goals of care

CPSO-mandated discussions for patients at risk of deterioration. Framework: elicit values → educate on illness and options → recommend a treatment plan → review on change. A facilitated values history is the foundation — treatment recommendations flow from it, not the other way around.

when to initiate

CPSO requires physicians to initiate a timely GOC discussion when a patient has significant illness and is at risk of clinical deterioration — this is an obligation, not optional.

Triggers for reassessment:

new serious diagnosis or acute deterioration
declining PPS over serial assessments
treatment trial without response
transition to higher level of care
surprise question negative (“would not be surprised if died in 6–12 months”)

early identification

surprise question (gold standards framework)

“Would you be surprised if this patient died in the next 6–12 months?”

if no or unsure → evaluate for general and disease-specific decline indicators → initiate palliative approach
palliative care alongside disease-modifying therapy from diagnosis, not reserved for the terminal phase

palliative performance scale (PPS)

PPS	Functional status
100%	fully ambulatory, normal intake, full consciousness
70%	reduced ambulation, normal or reduced intake, full consciousness
50%	mainly sit/lie, reduced intake, ± confusion
30%	bedbound, minimal intake, drowsy ± confusion
10–20%	bedbound, mouth care only, drowsy/coma

ECOG performance status

Score	Description
0	fully active, asymptomatic
1	symptomatic; restricted in strenuous activity but ambulatory
2	ambulatory, capable of all self-care; up >50% of waking hours
3	limited self-care; confined to bed/chair >50% of waking hours
4	completely disabled; bedbound

Choosing Wisely Canada

Avoid chemotherapy in patients with ECOG 3–4 who are unlikely to benefit.

conducting the discussion

framework (CPSO)

elicit values — understand the patient’s wishes, values, and beliefs before discussing options; these frame everything downstream
educate — ensure the patient/SDM understands the illness, available treatments, and achievable vs unachievable outcomes
recommend — make a clear treatment recommendation grounded in values and evidence — care is not a menu
review — reassess on change in condition or failure to respond to treatment

physician role vs patient/SDM role

Physician	Patient / SDM
clinical assessment, diagnosis, prognosis	personal wishes, values, life experience
determine which treatments align with values	select among recommended options or refuse
make a clear treatment recommendation	inform the recommendation with values

make a recommendation

Families can interpret absence of a recommendation as “choose from a menu.” Ground your recommendation in what you know of the patient’s values and the medical evidence — that is your role as the medical expert.

facilitated values history

The core of a GOC discussion — particularly when the patient lacks capacity and an SDM is deciding.

1. explain the SDM role

SDM decision-making ≠ normal family decision-making. Decisions are value-laden; the patient’s values should guide them.

“Our goal should be to honour your mother by trying to understand what she would choose if she were sitting here.”

2. understand the patient as a person

Demonstrate genuine curiosity — builds trust and situates the illness in the patient’s life.

what did they enjoy before admission? what was life like 6 months ago?
what was their role in the family? what brought them joy?

3. explore specific values

Move beyond generalities:

how did they feel about independence? about being cared for by others?
how willing were they to undergo suffering for the possibility of recovery?
how did they feel about living a long life vs living well?

4. explore value conflicts

The hardest and most informative step — which value prevails when they conflict?

“It sounds like your father values both being alive and being independent. If he likely couldn’t communicate or would depend on others for basic care, what do you think he would say about the treatments he’d want?“

5. summarise back

“It sounds like your brother valued being able to take care of himself. His work was important to him. He wouldn’t want to live in a nursing home under any circumstances, but he would be willing to undergo burdensome treatment if it got him back to baseline. Have I missed anything?“

6. ground the recommendation in values

“Based on what you’ve told me about your mum, I’m recommending a trial of ventilation to see if things improve quickly. If this doesn’t turn around in 48 hours, we should focus on keeping her comfortable.”

Acknowledge the difficulty of the SDM’s role — empathy and explicit permission to follow the patient’s values rather than carry the burden of the decision.

urgent GOC discussions

check EMR for prior documented wishes — but confirm currency with the patient/SDM; prior discussions may not reflect current values
explain why you are having this conversation now
start with broad approaches rather than item-by-item specifics
not everything needs resolution in one conversation — set up the next one for success
document thoroughly — for your own team and for colleagues inheriting the patient

documentation

A 90-year-old with multiple comorbidities transferred from LTC as a full code with no documentation of how that decision was reached is a common and avoidable scenario. Document the discussion, the values elicited, and the rationale for the plan.

supervising trainees in GOC

Graded responsibility based on trainee readiness and case complexity:

Level	Role
observe	trainee watches senior/attending lead
co-lead	trainee leads with senior present; can tap out
independent	carefully selected straightforward cases

Assess before assigning — trainee’s medical understanding, comfort with GOC and ethical/legal framework, and case suitability (aligned care team, established family relationship, non-urgent).

huddle before the room — shared understanding of status, options, meeting goals
let trainee know you may step in, and that they can ask for help
resist stepping in unless necessary — silence and imperfect phrasing are part of learning
debrief every time — what went well, one thing to work on