Current Care Planning: Align Care with What Matters Most
(adapted from Patientprioritiescare.org)4
- Identify what matters most to each older adult.
- Identify health outcome goals based on what matters most.
- Discuss medications, treatments and healthcare tasks that are helpful or burdensome.
- Align care with the older adult’s health goals and healthcare preferences.
These goals of care discussions are relevant to all care and treatment planning, particularly for older adults with multiple chronic conditions.
Advance Care Planning
- Clarify wishes regarding life-sustaining medical treatment in case of serious illness or end of life.
POLST (Portable Orders for Life-Sustaining Treatment)
An outpatient medical order for patients with advanced serious illness and limited prognosis that documents a patient’s preferences for CPR, intubation, hospital transfer, artificial nutrition, and more (polst.org)
Living will
An advance directive document signed by a patient that provides guidance for care preferences (such as withholding or withdrawing life support) in the event of future incapacity; may not be legally binding in some states
Health care proxy/ Medical power of attorney
Designates a surrogate decision-maker to make health care decisions on the patient’s behalf if he or she becomes incapacitated
Helpful Mnemonics for Communication
- “GOOD” for approaching life sustaining treatment conversations with older adults5,6Goals: Start with patient’s understanding and their goals.
Options: Review treatment options and expected outcomes.
Opinions: Elicit patient opinion.
Document: Consider advanced care planning documentation if appropriate.
- “REMAP” for goals of care conversations with older adults with serious illness7 (from vitaltalk.org)
Reframe: Assess patient understanding; if applicable, “We’re in a different place now.”
Expect emotion: Make space for patient’s reaction and respond to it.
Map goals: Elicit goals and desired outcomes.
Align with goals: Validate patient goals.
Plan: Medical care and treatment should align with goals.
Interprofessional Team Involvement: Consider social work, nursing, mental health, chaplaincy, hospice and palliative medicine.
Tools for Matters Most