Goal of Care Discussions (GOCD)

Goals of care discussions are needed to support people with serious illness when they face treatment and/or care decisions. 

  • These discussions take place for many different treatment and/or care decisions - they are not the same as someone's code status.
  • They are discussions in the context of a current illness.
  • Their aim is to align treatment/care decisions with a person's goals, values and priorities.
  • And to support people if their goals cannot be achieved.
  • Everyone in a person's healthcare team has a role to play in goals of care discussions.

On this page:









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Why are goals of care discussions important?

Goals of care discussions (GOCD) are important because treatment and care decisions:

  • can be complex, with no obvious one right decision and therefore require input of a person's values, goals or priorities

These discussions:

  • happen in all health care settings
  • can be supported by all healthcare practitioners
  • will happen many times over the course of an illness as different treatments decisions come up
  • require skillful communications: listening to understand, speaking to be understood and responding to emotions




Priya has advanced dementia. She is at home and develops a fever and decreased level of consciousness. Her family doctor engages Priya's family in a goals of care discussion to determine if she should go to hospital or be cared for at home. 

Bob has had several heart failure exacerbations, has symptoms at rest and he is approaching end of life. His cardiologist wonders if the ICD is still consistent with Bob's goals and values so engages him in a goals of care discussion about deactivating his ICD.

Tran now has end-stage breast cancer. She finds it hard to manage at home and wants to focus on comfort and on helping her family cope. Her care coordinator has a goals of care discussion with her to see if a palliative care unit would help her achieve her goals.



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Why are goals of care discussions challenging?

Clinicians often say they:

  • lack training to support people through what often are emotional conversations
  • worry about removing hope or causing distress
  • worry about managing uncertainty, especially about prognosis
  • do not feel they have time required for these discussions

We also know:

  • it is hard to witness suffering and these conversations often involve difficult choices
  • clinicians feel that they have failed if they don't have treatments to reverse or treat an illness

But with knowledge and skill, these conversations will allow you to make recommendations and plans that best align with your patient's goals and values. 

With skill, you will also learn to support your patients when if their goals are not medically achievable.



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Outcomes of goals of care discussions

Goals of care discussions aim to align treatment and care decisions with a person's goals and values while supporting them if their goals and values cannot be achieved.   

Three outcomes of GOCD are:

  • People and their SDMs improve their understanding of the illness including what to expect in the future.
  • Treatment and/or care options are explained and goals and values are explored. 
  • Treatment and/or care recommendations take into consideration people's goals, values and wishes.

There are many values-sensitive decisions that result from goals of care discussions, for example:

  • starting, continuing or stopping chemotherapy;
  • deactivating an ICD;
  • starting or stopping dialysis; 
  • being cared for in a palliative care unit or at home.



A person's Code Status is not their Goals of Care

A person's code status is not a "goal of care" -- it is just one treatment decision among many that can be the outcome of a goals of care discussion. 



Treatment Plans

A treatment plan (or plan of treatment)  provides the capable person (or if incapable, the SDM) an opportunity to consent to a group of treatments, some of which may occur in the future. This is not an “advance consent”, as it is consent related to a current state of health. A plan of treatment may be an outcome of a goals of care discussion.

A “plan of treatment” means a plan for care of a patient that,

  • is developed by one or more health practitioners,
  • deals with one or more of the health problems that a patient has,
  • may deal with one or more of the health problems that the patient is likely to have in the future given the patient’s current health condition, and
  • provides for the administration to the patient of various treatments or courses of treatment and may, in addition, provide for the withholding or withdrawal of treatment in light of the patient’s current health condition, 
  • it requires all the same components as informed consent.

In other words, If making a treatment plan for a future situation, the patient (or SDM) has the information necessary to make an informed and contextualized decision that is related to the current condition.

Examples include: a person can consent to multiple cycles of chemotherapy; a person can consent to recurrent blood transfusions; a person can consent to on-going dialysis; an SDM can consent to a community treatment orders. 

Reference: Health Care Consent s.13

  • A Code status decision (DNR, DNI, etc) can be treatment plan and the table below shows you how it differs from an advance care plan wish.


    Example Statement


    Current code status

    Person is Expressing a wish (ACP)

    In the future if I’m in ‘x’ state, I would prefer to be provided with medical care but would not want to be resuscitated”

    • This is advice to the SDM who at some point in the future will use this information to provide consent for a specific code status such as Full Code or DNR/DNI, etc.
    • No change (Full Code)

    Person or SDM (if person incapable) is consenting to a Treatment Plan (GOCD)

    “In my current state ofhealth,I do not want to receive resuscitation in the event of cardiopulmonary arrest”

    “Based on x’s current state of health, I agree to the following code status”

    • Consent given tothe attending medical team.
    • This code status is written on the chart as an order
    • Changedto reflect the code status that the person or SDM provided consentfor
    (Acknowledgment: Nadia Incardona)



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How goals and values inform decision-making?

Deciding on a treatment and/or care plan involves knowing the potential outcomes, risks and benefits. 

But often, to choose among options requires knowing what a person is aiming for -- what are their goals, hopes and fears.

In these situations, the input of a person's goals is the missing piece in determining the right treatment decision. 








For example, consider a third line chemotherapy treatment that:                      

  • May give someone more time (months)
  • Requires visits to hospital and treatment
  •  Will cause fatigue and some other side effects.


Person A: 

This person's goals include spending as much time at home as possible and avoiding time in hospital and away from family.  His goals don't include adding  additional quantity of time.  His worries include: worsening fatigued and worsening nausea. These symptoms make it hard for him to spend quality time with his family. 

Based on these values and goals, Person B  is likely to decide against chemotherapy

Person B:

For Person B her goals include living until her son graduates in a few months.  She wishes to have any treatment that might add enough time.

Based on her goals, she may decide to accept chemotherapy if it has a chance of meeting that goal. 






It is the same illness, the same illness trajectory and the same treatment options.

Person A has different goals and values from person B.

A person's goals and values are essential ingredients in helping them make treatment decisions.

So in our case above we see different treatment choices, as the decision hinges on their goals and values.

When we focus on goals and values, treatment decisions become clearer.  People care about how the outcomes of treatments meet their goals and values. They don't focus on the treatments themselves. Yet, health care practitioners often talk just about the treatments, not about the outcomes.

It isn't what treatment the person wants -- it is what they are hoping to achieve and what matters to them -- not the specific treatment. 



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The role of inter-professionals

All health care practitioners have a role in supporting people in a goals of care discussion.

  • Even if you aren't the clinician proposing treatment, you can explore someone's need for better illness understanding.
  • You can assist in helping someone get the information they need.
  • You can listen what people express about their worries, questions, goals and priorities. Just being open to listening to people will provide a lot of information that supports people when they need to have a goals of care discussion.


"it sounds like you aren't sure what the treatment options are...would it be okay if I asked the team to come back and explain them?"

"what are you hoping you'll be able to do when you leave the hospital?" 

"you've heard some difficult news...and you said you have things you still need to do...can you tell me some of them?"



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Improve your goals of care discussions

It takes knowledge, skill and practice to improve discussions about treatments and/or care decisions that are patient-centred and values-based.  Most important is to listen to your patient rather than impose your own values and goals. With good listening and openness, you will align with your patient and find solutions together.

  • Learn the principles underlying an effective goals of care discussion
  • Use a conversation guide
  • Practice a set of skills to engage in good conversations
  • Use reflective practice to improve
  • Watch an E learning Module for more information about having these discussions.
To enquire about Training Workshops, email nav.dhillon@hpco.ca



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Document Goals of Care Discussions

Documentation of a goals of care discussion helps ensure clarity and consistent care.

  • Even partial discussions can and should be documented.  Other clinicians can pick up and continue the conversation if it is well documented. 
  • Document in the patient's own words as much as possible.

There are four components to document. 

  • Illness understanding
  • Information given
  • Goals/values
  • Treatment recommendations

Illness Understanding: Mr. Righter understands his cancer is worse and that the last chemotherapy wasn't helpful.

Information given: We discussed the next chemotherapy options -that there is a 30% response rate. I introduced the palliative care team today as I think he would benefit from their support going forward.

Values/goals: He is hoping to have more time as he is enjoying the time he is spending with family and still feels strong enough to do things he loves such as getting into the garden and visiting his grandchildren. His is worried about his wife...I have suggested she come to the next appointment to meet with our social worker.

Treatment and care recommendation: I have recommended we try the next chemotherapy and will reassess with CT in 8 weeks. He is still keen to treat reversible illnesses at this time. I have not discussed code status at this time, but will bring it up in the next visit.

Illness Understanding: Mr. Brown is struggling with understanding his kidney issues: "I know dialysis is going to fix my kidneys".

Information given: We discussed that dialysis doesn't fix kidneys -- he seems to be understanding .

Values/goals: He wants to think about this more as he hadn't realized how ill he actually is.

Treatment and care recommendation: Continue wth dialysis -- continue discussion next visit.