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Advance Care Planning: Goals of Care Designations

March 23, 2018

You only die once. But, if given a second chance, would you have chosen to die differently?

Your medical team needs to understand your wishes and specific preferences for resuscitation and care in the instance of a life-threatening illness or change in your health.

Let us get the conversation about end of life experience started.

EngageWithGrace

Advance care planning is a way to help you think about, talk about and document your wishes for health care.

An Advance Care Directive (or living will) is a legal document that gives your health care team and your loved ones the confidence to speak for you when you can no longer speak for yourself.

Here are the steps in planning for the end of life.

Step 1 – [Think about what’s right for you]
You hold personal beliefs about prolonging life and measuring the value of quantity against quality of life.

Step 2- [Learn about your own health]
What do you understand about your medical diagnosis and prognosis? What can you expect from various medical procedures and treatments? What can they do and what can’t they do?

Step 3 – [Choose someone who will speak for you when you can’t and who will make decisions on your behalf]
That person is known as your agent, proxy, alternate decision maker, or substitute decision maker

Step 4- [Talk about your wishes]
Communicate your wishes and values regarding health care to your family and doctor.

Step 5 – [Record your wishes]
Document your wishes in a personal directive. This directive only comes into effect when you are unable to make decisions (what we refer to, in medical parlance, as a lack capacity).

You can review these steps and reinforce some of the concepts at the following links:

https://theconversationproject.org/ (International)

http://www.advancecareplanning.ca/ (Canada)

Additional resources

Alberta: conversationsmatter.ca
SK: https://www.saskatoonhealthregion.ca/patients/Pages/Advance-Care-Directive.aspx
BC: https://www.youtube.com/watchv=5BD9yJJdhIQ&feature=youtu.be

What is CPR and is it right for me?

Ask yourself the following: What are my hopes for this treatment? What benefits or burdens could I expect?

 

 

CPR tries to restore blood flow temporarily when an individual’s heart or breathing stops. It involves repeatedly pushing down hard and fast on the chest and may include mouth-to-mouth breaths or using a device to push air into the lungs. Electric shocks may also be used to try to correct the rhythm of the heart.

The survival rate of CPR is low. It works best in a young, healthy, person whose heart suddenly stops. Success rates drop to around 10% in people with chronic disease and a mere 6% in older people. Those who do survive CPR usually need advanced life support machines and medicines in a hospital intensive care setting.

CPR does not necessarily improve the illness that caused the heart or breathing to stop, so many people do not return to the life they previously enjoyed. The risks of surviving CPR include physical disability and brain injury. Survivors may not be able to return to their homes or live independently anymore.

To help you understand what medical staff can reasonably provide for you and what your expected outcomes of treatment are, ask your doctor about a medical recommendation based on your medical condition and preferences.


Alberta Province and our clinic

In Alberta, a Goals of Care Designation is a medical order used to communicate the focus of care including the preferred location of that care. This personal directive may change over time as circumstances and health conditions evolve.

The three general categories of care are:
Resuscitative care, Medical care, and Comfort care

Resuscitative care focuses on prolonging life and cure. These measures may not achieve the aim of restoring previous health. Interventions include CPR, ICU, medications and ventilation (a tube down your windpipe when you can’t breathe on your own).

Medical care focuses on prolonging life and curing or controlling disease without resuscitation or ICU. It is the focus in people for whom CPR and a breathing tube won’t work and is unlikely to restore their state of health. This category of intervention may include dialysis, feeding tubes, antibiotics, surgery, and hospital admission.

Comfort care focuses on maximising comfort and relieving symptoms like pain and shortness of breath. No resuscitative treatments are provided. This category is not less care, but the focus shifts to quality of life, and relief of symptoms. These patients are usually treated at home but sometimes hospitalisation is needed for optimal comfort.

There are sub-categories to these goals of care designations. Each patient decides on their wishes regarding chest compressions, intubation, ICU admission, surgery, site transfer, and symptom control.*

The information related to your Goals of Care is carried in a medical passport called a Green Sleeve. The Green Sleeve is a plastic pocket that you carry with you between different care providers and sites. It contains your personal directive, name of an agent, and a medical order completed by your doctor (goals of care). The Green Sleeve should be kept on or near the fridge.

**Doctor’s notes**
R1: Full resuscitation protocol
R2: No chest compressions (restarting of heart when stopped) but can be intubated
R3: ICU but no chest compressions or intubation
M1- Transfer to acute care but no ICU
M2- Care within the patient’s current location (home/long-term care). Transfer to an Acute Care hospital would rarely be considered and would only occur to achieve better symptom control
C1- Transfer to a new health care setting may be undertaken to understand or control symptoms.
C2- Goal of care is directed at preparing for death, which is expected to occur within hours or days. Transfer to a new healthcare setting is not usually undertaken.

Major surgery is not usually undertaken for M2 and C1 designated patients but can be considered, in the event of unexpected illness and injury, for procedures aimed solely at symptom relief.

 

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