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Goals of Patient Care
Goals of Patient Care
- Goals of Patient Care is a discussion and documentation that establishes the most medically appropriate, realistic, and patient centred treatment to apply in the event of a patient’s clinical deterioration during an episode of care.
- It is a clinical care planning process that facilitates proactive shared decision-making between the treating health professionals, the patient and their families/carers and supports person-centred care.
- WA public hospitals use the statewide Goals of Patient Care form to provide a clear, consistent and effective approach to establish the goals of medical care for patients.
- WA Health Service Providers have policies, procedures and guidelines in place for the use of Goals of Patient Care forms in their services.
The Goals of Patient Care form is available in electronic and paper versions:
- Goals of Patient Care BOSSnet eForm – exclusively available to health services using BOSSnet (Digital Medical Record)
- Goals of Patient Care iCM eForm – available to health services that do not use BOSSnet / Digital Medical Record
- Goals of Patient Care Form MROOH.1 (PDF 324KB), a paper version of the form used if the electronic version is not accessible.
About Goals of Patient Care
The Goals of Patient Care form is completed as part of ongoing discussions between the treating health professionals, the patient and their family and carers. This care planning process captures and documents the patient’s preferences for care during clinical deterioration, including limitations to treatment for the current admission. A patient’s goals of care may 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, so it is important to revisit discussions regularly.
The form complements and supports the use of advance care planning documents.
Importance of Goals of Patient Care
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 clear and honest information that assist patients and families to understand treatment options. This should be done in light of their values, changing health/illness and realistic longer term and meaningful health outcomes.
This process is relevant for most patients who may deteriorate, either predictably or unforeseeably and particularly important for those who have chronic illness or are within the last 12 months of life. Failure to identify these patients can reduce their quality of care through exposure to harmful, non-beneficial treatments or delay provision of comfort- focussed care.
Goals of care in other settings
The Goals of Patient Care form has been adapted for use in different settings of care:
Goals of Patient Care training and education resources
Goals of patient care training video
Communication tips
Education and training
Relationship to advance care planning
Goals of Patient Care and advance care planning are separate but related processes. Goals of Patient Care forms should align with the person’s advance care planning documents and may include treatment decisions that were not considered when the person prepared their advance care planning documents.
The content of any advance care planning document should be discussed during a Goals of Patient Care discussion. Completion of the Goals of Patient Care form in the inpatient setting may be a prompt to continue advance care planning conversations with care providers in the outpatient settings, including GPs.
For more information on advance care planning see Advance care planning information for health professionals.
Clinical assessment tools
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. Refer to your local/organisational policies and procedures for the preferred tool.
One example of such a tool is the Supportive and Palliative Indicators Tool (SPICTTM).
Supportive and Palliative Indicators Tool (SPICTTM)
SPICT aims to reduce the impact of prognostic ambiguity and improve clinician confidence in identifying patients with deteriorating health due to one or more advanced conditions earlier in the course of the hospital admission, or earlier in the course of illness. It guides holistic assessment and care planning.
SPICT for health professionals
SPICT for patients, family and professional carers
The SPICT™ tool is available as a free app on iOS for iPhone and iPad, and as an app for Android.
Uploading to My Health Record
WA Health hospitals are able to upload the BOSSnet GoPC, the Non-BOSSnet iCM GoPC eForm and advance care planning documents to My Health Record. These documents can only be uploaded to My Health Record with the patient’s consent.
Storing Goals of Patient Care clinical documents in My Health Record allows other healthcare 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 further advance care planning discussions.
The Australian Digital Health Agency provides information on uploading to My Health Record, including 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).
Last reviewed: 03-07-2024
Produced by
End-of-Life Care Program