MEDICAL GOALS OF CARE (GOC) PLAN 
                        STATEWIDE
FACILITY:	PT ID	

	

	

	

Surname: <<Patient Demographics:Surname>>
Other Names: <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>
Date of Birth: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>>, <<Patient Demographics:City>> , <<Patient Demographics:Postcode>>	

Determine the patient’s Goals of Care and complete the form below. If changes are made, mark as VOID and complete a new form. See instructions on back page.	
Diagnosis: <<Diagnosis>>	
NO LIMITATION OF TREATMENT	Acute Hospitals	Community, Rural or other 	
A. The goal of care is CURATIVE or RESTORATIVE.
c For CPR and all appropriate life-sustaining treatments 	For CODE BLUE	For full resuscitation	
LIMITATION OF MEDICAL TREATMENT
c Patient has an Advance Care Directive and / or has requested the following treatment limitations:  
	
B. The goal of care is CURATIVE or RESTORATIVE with limitations:
c NOT FOR CPR but is for all respiratory support measures 
------------------------------------------------------------------------------------------------------------->
c NOT FOR CPR or INTUBATION but is for other active management 
------------------------------------------------------------------------------------------------------------->
Specific notes: 	For CODE BLUE and MET calls	

For MET calls NOT for CODE BLUE	

	For treatment and consider transfer to acute hospital	
C. The goal of care is PALLIATIVE.
c NOT FOR CPR OR INTUBATON ------------------------------------------------------------------------------------------------------------->
Specific notes: 	          MET call
      c  YES	

          MET call
      c NO	

	Contact medical officer for treatment plan	
D. The goal of care is COMFORT as the patient is dying.
c NOT FOR CPR or INTUBATION ----------------------------------------------------------------> 	For terminal care
NOT for any EMERGENCY calls	
Reason for limitation of medical treatment:	c medical grounds 	c patient wishes	
Discussed with: 	c patient 	c person responsible	
Completing Doctor (print name): <<Doctor:Name>>	Designation:	
Signature: 	Date: <<Miscellaneous:Date>>  Time: <<Miscellaneous:Time>>	
GP/consultant responsible (print name):	GP / consultant informed:  c YES  c NO	
This form is valid for ambulance transfer and for use in the home or care facility.	
Patient (print name): <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>>	PT ID										
Instructions	
1.	Tick the box on the form that best describes the goals of care for the patient at this time.

A.	CURATIVE or RESTORATIVE – if no treatment limitations are required tick box A. Refusal of a single treatment, such as blood products, in the context of otherwise full active treatment should be documented under limitations of medical treatment.

B.	CURATIVE or RESTORATIVE with limitations – If in an acute hospital, limitations to code blue or MET calls can be further documented. If in the community, the patient is for active treatment and transfer to a hospital if appropriate.

C.	PALLIATIVE – The treatment aim is quality of life. If in an acute hospital, limitations to MET calls can be further documented. If in the community, rural facility or other THS health facility the medical officer can be contacted for further direction in management.

D.	COMFORT – The treatment aim is comfort while the patient is dying. The prognosis is hours to days.
1.	The details of the GOC discussions should be clearly documented in the patient’s clinical record.
2.	The ultimate responsibility for treatment decisions is a medical one and should always be discussed with the patient and/or family where practical.
3.	The GOC form may be completed by a Consultant, Registrar or Resident Medical Officer, RMP or GP.It must not be completed by an Intern.
4.	The completed GOC form is filed in the current admission record, in the alerts section.
5.	If the GOC change, the old form should be crossed out, marked VOID and a new form completed.
6.	On discharge, a copy of the form can be provided to the patient or to the GP with the discharge summary if appropriate.
7.	Ambulance Tasmania will recognise and act in accordance to the GOC form.
8.	General practitioners or specialists may complete a GOC plan for ongoing care in the community and this form can be sent with the patient to the hospital if required.
9.	Day patients who are low risk are not required to have a GOC form completed.	
Abbreviation Key:  CPR  Cardio-Pulmonary Resuscitation |  GP  General Practitioner  |  MET  Medical Emergency Team  |  THS  Tasmanian Health Service  |  RMP  Rural Medical Practitioner	

Template updated by Primary Health Tasmania October 2020 (MD)