Goals of Care

One in three high-risk patients choosing surgery will experience serious medical complications leading to long-term decline in health and quality of life. Often patients do not receive the information they need to make an informed decision about surgery. (1)

Essential communication regarding goals of care is essential for aligning surgical interventions with patient values, preferences, and clinical realities. Shared decision making is a collaborative process between clinicians and patients, which aims to select the most suitable treatment option based on best available evidence and informed patient preferences. (1)

Screening Tools

  • Do you have an advanced care plan - a list of instructions to help guide a trusted person to make health care treatment decisions on your behalf if required?
  • Have you identified a substitute decision maker - someone you trust to make health care treatment decisions on your behalf if you are unable to do it yourself?
  • Is the patient at higher risk of perioperative complications? (e.g., advanced age, frailty, poor functional capacity, moderate/highly invasive surgery, multiple comorbidities)

Optimization is recommended for patients that answer No to question 1 or 2, or Yes to question 3.

Prehabilitation and Optimization Recommendations

Patient Education
  • Encourage patients to think about what matters most for their health.
  • Provide Advance Care Planning Guide and What Matters Most to Me Worksheet
  • Refer to online patient resources
Preoperative Goals of Care Discussion
  • Lead with "What should I know about you as a person to help me take the best care of you that I can?"
    • Intended to open a patient-centred, narrative conversation that goes beyond symptoms and diagnoses.
  • Ask the following questions:
    • What worries or concerns do you have about your upcoming surgery?
    • Can you share what you understand about your current health?
    • How do you hope that this surgery will help you?
    • Are there any outcomes from this surgery that you would consider unacceptable?
  • Use the best-case scenario /  worst-case scenario framework (2,3), a narrative and visual decision-support tool designed for high-stakes conversations. Refer to online provider resources.
Referral for Comprehensive Geriatric Assessment (CGA)
  • Consider preoperative assessment by Geriatrics to delineate risk

References

1. Centre for Perioperative Care. (n.d.). Shared decision making for clinicians. Retrieved October 21, 2024, from https://www.cpoc.org.uk/guidelines-resources-resources/shared-decision-making-clinicians

2. Kruser, J. M., Nabozny, M. J., Steffens, N. M., Brasel, K. J., Campbell, T. C., Gaines, M. E., & Schwarze, M. L. (2015). "Best Case/Worst Case": Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions. Journal of the American Geriatrics Society, 63(9), 1805–1811. https://doi.org/10.1111/jgs.13615

3. Taylor, L.J., Naboznym, M.J., Steffens, N.M., Tucholka, J.L., Brasel, K.J., Johnson, S.K., Zelenski, A., Rathouz, P.J., Zhao, Q., Kwekkeboom, K.L., Campbell, T.C., Schwarze, M.L. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surg. 152(6), 531-538. https://doi.org/10.1001/jamasurg.2016.5674