PCNOW Advocacy Alert #2
Documenting Goal of Care Conversations

As the saying goes, if it isn’t documented, it didn’t occur. When it comes to documenting goal-of-care conversations for seriously ill patients, there is often a gap between current practice and the ideal.  Failure to adequately document these conversations can lead to over-medicalization of the dying patient, increased patient/family and health professional suffering, unnecessary and prolonged hospital stays, and higher health care costs.  This Advocacy Alert is designed to ensure that all hospitals and long-term care settings have goal of care conversation templates in their Electronic Medical Record. 

What is a Goal of Care Conversation (GOCC)?   The GOCC is when discussion takes place between the patient or surrogate and health care team to define patient goals—physical, social, spiritual or other patient-centered goals—that arise following an informed discussion of the current disease(s), prognosis, and treatment options.  These conversations should include:

  • Who was present

  • What was discussed

  • What was decided

  • What are the next steps

Supporting features that should also be documented include:

  • Presence or absence of an advance care planning document

  • Whether the patient has decision making capacity; if not, who is making decisions and with what legal authority

  • Clinician prognostic estimate (time and function)

For patients in whom a decision is made to withdraw life sustaining treatments, additional key information can include:

  • Recommendation for hospice referral

  • Role of current/future artificial nutrition/hydration

  • Decisions regarding re-hospitalization

  • DNR status and Disposition plan

What can you do?

  • Learn if your facility has an EMR or paper GOC template

  • Review PCNOW sample templates:

  • Learn the process at your site to develop and standardize a documentation tool

  • Convene key stakeholders: ICU, ED, Palliative Care, Hospitalist program, Nursing, Social Work, Discharge Planning, EMR team

  • Share your tools and experiences with PCNOW