Welcome
Table of Contents
Introduction
Learning Objectives
As a Nurse...
Goals of Care in Advanced Illness
Goals-oriented Decision-making
Check Your Understanding
Importance of Goals of Care Discussions
Clinical Scenario
Potential Goals of Care
Check Your Understanding
When Goals of Care Discussions Should Occur
Triggers for Goals of Care Conversations by Disease
Triggers for Goals of Care for Patients with Cancer
Check Your Understanding
Truth Telling and Maintaining Hope
Truth Telling and Hope
Avoiding False Hope
Setting Goals to Sustain Hope
Reflecting on Truth Telling and Setting Goals of Care
Helping Your Patient Refocus their Hope
Clinical Scenario
Language & Frameworks for Goals of Care Conversations
Goals of Care Communication Strategies
Useful Language to Begin Goals of Care Discussions
The SPIKES Protocol for Goals of Care Discussions
Serious Illness Conversation Guide
Serious Illness Conversation Demonstration
Check Your Understanding
How to Talk End-of-Life Care with a Dying Patient
Discussing Treatment Goals
Initiating the Goals of Care Conversations
Advance Care Planning
Substitute Decision-Makers
Setting Goals with Substitute Decision-Makers
Clinical Scenario
Advance Care Planning & Goals of Care
Core Competencies in Advance Care Planning
Patient, Family, and Health Care Professional Roles
ACP and the Law
Advance Care Planning: Self-reflection
Closing Quote
Create Your Action Plan
Summary
Abbreviations
References