Discussion - Goals of Care

I personally reviewed [Mr./Mrs. Name]'s history to include prior admissions, diagnostic testing, and previously discussed treatment options.  It was noted that the patient [does/does not] have an [advanced directive/DNR/DNI].  Given [his/her] history of [previously diagnosed life-limiting disease], I wanted to discuss their goals of care at this time.  [Mr./Mrs. Name]'s [all family members present preferably with names] were at the bedside and invited to be involved in this discussion with the patient's permission.  [Nurse or other specialists] were also at the bedside as part of this conversation.  We offered to have a Chaplain at the bedside [which patient accepted or refused/Chaplain's name].

[Mr./Mrs. Name] states their primary goal today is [relief of pain/etc.].  [Mr./Mrs. Name] states that they [would/would not] wish to have a breathing tube placed or be placed on a ventilator should their condition worsen to the point this might be necessary.  [Mr./Mrs. Name] states that they [would/would not] wish to be resuscitated with compressions on their chest, electric shocks (defibrillation), or have resuscitative ACLS drugs given should their heart stop beating or go into a non-perfusing rhythm.  [Mr./Mrs. Name] does wish to have [describe treatments patient agrees to here].

We allowed [Mr./Mrs. Name] and their family to have all of their questions answered to the best of our abilities.  We discussed plan for [admission/further treatment].

https://emottawablog.com/2019/04/a-how-to-guide-to-goals-of-care-discussions-in-the-emergency-department/
https://www.aliem.com/pv-card-palliative-care-screening/