Goals of Care Management

Advance Care Planning (ACP) is a way to help patients, families and decision-makers to think and talk about their wishes for health care. A Goals of Care Designation (GCD) is a medical order used to communicate the patient's general aim for health care, including any preferred location for and limits to that care.

The Connect Care clinical information system has tools that facilitate recording patient's wishes, attaching advanced care planning documents to the chart, documenting evolving wishes, capturing a specific GCD status and sharing this information across the continuum of care. Quick info:

Goals of Care Designation (GCD)

Summary goals of care information is prominent in the Patient Storyboard, which appears as the leftmost column of all opened patient charts. At the top of Storyboard, just underneath the patient identifiers, is a "ACP/GCD" line. Hovering over this brings up a summary of the current patient's goals of care information, including:

Goals of Care History and Documentation

Selecting (clicking on) the ACP/GCD line in Storyboard opens an "Advanced Care Planning and Goals of Care Designations" navigator within the patient's chart. The navigator has links for activities that relate to capacity assessment, designating alternate decision-makers and jumping to the Orders activity to enter a GCD order. 

There is also a link to a "Tracking Record" (see below) where documentation about additional details or changes in patient wishes should be recorded. Ideally, a GCD Tracking Record note is added each time there is a change in GCD designation.

Goals of Care Designation Orders

A Goals of Care Designation (GCD) is required for all patients in all contexts (emergency, outpatient, inpatient, long-term care, continuing care, etc.). A first registration of a patient's GCD level is entered into Connect Care as a prescriber order, as are any subsequent changes to the GCD level. 

A GCD order becomes active upon signing and remains active until changed or replaced. It pertains wherever Connect Care is the record of care, spanning all encounters. It is automatically printed or faxed when transitions of care involve facilities that do not use Connect Care as the record of care. 

It is important to ensure that all patients have an active GCD, to enter changed orders with care, and to periodically review GCD orders in compliance with advanced care planning policies. All GCD orders include details about the location and authorization for the order, as well as a space for any clarifying comments. More details, as well as evolving considerations, are documented in the GCD "Tracking Record". Common GCD order tasks for prescribers include:

GCD Tracking Record

The Goals of Care Tracking Record helps document the content of Advance Care Planning (ACP) and Goals of Care Designation (GCD) conversations or decisions. Notes can be added as needed and should be added whenever there is a change in GCD status. 

Tracking notes can help other health care providers (shared across the continuum of care) to be aware of previous conversations, to understand the reasons for a particular GCD order and to heed any specific limits to care. Tracking record notes are printed and included with a patient's "Green Sleeve".

Tracking record notes can address any of the following questions, usefully included in discussions about advance care planning:

Missing GCD Orders

All patients should have a GCD status, achieved through entry or re-entry of a GCD order. There are a few places in the chart where clinicians are reminded about GCD orders requiring attention.

Green Sleeve GCD

While Connect Care expands across sites, the goals of care directive "Green Sleeve" (printed) remains an important tool for documenting patients' wishes. Any Connect Care GCD order automatically generates a new printout. Normally, this is used to replace any Green Sleeve content. The printed artefact stays with the patient (typically placed in a residence refrigerator for ease of EMS access) and is invaluable to providers who do not have access to Connect Care.