Using Goals Of Care To Develop A Patient Centered Plan

Instructions

All information needed to earn ce credit is found in this self-learning activity.

Read and study the text.
Answer the questions found in the posttest assessment at the end of the activity.
Complete and submit the evaluation form.

Disclosures:

This course content will be reviewed on or before July 31, 2026.

Nurses: A score of 80% is required to earn the continuing nursing professional development contact hours. This activity will award 1.0 contact hours upon successful completion of the self-learning activity to nurses, social workers, licensed professional counselors. All others are advised to seek approval from their licensing board before purchasing.

Upon successful completion, a certificate so indicating will be awarded. Ames Heigh, LLC is approved as a provider of nursing continuing professional development by New Mexico Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. This activity will award 1.2 contact hours.

About the Author

Dana M. Beyers, MSN, RN, GNP has been a nurse since 1986 and is a Geriatric Nurse Practitioner providing primary care for older adults in skilled nursing facilities. Dana also has a Legal Nurse Consulting business providing review of medical cases for merit or in defense of lawsuits involving care provided to older adults.

The author and planners of this NCPR activity have no relevant financial relations to disclose.

The Board of Social Worker Examiners approved Ames Heigh LLC (#4207) to award credit for this program and this credit is also accepted for LPCs.

Learner Outcome: Nurses will have the knowledge to engage in discussions with patients and their families on choices available to them regarding goals of care. They will recognize diagnoses of chronic health problems, end of life issues, and the pros and cons of using CPR. Nurses will be knowledgeable about the consequences of families and patients not being informed of their options.

INTRODUCTION

Goals of care refer to the preferences on an individual about the medical care they wish to receive. Specifically, interventions that may prolong life such as cardiopulmonary resuscitation (CPR), a feeding tube or the use of mechanical ventilation. We will focus on goals of care discussions, specifically in the geriatric population. These discussions are an integral part of determining priorities and preferences of older adults and function as a guide for the family and care givers, particularly in times of changing health conditions. There are several ways an individual can make their wishes and preferences known to loved ones and the medical care team. Having “directives” i.e., directions will help avoid unwanted medical care and will lead to care which is in line with the individuals wishes. Not adhering to documented goals of care preferences is poor quality care and can lead to errors in medical treatment. Suggestions for appropriate times to have goals of care discussions in order to document patient wishes will be addressed. There are many barriers that prevent advanced directive documentation, several will be presented. Scenarios of goals of care discussions used to guide the care of two patients will be provided.