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A Conversation Guide for Goals of Care Discussions

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This Guide provides a framework including 'scripts' to assist you with engaging patients and/or their substitute decision makers (in the case of an incapacitated patient) in goals of care (GOC) conversations  that lead to medical orders for the use or non-use of life-sustaining treatments.

This communication process is different from Advance Care Planning (ACP), which is a communication process wherein people plan for a time when they cannot make decisions for themselves. ACP includes reflection on and determination of a person's values and wishes or preferences for care at the end of life. These expressions are generally made outside of the clinical context and are not to be misconstrued as medical decisions. A medical decision requires consideration as to whether the wishes and preferences are clinically indicated.

Goals of care conversations consist of putting prior ACP conversations about wishes into the current clinical context, resulting in medical orders for the use or non-use of life-sustaining treatments. Many patients in the health care system have not engaged in ACP activities. However, you will still need to engage them in making medical treatment decisions when they are seriously ill. We caution you against rigidly reading these scripts or using this tool as a checklist. It is intended to mark the path that you must cover with the patient and support the conversation. The conversation must still be natural and engaging and does not necessarily need to follow the same order as the ideas presented below.

Not all patients will require the same conversation. It depends on their risk of death. The figure below indicates that you are trying to categorize whether the patient is at low-risk of mortality (in which case a detailed GOC is not warranted), intermediate or uncertain risk (detailed conversation warranted) or imminently dying (conversation is focused on preferences or needs related to dying rather than medical treatment focused).

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