Goals of Care

Aligning patient priorities to provide person- and family-centred care.

About

Goals of Care discussions are meant to achieve a shared understanding (between health care provider and patient) of the patient’s overall priorities and expectations for health care and perception of quality of life.

This shared understanding helps support shared decision-making that incorporates best available medical evidence, provider experience, and patient priorities.  

Terms & Definitions

 

 

Advance Care Planning

Advance care planning is the process of reflection and communication. It is a time for patients to reflect on their values and wishes, and to let their loved ones know what kind of health and personal care they would want in the future if they were unable to speak for themselves1.

Goals of Care

A person’s goals of care are their overall priorities and expectations for health care. These are based on their personal values and perception of quality of life, and what is meaningful and important to them.

Level of Intervention

The level of intervention describes the scope of medical interventions that are anticipated to be helpful in achieving the patient’s goals of care. Level of intervention encompasses more than code status and is determined only after a high-quality goals of care discussion about patient’s priorities, health condition, and preferred location of care.

1Adapted from ACP in Canada: PPS AU Canada. (2021, September 17). Retrieved June 23, 2022, from https://www.advancecareplanning.ca/


Capacity

Capacity is the ability to understand information that is relevant to the making of a personal care decision and the ability to appreciate the reasonably foreseeable consequences of a decision or lack of a decision. A personal directive only comes in effect when the maker lacks capacity to make a personal care decision. A person is presumed to have capacity unless they are formally assessed as being incapable by an appropriate health care provider.

With regard to health care and treatment, a person with capacity is able to understand: 

  • The medical condition for which a treatment or intervention is proposed. 
  • The nature and purpose of the treatment or intervention.
  • The risks involved in undergoing the treatment or intervention.
  • The risks involved in not undergoing the treatment or intervention.

Only a “person with capacity” may make a personal directive. The definition of capacity under the Nova Scotia Personal Directives Act requires a maker to have “...the ability to understand information relevant to making the personal care decision…” (Nova Scotia Personal Directives Act, 2008). Therefore, if a person lacks capacity to make the underlying personal care decision for which they are appointing a delegate, they lack the capacity to make a valid personal directive.

Personal Directive

A Personal Directive (PD) is a legal document that allows a person to communicate what, how, and/or by whom personal care decisions are to be made in the event the person is no longer capable of making these personal care decisions on their own.

Personal care decisions include those related to health care, nutrition, hydration, shelter, residence, clothing, hygiene, safety, comfort, recreation, social activities, and support services.

A PD does not include financial decisions, which are in other planning tools such as an Enduring Power of Attorney document. 

A valid PD needs to be written, dated, and signed by the person whose wishes are outlined in the PD, and witnessed by an adult that is not the delegate. If the ‘maker’ (person who makes a personal directive) is unable to sign, the personal directive needs to be signed by a person who is not a delegate or the spouse of the delegate on behalf of the maker at the maker's direction and in the maker's presence, and in the presence of a witness who must also sign (Nova Scotia Personal Directives Act, 2008). 

Substitute Decision Maker

Substitute Decision Maker (SDM) is not a legal term used in the Personal Directives Act. It is a general term used to refer to the person making decisions on someone else’s behalf. This is not the same as “next of kin”. 

A Substitute Decision Maker can be a Delegate or Statutory Decision Maker, as outlined in the Nova Scotia Personal Directives Act.

Delegate 

A Delegate is a person authorized under a personal directive to make, on the maker's behalf, decisions concerning the maker's personal care (Nova Scotia Personal Directives Act, 2008).

Here, the ‘maker’ refers to the person who makes a personal directive (Nova Scotia Personal Directives Act, 2008).

Statutory Decision Maker

A Statutory Decision Maker is the person’s “nearest relative”. This is used when a delegate has not been identified in a personal directive. 

According to the Nova Scotia Personal Directives Act2, the "nearest relative" means, with respect to any person, the relative of that person first listed in the subclauses.

Green Sleeve

The Nova Scotia Green Sleeve is a green folder that’s used to keep important documents to help communicate a patient's health care plans, goals and care wishes to health care providers. Patients should keep their Green Sleeve somewhere easy to find and should bring it with them to health care appointments or emergency department visits.

Role of Most Responsible Health Care Practitioner (MRHCP)

Goals of Care discussions can be initiated by any member of a person’s health care team; however, the Most Responsible Health Care Practitioner (MRHCP), who is either a Physician or Nurse Practitioner, is ultimately responsible for:

  • Reviewing any previous Goals of Care documents and ensuring that a Patient Centered Priorities and Goals of Care form is completed, to validate and/or update the information.
  • Considering the patient’s baseline and current condition(s), priorities, values, and goals and ensuring all appropriate care options are presented to the patient and family.
  • Ensuring the care team is aware of the outcome of the discussion, including the Level of Intervention, to support alignment between the patient/ statutory decision maker priorities, values and goals, and clinical decision-making. 
  • And finally, signing off on the Goals of Care documentation for that patient.