Patients dealing with a life-limiting illness will face many decisions, including those related to preferences about how they want their medical care handled when different issues or decisions arise. During a crisis or whenever medical decisions need to be made, established goals of care can provide an important indication of medical preferences and guidance for action.

It’s important to keep in mind that these decisions are up to the patient, if capable, and substitute decision-maker or family if not. It can be challenging when a patient or family decides on a treatment plan that differs from what you think you would choose for yourself. Remember that there will be circumstances and factors about which you are unaware.

Goals of care can shift as illness progresses and should be revisited throughout the course of an illness.

 Developing a care plan requires:

• Assessment of the patient.

• Review of decision-making documents, if they exist.

• Discussions with the patient, substitute decision-maker, or others as defined by guidelines established within your province or territory. 

Determining goals of care and developing the care plan may be complicated if the patient isn’t conscious and doesn’t have a decision-making document or a substitute decision-maker. This is discussed in greater detail in the pages that follow.