Clinical In-Service Goals of Care. Josh Stachniak

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1 Clinical In-Service Goals of Care Josh Stachniak

2 Agenda 1. Purpose of Today s Presentation 2. Overview of Goals of Care 3. Consent and Goals of Care 4. Dispute Resolution and Goals of Care 5. Advanced Care Planning and Minors 6. Exploration of Clinical Examples 7. Questions/Feedback and Next Steps

3 Objectives for today 1. Explore the underlying rationale for the use of Goals of Care (GoC) and the associated benefits and drawbacks 2. Relate the GoC process to the principles of consent to treatment 3. Explore dispute resolution mechanisms to deal with exceptional situations arising from GoC situations 4. Talk about next steps for GoC within Covenant Health

4 Goals of Care overview Summary of GoC designations

5 Goals of Care stated purpose (AHS and COV) AHS OBJECTIVES To guide health care professionals, patients and alternate decision-makers regarding the general intentions of clinically indicated health care, specific interventions, and the service locations where such care will be provided. To provide guidance for health care professionals to assist in rapid decision-making in the clinical environment. COV Purpose To guide health care professionals, patients and alternate decision-makers to determine the general intentions of clinically indicated health care, specific interventions, and the service locations where such care will be provided. 1. To serve as a communication tool for health care professionals to assist in decision-making in the clinical environment. 2. To establish a consistent process for: documentation of the Goals of Care and Advance Care Planning revisiting decisions when patient/resident s health status changes determining Goals of Care Designation

6 Goals of Care - Principles AHS PRINCIPLES Alberta Health Services respects human dignity by providing care that is clinically indicated and ethically appropriate and seeks to understand patient values regarding care provision. Within Alberta Health Services, Advance Care Planning will be the process by which health care professionals and patients and/or alternate decision-makers consider the clinically indicated future care for a patient. These conversations allow for respectful understanding of patient s wishes concerning general care focus as well as initiation, continuation and limits of specific interventions. This process will include communication between health care professionals, patients and when appropriate, alternate decision-makers.

7 Goals of Care - Principles Goals of Care Designations (R-M-C) are the mechanisms by which health care professionals describe and communicate the general focus of care for a patient. Goals of Care Designations include direction about the general focus of care and some specific actions within that focus of care. Goals of Care Designations incorporate the values and wishes of a patient, as well as guide medically indicated interventions in service of those values and wishes. There are four primary roles for the Advance Care Planning/Goals of Care Designation: 1. To serve as a communication tool for healthcare professionals to assist in decisionmaking in times of crisis; 2. To guide healthcare professionals and patients/residents regarding the locations and general intentions of the care and interventions that are to be provided; 3. To provide patients/residents with an opportunity to express their wishes for their care; and 4. To provide patients/residents with a clear process for revisiting decisions as their health status changes.

8 Consent and Goals of Care All care relationships flow out of a consensual relationship to treatment, with very limited exceptions (Mental Health Act). Informed Consent is defined as: the agreement of a patient (or their alternate decision maker) to the patient undergoing a treatment/procedure after being provided with the relevant information about the treatment/procedure(s), its risks and alternatives and the consequences of refusal. How does this concept relate to Goals of Care? Consent is not completing a form, it is a conversation and understanding of treatment options and alternatives. Goals of care help facilitate conversation and understanding about treatment goals and objectives, allowing better understanding of the patient s consent to a treatment plan in situations where the patient can no longer give voice to their decision. Although advance care planning conversations don't always result in determining goal of care designation, they make sure your voice is heard when you cannot speak for yourself. AHS Advanced Care Planning website

9 Dispute Resolution (GoC) Decision-making by patients and the health care professionals who provide care to them is an integral component of health care. When circumstances bring significant complexities, including disagreement in what care is to be provided, additional decision support may be required. AHS Procedure GoC, Appendix C Procedure recommends use of Decision Support Resources including: 1. Inter professional health care team 2. Second Opinion from another physician 3. Social Work/Spiritual Care/Palliative End of Life Support 4. Ethics, Capacity Assessment Team, Legal Services, Patient Relations Covenant Health has established an Exceptional Situations Committee which can potentially assist depending on the nature of the issue, contact Patient Relations for a referral

10 Advanced Care Planning and Children A patient under the age of eighteen years is presumed to be a minor patient without capacity, unless assessed and determined to be a mature minor. The advantages of advanced care planning and establishing GoC for the general patient population also apply to conversations about GoC for minor patients. The Canadian Paediatric Society has issued a position statement on advanced care planning for paediatric patients available at:

11 Example Situation #1 A physician admits a 30 year old patient showing some signs of depression. The patient indicates to the physician during a goals of care discussion to Put me as M2, I don t want people to waste time on me. What are the ramifications and issues to explore arising from this statement?

12 Example Situation #2 A physician is working with a 2 year old with pneumonia and the parents say to the physician "If he dies it is god's will and we should not interfere. What does his mean for goals of care and clinical interventions?

13 Example Situation #3 A terminal metastatic lung cancer patient has been admitted. The patient is his own decision maker, but wants his son to participate with decision making. The son participates by phone as he lives in Vancouver and has not seen Dad in 2 years. The son insists his father be R1. Dad doesn't want to cause waves so agrees. What would this mean to the care team?

14 Example Situation #4 An elderly patient with advanced end stage COPD and early dementia insists on being an R1. If put on a ventilator she will likely never come off. She is still own decision maker. How should a physician proceed with clinical interventions?

15 Feedback and Next steps Thoughts and Questions? What are the next steps with this information to assist clinicians?

16 Resources Covenant General information page Covenant Policy AHS FAQ AHS Policy

17 Questions and contact Josh Stachniak Legal Counsel & Director Risk Management Heather Gallant Legal Counsel

NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section.

NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section. TITLE ADVANCE CARE PLANNING AND GOALS OF CARE DESIGNATION SCOPE Provincial APPROVAL AUTHORITY Clinical Operations Executive Committee SPONSOR Seniors Health PARENT DOCUMENT TITLE, TYPE AND NUMBER Not Applicable