Most health care professionals would agree that conversations around goals of care are key to patient-centered care. Hospital systems, however, are not always set up to facilitate these important discussions. At Toronto’s Humber River Hospital, an Advance Care Planning (ACP) Steering Committee worked carefully to develop an Advance Care Planning Program that makes these conversations happen earlier – and more often.

The hospital surveyed health care teams in 2011 and discovered that information about end of life conversations and goals of care were often difficult to find in the patient’s chart. Staff also felt that these conversations should be started earlier, and that the language needed to be standardized so that everyone could easily understand a patient’s goals of care.

The hospital’s Advance Care Planning Steering Committee began working towards developing tools and processes to standardize language and implement best practices to facilitate advance care planning. “Our focus was to make sure that everyone – patients, families, health care professionals – understood the patient’s goals of care and knew where to find the information in the chart” says Bob Parke, a Bioethicist with the hospital and Committee Co-Chair.

The Committee adopted an Advance Care Planning definition which included all future health care decisions, not just end of life care.

The Committee developed an ACP education package for patients and their families with the theme “think about it – talk about it – share it”. The package includes an interactive workbook, an information brochure and a guide for Substitute Decision Makers. This information is distributed early in the care process to patients with chronic and recurring illnesses, such as dialysis patients.

A centerpiece of the Committee’s work was the creation of the Goals of Care Order Form. The Order Form is completed in discussion with the patient, allowing the patient to make treatment choices based upon their wishes. When completed, the patient receives a copy of the Goals of Care Order Form, thus ensuring that the process is transparent and there is a common understanding of the choices made.

“Goals of care should be reviewed when a patient’s condition changes, or at the request of the patient or the treatment team” says Parke. “We encourage patients and their families to bring the Form to all medical appointments – this helps to ensure that everyone stays on the same page and it also helps to facilitate conversations.”

With the assistance of a project coordinator, the Advance Care Planning Program was integrated at all three sites of the hospital. Education resources were created for staff and physicians. A new tab in the patient’s chart called “Advance Care Plans” was created to clearly identify the location of the Goals of Care Order Form and any related advance care planning documents. Electronic screens were revised to reflect the new language of the Goals of Care. A process was designed to evaluate the initial implementation period. Monitoring activities continue to ensure effective use of the resources.

Parke says that the Program has been a success at all levels. Physicians have noted that the common language facilitates discussions, and information is easier to find in the chart. Accreditation Canada also commended the hospital on the Program at the end of its Accreditation survey last October.

“Having the information clearly identified, with terms that everyone can understand, has been critical to success” says Parke. “But most important was having everyone buy into the new process. With everyone on the same page, we can truly focus on patient-centered care.”