Implementation of ‘Goals of Patient Care’ medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial

Abstract

IntroductionSystematic reviews demonstrate that advance care planning (ACP) has many positive effects for residents of aged care facilities, including decreased hospitalisation. The proposed Residential Aged Care Facility (RACF) ‘Goals of Patient Care’ (GOPC) form incorporates a resident's prior advance care plan into medical treatment orders. Where none exists, it captures residents' preferences. This documentation helps guide healthcare decisions made at times of acute clinical deterioration.Methods and analysisThis is a mixed methods study. An unblinded cluster randomised controlled trial is proposed in three pairs of RACFs. In the intervention arm, GOPC forms will be completed by a doctor incorporating advance care plans or wishes. In the control arm, residents will have usual care which may include an advance care plan. The primary hypothesis is that the GOPC form is superior to standard ACP alone and will lead to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome will be an analysis of the effect of the GOPC medical treatment orders on emergency department attendances and hospital admissions at 6 months. Secondary outcome measurements will include change in hospitalisation rates at 3 and 12 months, length of stay and external mortality rates among others. Qualitative interviews, 12 months post GOPC implementation, will be used for process evaluation of the GOPC and to evaluate staff perceptions of the form's usefulness for improving communication and medical decision-making at a time of deterioration.DisseminationThe results will be disseminated in peer review journals and research conferences. This robust randomised controlled trial will provide high-quality data about the influence of medical treatment orders that incorporate ACP or preferences adding to the current gap in knowledge and evidence in this area.Trial registration numberACTRN12615000298516, Results.

Risk factors and early prediction of clinical deterioration and mortality in adult COVID‐19 inpatients: an Australian tertiary hospital experience

“…There were four GOPC categories: Goal A identifies patients without treatment limitations for whom cardiopulmonary resuscitation (CPR) would apply; Goal B, those for whom some treatment limitations apply, including not for attempted CPR but for intubation; Goal C, for whom investigations or treatment should only be undertaken if non-burdensome; and Goal D identifies patients who are in the terminal stage of illness for whom all interventions should be for comfort only. 12 From the total cohort of COVID-19 inpatients, we selected patients who had complete data for calculating their 4C Deterioration and DL-Poor scores (Table S1). Similar to the studies that originally validated the prediction tools, we defined inhospital clinical deterioration as initiation of ventilatory support, admission to an intensive care unit (ICU) or death.…”

How to Improve the Drafting of Health Profiles

“…The training on the CIRS instrument helps clinicians to assess their patients globally, without focusing exclusively on the acute problem that is the main reason for admission. In fact, when clinical conditions deteriorate, it is almost never due to a single problem [ 32 ]. A comprehensive approach to the patient, focusing on all organs and systems, provides a more complete picture and allows for more targeted and effective care [ 33 ].…”

Testing a new form to document ‘Goals‐of‐Care’ discussions regarding plans for end‐of‐life care for patients in an Australian emergency department

“…Other published literature on GOC forms in Australian hospitals focuses on the use of these forms in the general hospital setting, 17 in-hospital rehabilitation 23 and a residential aged care facility. 16 Use of these forms is to provide a plan of care (including for CPR) in the event of patient deterioration, and is informed by patient wishes and advance care plans. One version 23 includes a summary of the patient's likely response to CPR and critical intervention as part of an overall summary of discussion.…”

“…There is limited literature to inform GOC content. Several forms have been described, mainly taking a final summary, tick‐box approach; however, we could not find any specific to the ED setting.…”