Advance Care Planning: Goals of Care Designation

Transcription

1 Advance Care Planning: Goals of Care Designation Approved by: Vice President and Chief Medical Officer; and Vice President, Mission, Ethics & Spirituality Corporate Policy & Procedures Manual Number: Date Approved September 27, 2017 Date Effective November 10, 2017 Next Review November 2020 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. Purpose To guide health care professionals, patients/residents/clients1 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. To serve as a communication tool for the health care team to assist in decisionmaking and the promotion of Advance Care Planning and Designation decisions in the clinical environment. To provide guidance for the health care team in rapid decision-making in the clinical environment. To establish a standardized process for: engaging in Advance Care Planning and determining a Goals of Care Designation with patients and/or alternate decision makers documentation of the Goals of Care Designation Order and Advance Care Planning conversations reviewing decisions when patient s health status changes Policy Statement Within Covenant Health, Advance Care Planning will be the process by which health care professionals, patients and/or alternate decision makers consider the clinically indicated current and future care of patients. Advance Care Planning conversations allow for respectful understanding of a patient s wishes concerning general care focus, as well as initiation, continuation, discontinuation, and limitations of specific interventions. This process will include communication between the health care team, patients and when appropriate, alternate decision makers. Goals of Care Designations (R-M-C) are the mechanisms by which the health care team describes and communicates the general focus of care for a patient and 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. 1 Hereafter, all references to 'patients' includes residents and clients.

2 Page 2 of Applicability This policy and procedure applies to all Covenant Health facilities, staff, members of the medical staff, volunteers, students and any other persons acting on behalf of Covenant Health. Responsibility Advance Care Planning and Goals of Care Designations are the clinical responsibility of the most responsible health practitioner. The most responsible health practitioner shall demonstrate compliance with this policy and procedure by ensuring that an order reflecting the Goals of Care Designation is documented on the health care record of clinically appropriate patients, utilizing the Goals of Care Designation Order form. Advance Care Planning and Goals of Care Designation conversations between the health care team, the patient and/or alternate decision maker are to be documented on the Advance Care Planning Tracking Record Goals of Care Discussions form. Note: If a Goals of Care Designation order is completed by a medical resident, please refer to the Medical Staff Bylaws & Rules: Supervision of Medical Students and Residents on the Medial Staff Portal (see 'Related Documents' list). Principles As a Catholic, faith-based system, Covenant Health is committed to ensuring respect for human dignity by providing care that is medically and ethically appropriate. Through Advance Care Planning, members of the health care team seek to understand patient s values regarding health care choices. All adults should be given the opportunity to participate in Advance Care Planning as a part of routine care, started early in a longitudinal relationship with the health care team and revisited when the health or wishes of an adult changes. All patients and all alternate decision makers (when applicable) shall be made aware of the Advance Care Planning and the Goals of Care Designations framework and process. Goals of Care Designations shall be utilized throughout Covenant Health facilities to communicate general care direction, location of care, and transfer opportunities for current and future care of patients. A Goals of Care Designation order is prescriptive but is also subject to the clinical judgement of the current most responsible health practitioner. There are four primary roles of Advance Care Planning and Goals of Care Designations: 1. To serve as a communication tool for the health care team to assist in decisionmaking in times of crisis; 2. To guide the health care team and patients regarding the locations and general intentions of the care and interventions that are to be provided; 3. To provide patients with an opportunity to express their wishes for care; and

3 Page 3 of 4. To provide patients with a clear process for revisiting decisions as their health status changes and/or location of care changes. Procedure Detailed descriptions of the Goals of Care Designations, and important clinical features embedded in them, are included in Appendix A: Goals of Care Designations Description 1. Advance Care Planning Conversations 1.1 Any member of a patient s health care team may initiate and participate in Advance Care Planning conversations. In collaboration with other members of the health care team, the most responsible health practitioner should ensure that these conversations include the steps involved in Advance Care Planning, in which patients are encouraged to: a) Think about think about their values and wishes; b Learn learn about their own health; c) Choose Choose someone to make decisions and speak on their behalf; d) Communicate Communicate their wishes and values about health care; e) Document Document their wishes in a personal directive. 1.2 It is understood that the patient and/or alternate decision maker shall be engaged in all related care planning discussions and decisions. 1.3 Patient wishes and values may change over time or with changes in their health; it is important to keep the conversation open and to discuss these changes. 2. Goals of Care Designation Conversations 2.1 Where clinically indicated, Goals of Care Designation conversations shall take place with the patient as early as possible in the individual s course of care and/or treatment. These discussions explore the patient s wishes and goals for clinically indicated treatment framed within the therapeutic options that are deemed appropriate for the patient s clinical condition. NOTE: In the event the patient lacks capacity and a personal directive exists, a reasonable effort shall be made to obtain the personal directive in order to inform conversations regarding a Goals of Care Designation. 2.2 General guidance for when it would not be clinically indicated or appropriate for a Goals of Care Designation conversation to take place include, but are not limited to: a) conversations which could compromise health;

4 Page 4 of b) conversations which could delay emergency intervention; and c) conversations which are not relevant to the current clinical scenario or care pathway for the patient (e.g. low risk/intervention for an otherwise well patient). 2.3 Conversations about Goals of Care Designations are undertaken with the patient or, if the patient lacks capacity to make such decisions, with the patient s alternate decision maker. If the patient s alternate decision maker cannot be contacted or if there is no alternate decision maker, the most responsible health practitioner may have the Goals of Care Designation conversation with a family member with whom the patient has a significant relationship as long as that discussion would not be in conflict with any previously expressed wishes by the patient regarding the release of information to that family member in accordance with the Adult Guardianship and Trustee Act (Alberta). 2.4 Any member of the patient s health care team may initiate and participate in an Advance Care Planning and Goals of Care Designation conversation. However, the most responsible health practitioner is ultimately responsible for ensuring that a clinically indicated Goals of Care Designation order has been discussed, established, and documented. a) It is understood that the patient and/or alternate decision maker shall be engaged in all related discussions and decisions. 2.5 In collaboration with other members of the health care team, the most responsible health practitioner should ensure that Goals of Care Designation conversations include: a) The patient s prognosis and the anticipated outcomes of current treatment; b) Exploration of the patient s values, understanding, hopes, wishes, and expected outcomes of treatment; c) The role of life-support interventions and/or life-sustaining measures and their expected degree of benefit and burden; d) Information regarding comfort measures; e) If appropriate, an offer for involvement of resources such as, but not limited to, palliative care, social work, clinical ethics, or spiritual care, to provide support and guidance to the patient and/or the alternate decision maker; and f) A clear process for revisiting decisions.

5 Page 5 of 2.6 While conversations with the patient and/or alternate decision maker are crucial, the Goals of Care Designation Order form itself is a medical order and, as such, does not require a patient s and/or alternate decision maker s signature. 2.7 Once a Goals of Care Designation conversation has been held, and if clinically indicated, a Goals of Care Designation order shall be decided upon and documented on the Goals of Care Designation Order form and the conversation documented on the Advance Care Planning Tracking Record Goals of Care Discussions form. 2.8 Where a Goals of Care Designation has been ordered, patients or their alternate decision makers shall be informed of their specific Goals of Care Designation. 2.9 In a situation where it is determined that providing such information may negatively impact the health or safety of the patient, it may not be appropriate to inform the patient of his/her Goals of Care Designation. In this case, it is recommended that the most responsible health practitioner consider consulting with, but not limited to: a) Colleagues; b) Clinical Ethics Service; c) College of Physicians and Surgeons of Alberta; d) Canadian Medical Protective Association; and/or, e) Clinical Team; f) Regulatory Body 2.10 If a patient s most responsible health practitioner changes, the previous Goals of Care Designation order remains applicable unless changed by the new most responsible health practitioner When a Goals of Care Designation order is not documented on a patient s health record, then clinically appropriate life support interventions are provided if required. If it is known that the adult patient or alternate decision maker has previously expressed the refusal of such interventions, that refusal should be followed except in unusual circumstances where it would be clinically and ethically inappropriate to do so Where the patient and/or alternate decision maker and the most responsible health practitioner disagree on a Goals of Care Designation, consultation with the Covenant Health Patient Relations and the Covenant Health Ethics Center is strongly recommended.

6 Page 6 of 2.13 Where no Goals of Care Designation order exists, and in a health emergency, if: a) The patient lacks capacity; b) There are no known/available expressed wishes by the patient in regard to a Goals of Care Designation; and c) No alternate decision maker is immediately available: (i) (ii) The most responsible health practitioner, in consultation with members of the health care team, shall assess the potential benefits and burdens of the proposed interventions and write the most clinically relevant Goals of Care Designation order. If the most responsible health practitioner is not available to provide a Goals of Care Designation order, the patient will receive available life support interventions, including transportation to a facility that can provide assessment to determine appropriate care. 3. Personal Directive or Patient Request 3.1 Where an adult patient s personal directive is known to exist, a reasonable effort shall be made to obtain a copy for placement on the health record (preferably in the Green Sleeve). NOTE: A personal directive does not replace a Goals of Care Designation order. 3.2 Where the adult patient has expressed a wish to limit interventions that could be considered clinically indicated, whether directly or in a personal directive, the most responsible health practitioner has a responsibility to comply with the patient s health care wishes, after discussing those limitations with the patient or alternate decision maker, when prescribing a Goals of Care Designation order. NOTE: Wishes outlined in a personal directive that has not been enacted can inform the discussion, but it is the discussion with the patient that would take precedence. 3.3 Where the patient lacks capacity but has previously expressed a wish to initiate, continue, discontinue, or limit interventions that could be considered clinically indicated, whether directly or in a personal directive (which is enacted), the most responsible health practitioner has a responsibility to comply with the patient s health care wishes, after

7 Page 7 of discussing those limitations with the alternate decision maker, when writing a Goals of Care Designation order. a) In situations where the most responsible health practitioner has reason to believe that the patient may have provided instruction without contemplating the beneficial possibilities and relevant treatment burdens of the current clinically indicated interventions, then further discussion with the members of the health care team and the alternate decision maker should ensue. Consultation with the Covenant Health Patient Relations and the Covenant Health Ethics Center is strongly recommended. 3.4 Where the adult patient expresses a wish, either directly or in a personal directive that has been enacted, requesting interventions that are not clinically indicated, the most responsible health practitioner should engage in a discussion with the patient and/or alternate decision maker. If a mutually agreeable decision cannot be reached, further consultation with Covenant Health Patient Relations2 and the Covenant Health Ethics Center3 is strongly recommended. 3.5 When writing a Goals of Care Designation order, where a patient lacks capacity, an existing Goals of Care Designation order is not available, and a Goals of Care Designation conversation cannot take place with the alternate decision maker, the most responsible health practitioner should comply (unless defensible and valid clinical or legal reasons exist to not comply) with any request to initiate, continue, discontinue, restrict or limit specific treatment/interventions outlined verbally by the patient (prior to losing decision making capacity) or in a personal directive. a) In situations where the most responsible health practitioner believes that compliance with the request to initiate, continue, discontinue, restrict, or limit specific treatment/interventions is clinically and/or ethically inappropriate, then further consultation with Covenant Health Patient Relations and the Covenant Health Ethics Center is strongly recommended. 3.6 When the patient is a minor, the guardian is entrusted to make decisions in the minor s best interests. Wishes expressed by the guardian to initiate, continue, discontinue, or limit treatments that would be in the best interests of the minor will be documented in the Goals of Care Designation order. Where initiation, continuation, discontinuation, or limitation of treatment is requested but is not in the medical best interest of the minor, and there is dispute between the most responsible health practitioner and the guardian, further consultation with Covenant Health Patient Relations and the Covenant Health Ethics Center is strongly recommended. 2 Covenant Health Patient Relations contact information can be found at 3 Covenant Health Ethics Center Contact Information can be found at

8 Page 8 of 3.7 When the patient is a mature minor, the most responsible health practitioner shall discuss the Goals of Care Designation order directly with the patient. If a dispute arises, further consultation with Covenant Health Patient Relations and the Covenant Health Ethics Center is strongly recommended. Contact with the Director of Child and Family Services Authority may be required, depending on the situation. NOTE: A personal directive is intended to be informative rather than binding in nature. Even though a personal directive may contain a previous expressed wish for medical assisted death (assisted suicide or voluntary euthanasia) this does not obligate the Catholic health care organization to compromise its own institutional integrity. See Health Ethics Guide (2012), Article 91: A person s written or oral health care preferences are to be respected and followed when those directions do not conflict with the mission and values of the organization. NOTE: Please also refer to Appendix D: Goals of Care Decision Support Resources Related to Advance Care Planning and the Goals of Care Designations 4. Documentation of Advance Care Planning Conversations and the Goals of Care Designation 4.1 A Goals of Care Designation order will be written by the most responsible health practitioner. 4.2 The Goals of Care Designation order and specific instructions are documented on Goals of Care Designation (GCD) Order form (order form # COV). Image of the document is available in Appendix B. 4.3 Pertinent details of Advance Care Planning or Goals of Care Designation conversations with the patient and/or alternate decision maker shall be documented on the Advance Care Planning Tracking Record Goals of Care Discussions form (order form COV). Image of document available in Appendix C. 4.4 Original documentation of a patient s Goals of Care Designation Order form and the Advance Care Planning Tracking Record Goals of Care Discussion form is provided to the patient in the Green Sleeve (a greencolored folder provided to patients specifically to contain documents related to Advance Care Planning and Goals of Care Designations). a) The use of the Green Sleeve allows for recognition of the contents by all members of the health care team in all areas of Covenant Health. 4.5 When the patient presents for a health service and a health record is created for the purpose of that encounter, the Goals of Care Designation

9 Page 9 of Order form and the Advance Care Planning Tracking Record Goals of Care Discussion form shall be placed within the Green Sleeve which resides in the first section of the patient s health record in a timely manner. 4.6 When the patient moves throughout the system, the Green Sleeve accompanies the patient so that members of the health care team always have access to previous discussions that were documented on the Advance Care Planning Tracking Record Goals of Care Discussion form, the patient s current Goals of Care Designation, and other pertinent Advance Care Planning documents such as a personal directive or guardianship orders. 5. Goals of Care Designation across the Continuum of Care 5.1 The current Goals of Care Designation order travels with the patient regardless of care or living environment and shall be kept in the Green Sleeve. 5.2 When a patient transitions between sectors of care or services, the most current Goals of Care Designation order in effect from the sending location of care shall remain in effect until reviewed by the most responsible health practitioner in the receiving location of care. 5.3 When a patient is transferred between sectors of care or services, the most current Goals of Care Designation Order form and the Advance Care Planning Tracking Record Goals of Care Discussion form shall be included in the Green Sleeve in the transfer documentation. A photocopy of the documents shall remain with the sending facility as a part of the discharged chart. 5.4 When a patient is discharged from a facility, the discharge summary should communicate the discharged Goals of Care Designation order and pertinent details of Advance Care Planning conversations. 5.5 Resources for Advance Care Planning and Goals of Care Designation information shall be made available in all Covenant Health settings. a) Clinical providers and teams will have the resources available to facilitate Advance Care Planning and Goals of Care Designation conversations. b) Written information regarding Advance Care Planning and Goals of Care Designations will be available and provided for patients and alternate decision maker.

10 Page 10 of 6. Review of Goals of Care Designation (GCD) Orders 6.1 Reviewing, validating or altering a Goals of Care Designation order occurs (in conjunction with the patient and/or the alternate decision maker): a) When new circumstances or health issues arise; b) When patients are admitted into a new location of care; c) At the request of the patient and/or alternate decision maker; and/or d) If the patient and/or alternate decision maker disagrees with the Goals of Care Designation order. e) At continuing care sites, the Goals of Care Designation order shall be reviewed at least once annually. 6.2 Changes in a patient s Goals of Care Designation order shall be discussed between the most responsible health practitioner and the patient, or in the event that the patient lacks capacity, with the alternate decision maker. 6.3 When a new Goals of Care Designation Order form is filled out, the previous Goals of Care order is to be discontinued by drawing a diagonal line across the form, writing void, the date, and initialing. 6.4 All Advance Care Planning and Goals of Care Designation discussions are to be documented on the Advance Care Planning Goals of Care Discussion form. Definitions For the purposes of this policy and Appendices. Advance care planning means a process which encourages people to reflect and think about their values regarding clinically indicated current and future health care choices; explore medical information that is relevant to their health concerns; communicate wishes and values to those important to them their alternate decisionmaker, and their health care team; and record those wishes. Alternate decision maker means a person who is authorized to make decisions with or on behalf of the patient. This may include, specific decision-maker, a minor s legal representative, a guardian, a nearest relative, in accordance with the Mental Health Act, an agent in accordance with a Personal Directive, or a person designated in accordance with the Human Tissue and Organ Donation Act [Alberta]. Capacity means 1) the patient understands the nature, risks, and benefits of the procedure and consequences of consenting or refusing, and 2) the patient/resident understands that this explanation applies to him/her. In the context of treatment of a

11 Page 11 of formal patient or a person subject to a Community Treatment Order under applicable mental health legislation, capacity is addressed in section 26 of the Mental Health Act which states that a person is mentally competent to make treatment decisions if the person is able to understand the subject-matter relating to the decisions and able to appreciate the consequences of making the decisions. Goals of care designation means a codified instruction that provides direction regarding general care intentions, specific health interventions, transfer decisions and locations of care, for a patient as established after consultation between the most responsible health practitioner, patient and when appropriate, alternate decision-maker. Goals of care designation order means the documented order of care designation as as written by the most responsible health practitioner Green sleeve means a green plastic sleeve that holds Advance Care Planning documents including the Goals of Care Designation Order form, the Advance Care Planning Tracking Record Goals of Care Discussion form, a copy of the Personal Directive, and any other pertinent Advance Care Planning documents. This is the patients health passport. When a patient moves throughout the healthcare system, the Green Sleeve and documents go with the patient so that health care providers always know about the decisions they have made including their Goals of Care Designation Guardian means, where applicable: For a minor; a) as defined in the Family Law Act b) as per agreement or appointment authorized by legislation (obtain copy of the agreement and verify it qualifies under legislation; eg. agreement c) between the Director of Child and Family Services Authority and foster parent(s) under the Child, Youth and Family Enhancement Act; or d) agreement between parents under the Family Law Act; or as set out in the Child, Youth and Family Enhancement Act regarding guardians of the child to be adopted once the designation form is signed); e) as appointed under a will (obtain a copy of the will; also obtain Grant of Probate, if possible); f) as appointed in accordance with a personal directive (obtain copy of personal directive); g) as appointed by court order (obtain copy of court order) (eg. Order according to the Child, Youth and Family Enhancement Act); and a divorced parent who has custody of the minor. For an adult; a) an individual appointed by the Court to make decisions on behalf of the adult patient when the adult patient lacks capacity. Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act or the Health Professions Act, and who practices within their scope or role.

12 Page 12 of Health care provider means any person who provides goods or services to a patient, inclusive of health care professionals, staff, students, volunteers and other persons acting on behalf of or in conjunction with Covenant Health. Health record means the Covenant Health's legal record of the patient s diagnostic, treatment and care information. Life support interventions means interventions undertaken in an attempt to restore normal physiology and to support patients/residents with unstable physiology. This may include CPR, resuscitation and physiological support in a critical care unit. Life sustaining measures mean therapies that sustain life without supporting unstable physiology. Such therapies can be used in many other clinical circumstances. When viewed as life sustaining measures, they are offered in either a) the terminal stages of an illness in order to provide comfort or prolong life, or b) to maintain certain bodily functions during the treatment of intercurrent medical health conditions. Examples include enteral tube feeding and intravenous hydration. Without such therapies, the patient would eventually die. These measures should be medically appropriate and congruent with the patient s goals. Patients/residents in this situation are not generally candidates for CPR, resuscitation, and physiological support in a critical care unit.. Medical best interest means, according to Beachamp and Childress (2001) the Best Interest Standard protects another s well-being by assessing risks and benefits of various treatments and alternatives to treatment, by considering pain and suffering, and by evaluating restoration or loss of functioning. (pp. ) For a minor: The Family Law Act includes a non-exhaustive list of factors to be considered in determining what is in the best interests of the child. The list of factors to be considered in determining the best interests of the child include: the history of care of the child the child s views and preferences the benefit to the child in developing relationships with both guardians the nature and strength of existing relationships any history of family violence any civil or criminal proceedings that may be relevant to the child s safety or well-being. Mature minor means a person aged less than 18 years, who has been assessed and determined as having the intelligence and maturity to appreciate the nature, risks, benefits, consequences, and alternatives of the proposed treatment/procedure, including the ethical, emotional and physical aspects. Minor means a person aged less then eighteen (18) years. Most responsible health practitioner means the health professional who has responsibility and accountability for the specific treatment/procedure(s) provided to a patient and who is authorized by Covenant Health to perform the duties required to fulfill the delivery of such a treatment/procedure(s) within the scope of his/her practice.

13 Page 13 of Appendices Related Documents Appendix A: Goals of Care Designations Description Appendix B: Goals of Care Designation (GCD) Orders, order form COV Appendix C: Advance Care Planning Tracking Record Goals of Care Discussions, order form COV Appendix D: Goals of Care Decision Support Resources Related to Advance Care Planning and the Goals of Care Designation Covenant Health Policies/Procedures available Personal Directives, #VII-B-405 Consent to Treatment/Procedure(s) Policy, #VII-B-50 Consent to Treatment/Procedure(s): Adults with Capacity Procedure #VII-B-55 Consent to Treatment/Procedure(s): Adults with Impaired Capacity and Adults who Lack Capacity, Procedure #VII-B-60 Consent to Treatment/Procedure(s): Minors/Mature Minors, Procedure #VII-B- 70 Consent to Treatment/Procedure(s): Human Tissue and Organ Donation, Procedure #VII-B-75 Patient Concerns Resolution Process (PCRP), #III-95 Assessment of Decision Making Capacity, #VII-B-35 Education and Resources: Advance Care Planning and Goals of Care Designation CLiC Workspace: Advance Care Planning & Goals of Care Designations resource page located on the CompassionNet Alberta Health Services Advance Care Planning resource page: Medical Staff Portal: Advance Care Planning and the Goals of Care Designations page Other Resources: Covenant Health Medical Staff Bylaws & Rules: Supervision of Medial Students and Residents located on Medical Staff Portal: Office of the Public Guardian Website:

14 Page 14 of Province of Alberta. (2000). Personal Directives Act. Located at: Province of Alberta. (2008). Adult Guardianship and Trusteeship Act. Located at: Province of Alberta. (2006). Human Tissue and Organ Donation Act. Located at: Province of Alberta. (2003). Family Law Act. Located at: Canadian Mental Health Association. (2010). The Alberta Mental Health Act: A Guide for Mental Health Service Users and Caregivers (2nd ed.). Located at: pdf Alberta Child and Family Services: References Alberta Health Services. (n.d.). Palliative/end of life care (PEOPLC) information for the public: Calgary Zone. Retrieved from Aspx Revisions May 9, 2014 Alberta Health Services. (2014). Edmonton Zone Palliative Care Program: Admission and Referral Information. Retrieved from _general/2d12%20admission%20and%20referral%20information%20- %20October% pdf Beachamp, T., & Childress, J. (2001). Principles of Bioemedical Ethics (5th ed.). New York, NY; Oxford University Press. Catholic Health Alliance of Canada. (2012). Health Ethics Guide (3rd ed.). Ottawa, Ontario; Catholic Alliance of Canada. See specifically, Refusing and Stopping Treatment ( # 77-79); Attending to Differences and Distress in Decision Making) (#80-82); Advance Care Planning (#90); and A person s written or oral health care preferences are to be respected and followed when those directions do not conflict with the mission and values of the organization: (#91) Inform Alberta. (n.d.). Palliative Care Consult Service. Retrieved from /public/service/serviceprofilestyled.do?servicequeryid= #elegibilityinfo

15 Page 15 of Appendix A: Goals of Care Designations Description The Goals of Care Designation order provides direction regarding specific health interventions, transfer decisions, locations of care, and limitations on interventions for a patient as established after consultation between the most responsible health practitioner and patient or alternate decision-maker where appropriate. R May intervene with medical care, including Resuscitative Care if required Goals of care are directed at cure or control of a patient s condition. The patient would desire ICU care if it was required, and would benefit from ICU if the medical condition warranted it. R1 = Medical Care including ICU admissions if required, with intubation and chest compressions. Goals of care are directed at cure or control of a patient s condition. Treatment of illness may include transfer to an acute or tertiary care facility with admission to the ICU if indicated. Intubation or chest compression may be provided. Guide: R Medical Care and Interventions, Including Resuscitation i) General guidelines: This designation is for patients who would benefit from, and are accepting of, any appropriate investigations and interventions that the health system can offer, including physiologic support in an ICU setting if required. All appropriate supportive therapies are offered, including intubation. Chest compressions and intubation are performed during a resuscitative effort when clinically indicated. ii_ iii) Resuscitation is undertaken for cardio respiratory arrest or acute deterioration. Life Support Interventions are usually undertaken. iv) Life Sustaining Measures are used when appropriate within overall goals of care. v) Major surgery is considered when appropriate. The possibility of intraoperative complications, including death and the requirement for physiological support post-operatively should be addressed with the patient in advance of the proposed surgery, and general decisionmaking guidance agreed upon. vi) Transfer from current location of care is considered if an alternative location is required for diagnosis and treatment.

16 Page 16 of R May intervene with medical care, including Resuscitative Care if required Goals of care are directed at cure or control of a patient s condition. The patient would desire ICU care if it was required, and would benefit from ICU if the medical condition warranted it. R2 = Medical Care including ICU admissions if required, with intubation but without chest compressions. Goals of care are directed at cure or control of a patient s condition. Treatment of illness may include transfer to an acute or tertiary care facility with admission to the ICU if required. Intubation can be considered when indicated but chest compressions are not performed. Guide: R Medical Care and Interventions, Including Resuscitation i) General guidelines: This designation is for patients who would benefit from, and are accepting of, any appropriate investigations and interventions that the health system can offer, including physiologic support in an ICU setting if required, but excluding chest compressions. ii_ Resuscitation is undertaken for acute deterioration, but chest compressions should not be performed. iii) Life Support Interventions may be offered, without chest compressions. iv) Life Sustaining Measures are used when appropriate within overall goals of care. v) Major surgery is considered when appropriate. The possibility of intraoperative complications, including death and the requirement for physiological support post-operatively should be addressed with the patient in advance of the proposed surgery, and general decisionmaking guidance agreed upon. vi) Transfer from current location of care is considered if an alternative location is required for diagnosis and treatment.

17 Page 17 of R May intervene with medical care, including Resuscitative Care if required Goals of care are directed at cure or control of a patient s condition. The patient would desire ICU care if it was required, and would benefit from ICU if the medical condition warranted it. R3 = Medical Care including ICU admissions if required, without intubation or chest compressions Goals of care are directed at cure or control of a patient s condition. Treatment of illness may include transfer to an acute or tertiary care facility with admission to the ICU if required, but chest compressions or intubation should not be performed. Guide: R Medical Care and Interventions, Including Resuscitation i) General guidelines: This designation is for patients who would benefit from, and are accepting of, any appropriate investigations and interventions that the health system can offer, including physiologic support in an ICU setting if required, but excluding intubation and chest compressions. ii) iii) Resuscitation is to be undertaken for acute deterioration but chest compressions or intubation should not be performed. Life Support Interventions may be offered without intubation or chest compressions. iv) Life Sustaining Measures are used when appropriate within overall goals of care. v) Major surgery is considered when appropriate. The possibility of intraoperative complications, including death and the requirement for physiological support post-operatively should be addressed with the patient in advance of the proposed surgery, and general decisionmaking guidance agreed upon. vi) Transfer from current location of care is considered if an alternative location is required for diagnosis and treatment.

18 Page 18 of M May intervene with medical care, excluding tertiary level ICU Goals of care are directed at cure or control of a patient s condition. These patients either choose to not receive care in an ICU or would not benefit from ICU care. M1 = Medical care with transfer to acute care when required and without the option for live-saving ICU care. Goals of care are aimed at cure or control in any location of care, without accessing a tertiary level ICU. Treatment of illness may include transfer to an acute or tertiary care facility without admission to a tertiary level ICU. Guide: M Medical Care and Interventions, Excluding Resuscitation i) General guidelines: All active medical and surgical interventions aimed at cure and control of conditions are considered, within the bounds of what is clinically indicated, and excluding the option of admission to a tertiary level ICU for life-saving interventions. If a person deteriorates further and is no longer amenable to cure or control interventions, the goals of care designation should be changed to focus on comfort primarily. ii) iii) iv) Resuscitation is not undertaken for cardio respiratory arrest. Life Support Interventions should not be initiated, or should be discontinued after discussion with patient. Life Sustaining Measures are used when appropriate within overall goals of care. v) Major surgery is considered when appropriate. Resuscitation during surgery or in the recovery room can be considered, including short term physiologic and mechanical support in an ICU, in order to return the patient to prior level of function. The possibility of intra-operative death (option: life-threatening intra-operative deterioration) should be discussed with patient in advance of the proposed surgery, and general decision-making guidance agreed upon. vi) Transfer to another location of care is considered if that location provides more appropriate circumstances for necessary diagnosis and treatment.

19 Page 19 of M May intervene with medical care, excluding tertiary level ICU Goals of care are directed at cure or control of a patient s condition. These patients either choose to not receive care in an ICU or would not benefit from ICU care. M2 = Medical care without transfer to acute care and without the option for lifesaving ICU care. Goals of care are aimed at cure or control, almost always within the patient s current care environment. Treatment of illness may be undertaken in the current location without transfer to acute or tertiary care should that condition deteriorate. Guide: M Medical Care and Interventions, Excluding Resuscitation i) General guidelines: All interventions that can be offered in the current location of care are considered. If a person deteriorates further and is no longer amenable to cure or control interventions in that location, the goals of care designation should be changed to focus on comfort primarily. ii) iii) iv) Resuscitation is not undertaken for cardio respiratory arrest or acute deterioration. Life Support Interventions should not be initiated, or should be discontinued after discussion with patient. Life Sustaining Measures are used when appropriate within overall goals of care. v) Major surgery is not usually undertaken but can be contemplated for procedures aimed at specific symptom relief. Resuscitation during surgery or in the recovery room can be considered, including short term physiologic and mechanical support in an ICU, in order to return the patient to prior level of function. The possibility of intra-operative death (option: life-threatening intra-operative deterioration) should be discussed with patient/family in advance of the proposed surgery, and general decision-making guidance agreed upon. vi) Transfer to another location of care is not usually undertaken but can be contemplated if symptom management or diagnostic efforts aimed at understanding symptoms can best be undertaken at that other location.

20 Page 20 of C Provide comfort care Goals of care are directed at symptom control rather than at cure or control of a patient s underlying condition that is expected to result in death. All interventions are for symptom relief. C1 = Symptom Comfort Care Goals of care are for maximal symptom control and maintenance of function, without cure or control of the underlying condition. A diagnosis exists which is expected to cause eventual death. Guide: i) General guidelines: A diagnosis exists which is expected to cause eventual death. New illnesses are not generally treated unless control of symptoms is the goal. C Medical Care and Interventions Focused on Comfort ii) iii) iv) Resuscitation is not to be undertaken in the event of cardio respiratory arrest/failure. Chest compressions or intubation should not be performed. Life Support Interventions should not be initiated, or should be discontinued after discussion. Life Sustaining Measures can be used for goal directed symptom management. v) Major surgery is not usually undertaken but can be contemplated for procedures aimed at symptom relief. Resuscitation during surgery or in the recovery room can be considered, including short term physiologic and mechanical support in an ICU, in order to return the patient to prior level of function. The possibility of intra-operative death (option: lifethreatening intra-operative deterioration) should be discussed with patient/family in advance of the proposed surgery, and general decisionmaking guidance agreed upon. vi) Transfer should be contemplated if symptom management or diagnostic efforts aimed at understanding symptoms can best be undertaken in another location.

21 Page 21 of C Provide comfort care Goals of care are directed at symptom control rather than at cure or control of a patient s underlying condition that is expected to result in death. All interventions are for symptom relief. C2 = Symptom and comfort care during the last hours to days of life Goals of care are aimed at preparation for imminent death (usually within hours or days), with maximal efforts directed at symptom control. Guide: C i) General guidelines: Expert end of life care can be provided in any location. Medical Care and Interventions Focused on Comfort ii) iii) iv) Resuscitation is not to be undertaken in the event of cardio respiratory arrest/failure. Chest compressions or intubation should not be performed. Life Support Interventions should not be initiated, or should be discontinued after discussion. Life Sustaining Measures should be discontinued unless required for goal directed symptom management. v) Major surgery is not appropriate. vi) Transfer to another site is usually not undertaken due to risk of death during transport

22 Page 22 of Appendix B: Goals of Care Designation Order Form

23 Page 23 of Appendix C: Advance Care Planning Tracking Record Goals of Care Discussion Form

24 Page 24 of Appendix D: Goals of Care Decision Support Resources Related to Advance Care Planning and the Goals of Care Designation Preamble Collaborative and patient centered discussions between patients, families, and the health care team regarding Advance Care Planning and a Goals of Care Designation is an integral component of health care decision making. When circumstances bring significant complexities, including disagreements regarding what care is to be provided, additional decision support may be required. This Appendix details the decision support resources available within Covenant Health. The most responsible health practitioner has a responsibility to ensure a patient and/or alternate decision maker is informed of, and has access to, the decision support resources referenced below. Focus The Advance Care Planning and Goals of Care Designation Policy & Procedure advocates that the health care team, patients, and/or alternate decisions engage in conversations that inform and lead to the determination of a Goals of Care Designation Order written by the most responsible health practitioner. The role of health care professionals offering decision support is to assist patient, families, and the health care team: a) Who require additional information, time, and conversation related to Advance Care Planning and decision-making; and b) With reaching consensus on a Goals of Care Designation. Decision Support Resources Available The following identified services can be accessed using the current referral process: 1.1 Interdisciplinary Health Care Teams Generally, staff and physicians providing care to a patient have the required knowledge and experience with Advance Care Planning and Goals of Care Designations. 1.2 Programs Additional professionals are available on a consult basis, such as but not limited to: a) Social Work provides information and support regarding a patient s and family s social, emotional, economic, and environmental issues. b) Spiritual Care Services provide information and support regarding whole-person spiritual care, which may involve questions of identity, meaning, and fundamental issues of life and death. c) Palliative and End-of-Life Care Service provides palliative care consultative support for patients, families and health care teams to help manage complex palliative care needs including symptom management, psychological and spiritual support, education, and care planning (Inform Alberta, n.d,; Alberta Health Services, n.d.; Alberta Health Services, 2014)

25 Page of 1.3 Specialized Services Other specialized services can provide information and support with regard to specific issues. These can include, but are not limited to: 1.4 Second Opinion a) Covenant Health Ethics Services An ethics consultation provides a guided discussion for decision-makers, including patients, alternate decision-makers, families, and health care professionals, about ethical dilemmas in clinical practice. Contact information can be found at b) Covenant Health Patient Relations- the Patient Relations Department provides guidance to ensure that Covenant Health has the structures in place to meet the organization's legislated obligations under the 2006 Alberta Patient Concern Resolution Process Regulation. Contact information can be found on CompassionNet: The most responsible health practitioner shall expeditiously seek a second opinion from a physician with knowledge and skills relevant to the circumstances of the patient s condition. If not already undertaken, the patient/alternate decision maker shall be given the opportunity to request an additional opinion and be assisted to obtain one.