Goals of Care

Create a new Goals of Care Conversation
Update an active Goals of Care Conversation
Client Declined Conversation
Mark a Goals of Care Conversation Entered in Error 
End-date an existing Goals of Care Conversation

A GOC conversation clarifies a client’s wishes and preferences for care in the context of their current health condition and expected trajectory and is appropriate at any stage in a person’s health journey, not just at end of life. After the diagnosis of a serious illness, these conversations take on a new importance and can be initiated at any stage of illness, from time of diagnosis until end of life. For more information regarding Goals of Care conversations please visit the Goals of Care Support Team OneVCH page.

To add a Goals of Care Conversation for a client, navigate to the Goals of Care application Tile, which can be found under the Clinical Info home tile or for Home Health Clinicians, the Interprofessional Care Plan Home Tile. 

Create a new Goals of Care Conversation

In order to add or view a client’s Goals of Care you will need to navigate to the Goals of Care Application that is found in the Clinical Info or the Interdisciplinary Care Plan home tiles.

If a client does not already have an active Goals of Care Conversation started you will not see anything in the Goals of Care Tree on the left. To add a new Goals of Care Conversation for your client:

1. Click the pink Add a form button
2. If you belong to multiple teams, the Owner key lookup pop-up window will appear. Select the appropriate team you are documenting against and click Accept Changes
3. The Associated forms lookup will appear with GOALS OF CARE highlighted, click Select
4. The Goals of Care form loads, and the below fields auto-populate:
   • Status: ACTIVE
   • Last Updated: Defaults to your name and date
   • Valid From: Update the date to the date the conversation was had (Intervention date)
5. To save the form, you must enter the below mandatory field:
   • The Client’s ability to participate in Goals of Care Conversation: Tick the appropriate reason. NOTE: If the client or SDM does not want to have a Goals of Care Conversation with you at this time, please tick: Client/SDM declined opportunity to have conversation. When this is ticked a mandatory Reason field will appear, with a prompt to enter the reason the client declined the conversation (e.g. client able to express likes and dislikes, needs support to make treatment decisions)
   • Notes: Enter any applicable notes about the Client’s ability to participate in the goals of care conversation
6. In the Participants Involved in Conversation grid, click Insert a row and enter the following:
   • Recorded by:
   • Date Record: Defaults to today’s date (NOTE: This date is just the date recorded and does not mean this was the date the participant was involved in the conversation
   • If the client was involved in the conversation tick Client
7. Accept changes and save
8. If there were more participants involved in the conversation you will need to insert a new row for each person involved by ticking Other, then fill in the name of the participant and their relationship to the client such as the example below:
   • Name of other participant: Jane Doe 
   • Relationship to client: Daughter
9. Click Accept changes

NOTE: This grid is just a running list of all participants who have been involved in the Goals of Care Conversation. Dates are not important; it is just there to show who was involved throughout the duration of the conversation. Please DO NOT re-enter the same person multiple times into this grid.

10. In the Health Care Decision Maker grid, you will see the client’s Health Care Decision Makers that were entered via the Clinical Summary application. 
11. If you do not see your client’s health care decision maker in the grid, and you are able to confirm who the client’s decision maker is, Insert a row and enter all the appropriate details.
12. Accept changes and save.
13. In the Understanding and Information Sharing section there are a number of free text boxes. Enter information as applicable. 
14. In the Key Topics section there are a number of free text boxes. Enter information as applicable. Note: All information entered in the Key Topics section will appear in the Interprofessional Care Plan (ICP). 
15. Any recommendations related to the goals priorities and or concerns raised by the client should be entered in the free text box within the Recommendations section. Any recommendations related to the client’s care plan should be entered into the ICP.
16. If you require any assistance regarding what information should be included in any of the above sections please refer to the Goals of Care Support Team OneVCH page.
     

Update an active Goals of Care Conversation

If a client already has an active Goals of Care Conversation underway you will see it in the tree on the left

 

1. Click on the date under need the ACTIVE Goals of Care conversation and the form will load on the right.
2. Edit the form as applicable.
3. Save.
   NOTE: any changes made to documentation, including additions and deletion of information that is no longer applicable, can be viewed by right-clicking and selecting Version History.
    

Client Declined Conversation

If the client or SDM does not want to have a Goals of Care Conversation with you at this time, you will 
still need to create a Goals of Care form to document this. To add a new Goals of Care Conversation for your client:

1. Click the pink Add a form button.
2. If you belong to multiple teams, the Owner key lookup pop-up window will appear. Select the appropriate team you are documenting against and click Accept Changes.
3. The Associated forms lookup will appear with GOALS OF CARE highlighted, click Select
4. The Goals of Care form loads, and the below field auto-populate:
   • Status: ACTIVE
   • Last Updated: Defaults to your name and date
   • Valid From: Update date the to date the conversation was had (Intervention date)
5. In order to save the form, you must enter the below mandatory field:
   • The Client’s ability to participate in Goals of Care Conversation: Tick: Client/SDM declined opportunity to have conversation. 
   • Reason: Enter a brief reason the client declined the conversation
   • Notes: if you have additional notes that you want to enter about this declination, enter those here
6. Save.
7. The form will now become read only and the status will update to DECLINED CONVERSATION.
   This entry will now appear under a Conversation Declined heading in the tree on the left hand side.
    

Mark a Goals of Care Conversation Entered in Error

If you have documented a Goals of Care Conversation against the wrong client, or the details of the conversation are incorrect you will need to mark the form Entered in error. To do this:
 

1. Click on the pink Entered in error button
2. Save
3. The form will become read only and the status will be updated to ENTERED IN ERROR

End-date an existing Goals of Care Conversation

A GOC conversation will need to be end dated if:

 The client is being fully discharged from all community services.
 There has been a significant change to the client’s needs and/or health status. A few examples of a significant change include, but are not limited to, a change in the client’s ability or willingness to participate in a goals of care conversation, a sudden decline in function or health status or the client receiving a new diagnosis.

To end the current Goals of Care Conversation: 
1.  Open the existing Active Goals of care conversation and update the following:

Valid to: Enter the client’s discharge date or the date that it was first identified that the client’s goals of care were no longer applicable.

2.  Save. 
NOTE: The form will now become read only and the status will become HISTORIC.

To create a new Goals of Care Conversation:
1.  Follow the steps to Create a New Goals of Care Conversation and update the content to reflect the current goals of care for your client.