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Goals of care: a clinical framework for limitation of medical treatment

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The development of clear, effective and consistent clinical processes for decision making relating to limitations of medical treatment and documentation of the decisions is an ongoing challenge for all health care systems.

We propose a clinical framework called “goals of care” (GOC). This approach has been introduced and audited in two Australian health services (Royal Hobart Hospital, Tasmanian Health Organisation — South, and Northern Health, Melbourne, Victoria) and is being considered elsewhere. It is influenced by the Physician Orders for Life Sustaining Treatment approach (http://www.polst.org), which is widely used in the United States, coupled with the innovation of assigning each patient episode to one of three treatment categories based on the overall medical treatment goals for that patient at that time.

The three-phase model

Medical decision making is based on determining the GOC for the patient. The patient’s situation is assigned to one of three phases of care according to a realistic assessment of the probable outcomes of medical treatment. These phases are clinically defined intentional categories that take heed of, but are quite distinct from, personal goals expressed by patients. Patients can move from one category to another during their illness trajectory. The phases are curative or restorative, palliative, and terminal;