‘Goals of Patient Care’:

Proactive shared decision-making to establish medical treatment goals & treatment limitations

Dr Barbara Hayes - Palliative Care Physician Clinical Lead – Advance Care Planning

Member - Accreditation Standard 9 Committee

Managing the Deteriorating Patient Conference 2014

© B. Hayes.2014

Acknowledgement

Prof Michael Ashby and Dr Robyn Thomas from Royal Hobart Hospital & Southern Tasmania Area Health Service

Developed original Goals of Care model on which Northern Health’s approach is based.

© B. Hayes.2014

Brings together….

Person Centred Care

Advance Care Planning

Raising awareness

Capturing & implementing prior planning

Shared decision-making for potential deterioration

Medical Treatment Goals

Emergency Treatment Escalation (CPR/MET)

CPR/NFR decision-making

Community Endorsement of Medical Orders

© B. Hayes.2014

Rapid Response Teams

Initially developed to rescue deteriorating patients

- but dying patients progress through same trajectories

New role for RRTs

Diagnosing and managing EoL / dying

- up to one third of RRTs

(Jones D et al. 2013)

© B. Hayes.2014

Goals of Patient Care Summary

Doctor directed

In consultation with the patient

and/or Medical Substitute Decision-maker & family

Planning for urgent situations

or for when treating clinicians

are not around

© B. Hayes.2014

Advance Care Planning

Patient directed

In consultation with the clinicians

Planning for when the

patient can’t speak for

themselves

© B. Hayes.2014

‘ACP in 3-Steps’ © Northern Health 2009

© B. Hayes.2014

Goals of Patient Care Summary

• Routinely at the front of adult admissions to Northern Health - - All Medical Admissions

- Selected Surgical Patients (Emergency > 65yrs)

• Aim to complete within first 24-48 hours of admission

• Decisions to limit treatment must be discussed with treating Consultant (or their delegate)

© B. Hayes.2014

First of three sections:

Documents:

Substitute Medical Decision-maker Prior Advance Care Planning

© B. Hayes.2014

Second of three sections:

Documents: Medical treatment goals

© B. Hayes.2014

© B. Hayes.2014

Medical treatment goals

A quickly accessible summary of the agreed medical goals of care

Pro-active decision:

• general guidance about the ‘big-picture’ and medical treatment that is appropriate

• specific instructions about CPR and Code Blue / MET Calls etc

Identifies who has been involved in the decision

© B. Hayes.2014

Medical treatment goals

THREE treatment aims Curative or restorative

Primarily non-burdensome treatment & symptom management

Dying (Ashby MA, Stoffell B. 1997)

→ → FOUR patient medical goal categories

© B. Hayes.2014

Medical treatment goals

THREE treatment aims

→ → FOUR patient goal categories

A. Curative or restorative - no treatment limitations

B. Curative or restorative - some treatment limitations

C. Primarily non-burdensome treatment & symptom management

D. Terminal care (Ashby MA et al. 2014)

© B. Hayes.2014

Medical treatment goals based on -

…then within those constraints

…leading to

(i) A medical assessment & a medical decision about

treatment & what is possible

(ii) A shared decision-making discussion between clinician

and patient and/or substitute decision-maker

An agreed medical treatment plan including:

- Overall medical treatment goals &

- Specific emergency medical treatments / limitations

© B. Hayes.2014

Medical treatment goals

A. Curative or restorative - no treatment limitations

B. Curative or restorative - some treatment limitations

C. Primarily non-burdensome treatment & symptom management

D. Terminal care – all treatment is aimed at comfort during dying

(Ashby MA et al. 2014)

Default

© B. Hayes.2014

© B. Hayes.2014

Third of three sections:

Endorsement

• The medical orders can be endorsed after Consultant review to continue in the community or at another health service such as Residential Aged Care

should NOT come as a surprise after discharge

© B. Hayes.2014

Northern Health audit

August 2013 – Implementation

Point prevalence audit of medical admissions (Nov 2013)

• 101 files audited

82 (81%) forms completed

(Brimblecome C et al. 2014)

© B. Hayes.2014

Goals of Patient Care Summary

Systematically identifies patient’s Substitute Medical Decision-maker

Systematically captures prior ACP

Pro-actively identifies medical treatment goals and limitations to treatment escalation

Hand-over of Medical treatment orders for use in the community

© B. Hayes.2014

Goals of Patient Care Summary

Treating team know patient/family best – best placed to complete GOPC

Aim to complete at a time when discussions are more easily undertaken

Aim to avoid MET / Code Blue teams making these decisions, in a crisis, for an unknown patient

© B. Hayes.2014

References

• Ashby MA, Stoffell B. Therapeutic ratio and defined phases: proposal of an ethical framework for palliative care. BMJ 1991, 302:1322-24.

• Jones D et al. The rapid response system and end-of-life care. Current Opinion Critical Care. 2013; 19(6);616-623.

• Ashby M et al. Goals of Care: a clinical framework for limitation of medical treatment. (accepted for publication)

• Brimblecombe C et al. The Goals of Patient Care project: implementing a proactive approach to patient-centred decision making. Internal Medicine Journal. 2014; DOI: 10.1111/imj.12511

• Hayes B. Clinical model for ethical cardiopulmonary resuscitation decision-making. Internal Medicine Journal. 2013; 43:77

© B. Hayes.2014

Dr Barbara Hayes Barbara.Hayes@nh.org.au

Managing the Deteriorating Patient Conference 2014

‘Goals of Patient Care’

© B. Hayes.2014