Goals of care welcomed

DOCUMENTING agreed “goals of care” should become a routine part of hospital admission, as important as recording vital signs and the reason for admission, says a leading oncologist.

Associate Professor Ian Haines, medical oncologist at Melbourne’s Cabrini Private Hospital, applauded the development of a goals of care (GOC) framework by Tasmanian and Victorian palliative care physicians outlined in this week’s MJA. (1)

“It’s an excellent initiative. It shines a light on a central aspect of medical care”, said Professor Haines who, with coauthors, first raised the concept of a GOC in a 1990 MJA article cited by the current authors. (2)

The GOC framework — introduced at Tasmania’s Royal Hobart Hospital in March 2011 and Melbourne’s Northern Health in August 2013 — assigns a patient to one of three phases of care: curative or restorative; palliative; or terminal.

All admitted patients are assessed according to the framework, with the curative or restorative phase the default position. The patient assessment is shared with the patient or substitute decisionmaker and, if agreed, a GOC plan is placed in the patient’s medical record. The authors reported that staff feedback and audit data had been favourable.

“Many decisions to limit treatment occur in crisis situations”, the authors wrote. “GOC prompts treatment teams to proactively determine treatment goals at a time when the assessment is likely to be of higher quality and discussions with the patient and family are easier to arrange.”

Professor Haines told MJA InSight documenting GOC could help to address the common mismatch between medical staff and patients and their families, particularly in oncology.

“There can be a mismatch of up to 40%, where 70% of patients and families … think they are being treated for cure, when only 20%–30% of the medical staff think [the patient is] being treated for cure.”

Such an approach could enhance communication between patients and the nursing and medical staff, with continued reference back to the appropriateness of the currently documented GOC. He also welcomed input from GPs in participating in the development of GOC.

Professor Katherine Clark, medical director palliative care at the Calvary Mater Hospital, Newcastle, NSW, told MJA InSight the days of not-for-resuscitation orders were limited, and an alternative approach to engaging patients and their families in determining future medical treatment was “on our doorstep”.

A paradigm shift was needed in the health care system to improve the way dying was managed, she said, adding that the GOC definitions outlined in the Victorian/Tasmanian model were helpful.

“The literature is increasingly rich with data telling us that although people are dying in hospitals, hospitals don’t see themselves as the correct place of death. And, as a result, the experiences of some patients and their relatives are perhaps not aligned with their expectations.”

Professor Clark welcomed the MJA authors’ comments about the importance of “rigorous ‘postmarketing’ surveillance” in implementing such a model. She said the ability of the health system to deliver on the commitments made to patients was also crucial — from ensuring the medical and other staff were equipped with the appropriate communication skills to having appropriate palliative care services available.

She said that before interventions were widely implemented they should be supported by well-conducted research “with the aim of ensuring that such interventions provide the best care for the populations that we serve”.

Professor Haines told MJA InSight a “step-by-step” approach to implementation would ensure all branches of medicine were comfortable with the concept.

“I’d specifically like to see it trialled in intensive care and cardiac units — some specialists find this difficult, particularly if they have practised by a different model for up to 40 years”, he said.

It would also be helpful to see how the framework related to use of code blue and medical emergency team calls.

Professor Haines said GOC could work “hand in hand” with advance care directives.

“We are hoping to move more Australians towards writing advance care directives while they can do them, and I think that will also become more and more accepted in the years ahead.”
 

1. MJA 2014; 201: 452-455
2. MJA 1990; 153: 225-229

(Photo:  Squarepixels, iStock)