The information below is intended to help you engage patients and substitute decision makers in goals of care conversations. We'd appreciate any feedback you might have to improve this guide. Please use the comments sections below to provide your feedback.

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Pre-Conversation Considerations

  • Before you begin this conversation with the patient, you may want to check with them to see if they want family or other people to be a part of these discussions.
  • If applicable, consult with other members of the health care team involved in the patient's care, to get a consensus of capacity of the patient to provide informed consent; the patient's prognosis, planned treatments, and other related issues.
  • Clarify if the patient has appointed a substitute decision maker and encourage that person/those persons to attend especially if there are concerns about capacity.
  • Review the hospital chart and talk to staff to see if there is an advance care plan or if wishes are previously documented or verbalized.

For patients in Category #2 and some patients in Category #3, consider the following pathway:

  • Explain the need to address their goals of care and assess prior conversations/documentation about their health care wishes.

    "We try our best to keep patients in good health, but understand that there eventually comes a time when patients will start to get sicker despite our best efforts. Have you talked to anyone about your wishes for health care when you get really sick or are at the end of your life? And/or "Have you put anything in writing about your wishes?"

    • If yes, probe about the content of discussions and/or documents.
    • If no, suggest that planning ahead can help patients be assured that their wishes will be honoured and reduce stress for their loved ones if they are asked to help make decisions on the patient's behalf at a time of serious illness. Involve other disciplines such as social work, spiritual care, and nursing to support the family through the communication process. Ensure that you are aware of and follow consent and substitute decision-making laws in your province/ territory. These can be found at www.advancecareplanning.ca - click on "Resources in your Province/Territory" under Quick Links.

TIPS

  • A good way to normalize a difficult topic is to speak in the third person framing the issues as universal or general, not specific to the patient.

    Don't say: "If you get sicker, you are going to need to decide what you want." Say: "When people with serious illnesses get worse, they face decisions about their care. It is a lot less stressful on the patient and their family if conversations about their wishes happen before they get really sick."

  • Depending on the clinical condition and whether you have the luxury of time, you may choose to seek permission to have the conversation now since it's a big conversation and the patient may not be in a good space for it. Furthermore, asking for permission is a good relationship building strategy and something that can help put clinician and patient on more equal footing.

    Say, Is it OK if we talk now about what we might do if you were to get really sick? Or sicker?

    If they say no, explore reasons behind their reticence to engage in this important conversation and try and resolve concerns or barriers. In the end, if the patient is not ready to have the conversation, make a concrete follow-up plan to revisit the issue in the future.

    Say, Can I ask the social worker (or family member) to speak to you about this and I will come back in a few days to discuss it with you again?

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