Ngā whāinga tauwhiro
Shared goals of care are when clinicians, patients and whānau explore patients’ values, the care and treatment options available and agree the goal of care for the current admission and if the patient deteriorates.
Health service providers need to take a systems-level approach to shared goals of care to ensure these discussions occur with patients and whānau and are in line with their Te Tiriti o Waitangi responsibilities. The shared goals of care principles described here will help to guide providers in doing this.
The principles outline what is required for providers to have shared goals of care discussions with adult patients and their whānau. They may also be applied to other patient groups, for example, children, upon further exploration of the experiences of those involved.
We held national workshops in late 2017 and early 2018 with key stakeholders, including consumers and in late 2018 we established a multidisciplinary working group to develop a national. The group has met several times to develop draft principles and a draft shared goals of care form for testing. The principles have been developed through literature review, lived experience, expert opinion and testing with two district health boards (DHBs). They are primarily written for use by hospitals but may be applicable in other settings.
Why shared goal of care are important
When shared goals provide the basis for clinical treatment plans, there is less risk of a patient receiving unwanted or unwarranted treatments which is especially important if their condition deteriorates.
Evidence shows that engaging patients and whānau results in better health and care outcomes. The patient and whānau are more likely to feel valued and involved in their treatment, and their experience in hospital is better.
Providing excellent clinical care underpins clinicians’ values and drives their work ethic. Valuing shared goals of care discussions should become part of this care provision by all clinicians and links closely with choosing wisely. For some, this may mean a change in practice. It can be difficult and confronting to have these discussions but the outcomes warrant having them. There are guides and training that can help with these discussions, for example, the Serious Illness Conversation Guide.
Clinicians who communicate effectively, through sharing information and listening to seek understanding, can draw out patients’ values and preferences for care. This forms the basis for informed decisions about complex medical treatment options, should the patient’s condition deteriorate.
When shared goals of care discussions should take place
Shared goals of care are best explored when a patient is well, for example outpatient or when planning treatment or investigations are ideal settings to start these conversations.
However during an unplanned episode of care shared goals of care discussions should take place early- before episodes of acute deterioration so everyone can engage fully without the pressures of an evolving clinical crisis. Discussions should be documented with all adult patients, ideally within 24 hours of admission and be reviewed and documented during the admission if there are changes in the patient’s condition. If patients have advance care plans and/or advance directives, these need to support the discussion.
The discussion may be straightforward and brief if the patient and whānau understand the clinical situation, and therefore may be appropriately discussed on admission or on a ward round. For others, the situation may be more complicated and involve several discussions before a decision can be made. Through listening, clinicians will be able to pick up subtle cues from patients and whānau that indicate more time may be needed for these discussions.
MidCentral and Waitematā district health boards tested the draft principles and form between October 2019 and March 2020. They used the draft principles to prepare for testing and the form as an example of how to document the discussion and decision has been informed by their testing.
As part of our response to COVID-19, we have made shared goals of care forms, along with related factsheets, available for hospitals and aged residential care facilities on the talkingCOVID webpages.
From May 2021 we will be holding four regional workshops to assist district health boards in the implementation of the principles of shared goals of care. Following the workshop district health board project teams will work to plan their implementation and sustainability of shared goals of care and the linkages to other important information that helps inform discussions and decisions, such as advanced care plans.
- Shared goals of care principles
- Shared goals of care data collection tool
- Posters: shared goals of care principles
- Shared goals of care FAQs
- Preparation and implementation guide
- Shared goals of care forms (777/MET/RRT)
- Fact sheet: shared goals of care conversations (for consumers)
- Fact sheet: nurses and allied health workers
- Fact sheet: senior clinicians
- Fact sheet: hospital executives
- Fact sheet response teams
- Factsheet: capabilities for recognising and responding to acute deterioration
- Clinical governance recommendations
- Current system assessment template
- Shared goals of care project charter template
- Stakeholder assessment template
- Case for change
- Education powerpoint
- Project charter template
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