From the Guidelines
To have a goals of care discussion, it is essential to designate a medical professional to facilitate the meeting, review the patient's medical record, and introduce all attendees, as recommended by the American Society of Clinical Oncology consensus guideline 1. When conducting a goals of care discussion, several key steps should be taken to ensure a productive and patient-centered conversation.
- Before the meeting, review the patient's medical record for previous discussions of goals of care and end-of-life directives, as suggested by the American Society of Clinical Oncology consensus guideline 1.
- Introduce everyone present and explore the family's agenda for the meeting to create a framework for the discussion, as recommended by the American Society of Clinical Oncology consensus guideline 1.
- Share information about and/or documentation of previous discussions of goals of care and end-of-life directives, and elicit perspectives from all meeting attendees, as suggested by the American Society of Clinical Oncology consensus guideline 1.
- Identify key issues, disagreements, and perspectives clearly before problem-solving, and anticipate that in nonurgent situations, a resolution may not happen in the meeting itself, as recommended by the American Society of Clinical Oncology consensus guideline 1.
- Pay attention to interactions, such as who talks, to whom, and who is seen as a decision-maker in the family, and set a plan for follow-up, as suggested by the American Society of Clinical Oncology consensus guideline 1.
- Offer to include absent family members via telecommunications, if appropriate, to ensure all key decision-makers are involved in the discussion, as recommended by the American Society of Clinical Oncology consensus guideline 1. It is also important to incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate, as recommended by the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1. Additionally, addressing goals of care as early as feasible, but no later than within 72 hours of ICU admission, can help ensure that medical care aligns with patient values and reduces unwanted interventions, as suggested by the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1. Overall, a goals of care discussion should be approached with empathy, active listening, and cultural sensitivity, recognizing that goals of care evolve over time and should be revisited periodically, as recommended by the American Society of Clinical Oncology consensus guideline 1 and the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1.
From the Research
Preparation for Goals of Care Discussions
- Clinicians can prepare for goals of care discussions by developing their communication skills, such as active listening and empathy, as shown in a study where internal medicine residents participated in a simulation experience to train in goals-of-care conversations 2.
- A framework for effective communication can be followed, including advance care planning, delivering serious news, discussing prognosis, eliciting values, and medical decision making 3.
Strategies for Effective Goals of Care Discussions
- Strategies for effective goals of care discussions include considering patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources 4.
- Using an electronic medical record-based goals-of-care template can help ensure full coverage of important tasks, such as planning for transition to hospice and legacy work 5.
- Nurses and other healthcare providers can follow specific strategies to plan the discussion, overcome barriers, and offer useful resources and support 6.
Key Elements of Goals of Care Discussions
- Key elements of goals of care discussions include shared decision-making, patient-centered care, and ensuring that patients and families feel heard and satisfied with their conversation 2, 5.
- Clinicians should be able to discuss prognosis, hospice, and other care options with patients and families, and provide emotional support and empathy 2, 3.
- Effective goals of care discussions can lead to improved patient outcomes, increased patient satisfaction, and better advance care planning 2, 4.