Goals of care

Defining immediate care based on what a person wants

What it is

Goals of care are what a person wants to achieve during an episode of care, within the context of their clinical situation.

Goals of care:

• are what matters to the person
• are agreed between the person, family, carers, and health care team
• will change over time and be reassessed as necessary
• can include all types of care or considerations ranging from medical care, place of care, planning for future care.

Why it matters

Understanding the person’s goals of care in the context of advanced illness is an essential part of personalised care.

Setting and achieving goals in a person’s care can:

• empower the person
• enhance communication and collaboration between the interdisciplinary team
• improve satisfaction with care.

Ideally discussions about goals of care should be about how the person with advanced illness wants to live rather than having a limited focus on death and dying or terminal care.

In practice

Nurses have a role in helping the people in their care plan their care through discussing and setting goals. You can assist the person to set realistic goals by helping them to think about what they consider important and encouraging them to discuss their preferences.

The following open-ended questions can be helpful:

Checking and clarifying can ensure that the set goals truly reflect the person’s wishes:

Recording these goals allows the interdisciplinary team to be informed.

Conducting a family meeting can be useful to provide information, to address the questions and concerns of the person and the family, and to establish goals of care. 

Common goal areas in palliative care involve:

• social function (e.g. hobbies, social activities, relationships, attending family events)
• emotional function (e.g. confidence and anxiety)
• basic or personal activities of daily living (e.g. toileting, transfers)
• other activities of daily living (e.g. shopping, food preparation)
• symptom management (e.g. breathlessness, pain, weakness, and fatigue).

Goals are likely to change as the person’s illness progresses. 

Triggers for a discussion of goals of care include:

• clinicians recognising deterioration
• the person is admitted to hospital
• the person is admitted to a residential aged care facility
• a resident returns from ED or a hospital ward
• there are significant changes in the person’s condition or circumstances
• the person, substitute decision-maker or family expresses concerns
• the person asks questions such as 'What will happen to me?'