For more information about the Collaborative, please email GoalsOfCareMHRProject@health.wa.gov.au

To read more about the Collaborative and view the National Guidelines – Using My Health Record to store and access advance care planning and goals of care documents on the My Health Record website (external site).

Currently a statewide Goals of Patient Care form is being developed which will be piloted at several Western Australian health services.

A whole of health service pilot is currently being undertaken at Armadale Health Service. We wish to acknowledge Dr Nicholas Waldron, Consultant Geriatrician and Clinical Lead Falls Prevention Network, together with the clinicians and ward staff for the development of this training video.

• Goals of Patient Care – information for consumers (HealthyWA)
• Advance Care Planning
• COVID-19 information for patients, parents, visitors and carers
• Palliative care
• End of life care
• Clinical resources for End-of-Life and Palliative Care in the COVID-19 environment