About Advance Care Planning (ACP)| About Goals of Care Designation (GCD)| ACP and GCD Conversations| About GCD Orders| About the Tracking Record (TR)| About the Green Sleeve| About Personal Directives (PD)| About Naming the Public Guardian as an Agent in a Personal Directive| Clinical Clarifications| About Connect Care
About Naming the Public Guardian as an Agent in a Personal Directive
What is Advance Care Planning?
Advance Care Planningis a way to help patients think about, talk about and document wishes for health care in the event that they become incapable of consenting to or refusing treatment or other care. Being exposed to these conversations also prepares people for a time when they are still capable but may be faced with important health care decisions.
Why should a patient plan early?
None of us know what tomorrow might bring, or can predict our future health. Planning today can ensure that your wishes are known, no matter what the future holds. Advance Care Planning guides all decision-makers and may bring comfort and peace of mind to families and to those who may have to make healthcare decisions on your behalf.
What are the steps to take to get started?
What are Goals of Care Designations (GCD)?
GCDs are Most Responsible Health Practitioner (MRHP) orders that:
A GCD is seen as a short-hand communication tool that guides all members of the healthcare team and assures the patient’s voice in decision-making.
What is a Goals of Care Designation (GCD) Order?
A Goal of Care Designation Order is a medical order that specifies general care intentions, location of care and transfer opportunities for current and future care, and is signed by the most responsible health practitioner – usually a treating physician or nurse practitioner. A GCD order is determined by aligning the patient’s values, beliefs and care wishes with expert clinical advice regarding appropriate medical care.
Who should have an ACP conversation?
All adults can benefit from Advance Care Planning as we may have an unexpected event or change in our health. All patients and persons in health care should be given the opportunity to participate in an ACP discussion. Planning ahead enables others to know your wishes, including family members and those providing care. These discussions could be initiated by the primary care physician as part of the patient’s routine health care, but they can also be initiated by patients or other healthcare professionals. They can occur in all health care settings. Advance Care Planning conversations allow for respectful understanding of wishes concerning care, as well as specific interventions. These conversations include communication among health care professionals, patients, and when appropriate, alternate decision-makers.
What is meant by a GCD conversation?
These conversations explore the goals for treatment and the patient’s wishes framed within the therapeutic options that are appropriate for the patient’s current clinical condition, and those which may be relevant for the patient’s future clinical conditions. They incorporate the values and wishes of the patient as well as guide interventions. These conversations should ultimately lead to the most responsible healthcare professional writing an appropriate GCD order.
When should GCD conversations occur?
Conversations are best started early in the patient’s course of care and/or treatment and/or when clinically appropriate to the patient’s care. Conversations and decisions about GCD are carried out with the patient or with the patient’s alternate decision-maker if the patient lacks capacity to make such decisions.
If it is clinically appropriate to do so, there are times that are particularly important to engage in GCD conversations. Here are some examples:
How can a Health Care Provider introduce the topic of ACP/GCD?
Every clinical situation is unique; however, the following questions offer a non-threatening way to ask about ACP/GCD.
Explore discussions with family, agent or health care providers.
These questions lead to natural exploration of wishes, or may help you be aware if the patient has appointed an alternate decision maker (ADM) or agent.
Who can initiate and conduct Advance Care Planning/Goals of Care conversations?
A patient can ask to have this conversation. Any member of the patient’s health care team (for example; MD, RN, RRT, LPN, OT, SW,) can initiate the conversation and conduct appropriate parts of the Advance Care Planning discussion. A physician or nurse practitioner is ultimately responsible to ensure the most clinically appropriate Goals of Care Designation Order is in place.
The conversations may include:
Who is the Most Responsible Health Practitioner (MRHP)?
The MRHP is the physician or nurse practitioner who is overseeing the course of care for a patient. The formal policy definition is as follow:
Most Responsible Health Practitioner (MRHP) means the health practitioner who has responsibility and accountability for the specific treatment/procedure(s) provided to a patient and who is authorized by Alberta Health Services to perform the duties required to fulfill the delivery of such a treatment/procedure(s) within the scope of his/her practice. Currently in Alberta, to provide medical orders, the MRHP is usually a physician. In some circumstances, a Nurse Practitioner is the MRHP.
The MRHP definition is deliberately broad, to allow the flexibility to adapt to a change of clinical leadership or responsibility in any situation
While we talk about the Most Responsible Health Practitioner writing the GCD order – what does that mean?
Patients may see multiple physicians and Nurse Practitioners in the health care system, especially if they have health concerns needing specialist care. If that specialist is the one with the most accurate understanding of the diagnosis, treatments and potential outcomes or prognosis of the patient, then they are the most appropriate person to summarize the conversations amongst the patient and the care team and write the order.
Determining and writing a GCD Order is a cooperative activity involving the patient and whichever care providers are best placed to undertake these conversations. Often, the family physician is that care provider. As new information is understood from specialist consultants participating in the patient’s care, alterations to the Order may be required, and can be written by the consultant or the family physician
Here are some examples of times where the specialist might be best equipped to have the conversation and write the order. Note that oftentimes the family physician should be involved, may have written the GCD order, with the consultant confirming appropriateness in the context of what they know about the patient and treatment options:
If a patient’s most responsible health practitioner changes, the previous Goals of Care Designation order remains applicable unless changed by the new most responsible health practitioner. It should be reviewed with the patient by the new MRHP.
When should a GCD be reviewed?
Goals of Care Designations should be reviewed when new circumstances or health issues arise, when a patient is transferred to a new location of care or if the patient or alternate decision-maker requests it.
A Goals of Care Designations order is prescriptive – it guides the clinical team regarding the course of care and interventions - but is also subject to clinical judgement of the current most responsible health practitioner. If the current GCD no longer makes clinical sense or seems to be in conflict with the patient’s wishes, it should be reviewed and can be changed if necessary.
Is a patient signature required on the GCD order form?
Informed consent and patient signature are not required to make a Goals of Care Designation order because it is a medical order. As a medical order, it is the clinical responsibility of the most responsible health practitioner. It is standard clinical practice to engage the patient or alternate decision maker in all related discussions and decisions so their wishes are known and considered. A patient or ADM signature is not required for documentation.
Can a photocopy of the GCD order form be valid?
Original GCD order forms are recommended as one source of truth, however if a health care provider must make a copy of the original Goals of Care Designation Order for any purpose, the health care provider should add a notation to the copy stating “true copy of the current Goals of Care Designation order for this patient” with the staff member’s signature, date and printed name.
Instances of when retaining a GCD Order photocopy on the patient’s chart is needed:
When a patient is discharged from acute care and their Green Sleeve remains on the chart, what does the health care team and Health Records do to return the Green Sleeve to the patient?
The ACP/GCD documents and Green Sleeve are the property of the patient. The unit clerk is to place a copy of the ACP/GCD documents on the health record and return the originals in the Green Sleeve to the patient.
If the original remains on the chart after the patient has been discharged, the unit clerk is to call the patient or facility. If unable to contact the patient and return the Green Sleeve, then the unit clerk sends it to Health Records. Health Records is to then return it to the patient by mail.
How do GCD Orders in electronic format and paper work together?
There is a paper version of a GCD Order. The form on which the GCD Order is written should be stored in the patient’s Green Sleeve except in areas that use electronic order entry.
In areas using an electronic health record the GCD order is entered and viewed in electronic format. When a patient is transferred from an electronic health record entry site to a paper order entry site, the sending unit prints a paper copy of the GCD order and places it in the Green Sleeve, giving it to the patient. This process also occurs if the patient is transferred to their home.
Both paper handwritten and electronically generated print forms are considered originals.
What do I do with multiple completed GCD order forms?
When there are multiple completed order forms (e.g. as a result of transfers or changes to health status) the following may assist in organizing the patient’s Green Sleeve:
Does my patient need to have a GCD to be admitted to a designated living option?
While both a clear GCD order and Personal Directive are ideally completed prior to admission to a designated living option, they are not required prior to admission. If they have not been completed prior, this activity should be undertaken as soon as is reasonable after admission. If they have been completed prior to admission, the GCD Order should be reviewed upon admission to assure it still reflects an appropriate goal of care designation.
What is the Dispute Resolution Process?
Decision-making by patients and the health care professionals who provide care to them is an integral component of health care. When circumstances bring significant complexities, including disagreement in what care is to be provided, additional decision support may be required.
The following are some examples of circumstances where dispute resolution may need to be initiated:
The Most Responsible Health Practitioner (MHRP) has a responsibility to ensure a patient is informed of, and has access to, the decision support and dispute resolution resources found in the Advance Care Planning and Goals of Care Designation Procedure paragraph 7 and in Appendix C.
What happens if a patient refuses interventions?
Patient refusal of specific clinically indicated intervention(s) shall be honoured, within the bounds of applicable laws. Further conversations regarding patient refusal may be required.
Clinical judgment should determine the degree to which further conversations regarding patient refusal should be considered and whether or not a dispute resolution process should be invoked.
Do GCD orders need to be updated annually?
ACP GCD Procedure 2.1states that GCD orders are reviewed when clinically appropriate. Some services and programs develop internal review processes as “best practice”. For example in many continuing care facilities residents have an annual care plan review, and at this time their GCD is updated.
What is an ACP GCD Tracking Record (TR)?
The Advance Care Planning Goals of Care Designation Tracking Record is an AHS form that communicates to health care providers and others the ongoing decisions made about a person’s Advance Care Plan and Goals of Care Designation (GCD). The form reflects what was talked about; who was involved, what was decided and the reasons for the decisions, from the oldest to most recent conversation.
Benefits:
Why is the ACP/GCD Tracking Record always the original? Not a copy?
The original Tracking Record is kept in the Green Sleeve to allow care providers at each site access to and the ability to document the full record of conversations that have occurred over time. Having multiple versions/copies of the Tracking Record contributes to confusion and possible miscommunication. If multiple, sequential Goals of Care conversations have occurred, and a Tracking Record is full after noting each of these conversations, begin a new Tracking Record for the next conversation and keep the full prior Tracking Record in the Green Sleeve, stapled behind the current Tracking Record. When discharged or transferred, a copy is kept on the patient’s chart
Who can record information on the ACP/GCD Tracking Record?
Any health care professional or member of the healthcare team who documents in the chart can record information on this form. Patients and families don’t write on this form.
The Green Sleeve belongs to the patient. It is a plastic pocket that holds important Advance Care Planning documents and other forms that outline a patient’s goals for health care. It is given to patients who have had discussions or completed documents that refer to decision-making about their current or future care.
The information contained in the Green Sleeve is intended to ensure that all health care providers in any setting have access to important decisions related to the patient’s goals of care and guidelines for direction of interventions that have been discussed with the patient.
What documents are included in a Green Sleeve?
It is important that these documents reflect the patients’ most current information and serve as one source of truth. For more information,refer to: MyHealth.Alberta.ca- Green Sleeve Video
How does a patient receive a Green Sleeve?
All Albertans can receive a Green Sleeve from any Alberta health care provider. The public is encouraged to ask their health care provider or family doctor for one and plan for a time to discuss their health care wishes.
How can health care providers order ACP/ GCD supplies?
AHS providers can order Advance Care Planning and Goals of Care Designation supplies online through DATAOnline.
Non AHS users can also order Advance Care Planning and Goals of Care Designation supplies online at no charge through DATAOnline. They will be required to set up a user profile and input a credit card number, however as long as they order ACP GCD supplies only, they will NOT be charged.
When the patient is receiving care or is admitted, the Green Sleeve should be placed at the front of the patient’s chart. On discharge the Green Sleeve needs to be returned to the patient.
In the patient’s home the Green Sleeve is to be kept on or near the fridge (Emergency Medical Services (EMS) personnel know to look for the Green Sleeve here). The Green Sleeve is intended to accompany the person as they transfer between care providers and/or sites.
A Personal Directive is a legal document that a person creates while capable of making their own decisions. It allows the person to name a decision maker (called an “agent”) and provide written instructions in the event the person no longer has the capacity to make their own decisions.
A Personal Directive names an agent for decision-making about personal matters. It can provide direction about personal matters including medical treatments, where to live and legal decisions.
You can write a personal directive in your home. Alberta government - voluntary form referenced in Step 2 You don’t have to submit any documents to the court or the Office of the Public Guardian and Trustee. As soon as you and your witness sign it, it’s a legal document.
A Personal Directive does not cover financial matters; to leave instructions for managing personal finances, an enduring power of attorney is required.
When is a Personal Directive used?
When a person is deemed unable to make personal decisions and a decision is required, a Personal Directive may be brought into effect after a capacity assessment has been completed.
When this happens, the person named as the agent has the legal authority to make decisions on an individual’s behalf based on the information in the Personal Directive.
On its own, the presence of a Personal Directive does not take away decision making power of a patient or give any authority to the named agent. Specific processes need to be followed to ‘enact’ or bring a Personal Directive into effect.
If you listed someone to decide if you have lost your capacity to make decisions, this person does an assessment. Most people choose a family member or a friend. It doesn’t necessarily have to be your agent.
A physician or psychologist also does an assessment.
If they conclude that you aren’t able to make personal decisions, they sign this form: https://formsmgmt.gov.ab.ca/Public/OPG5522.xdp
If you didn’t list someone to decide and you have lost your capacity to make decisions, then 2 service providers (e.g. a doctor, a nurse, the manager of a care facility, a social worker, etc.) each do an assessment. At least one must be a physician or psychologist.
If they conclude that you aren’t able to make personal decisions, they sign this form: https://formsmgmt.gov.ab.ca/Public/OPG5522.xdp
When this happens, the Personal Directive becomes enacted and the person named as the agent has the legal authority to make decisions on an individual’s behalf based on the information in the Personal Directive.
An enacted Personal Directive stays in effect until such time that a patient regains capacity (separate capacity assessment process required), or dies.
For more information on the following visit the Office of the Public Guardian.
Where does a patient keep their Personal Directive?
A copy of the personal directive should be kept in the Green Sleeve as well as provided to the agent(s). The original should be kept in a safe place that is accessible if needed. It also can be registered with the Government of Alberta to provide contact information for the patient and their agents.
Who do patients share their Personal Directive with?
A copy of the personal directive should be given to the agent, family members, and your health care team.
Does the PD need to be enacted for the agent to give direction on the GCD?
Unless the Personal Directive is enacted, the agent has no legal standing to provide direction on the GCD order (in other words, if the person is still considered to have capacity, they are the legal decision-maker for their care). However, an individual may defer decision-making to another person by choice or include them in the discussions leading to a supported or joint decision. With capacity, that would be the individual’s choice.
Can the Public Guardian be named as an individual’s Agent in their Personal Directive?
Yes, however, the Public Guardian must consent to be named as Agent as per the Personal Directives Act legislation (see excerpt from the Personal Directives Act below):
SEC 7 (4) A personal directive may designate the Public Guardian as agent if
(a) the Public Guardian is the only agent designated in the personal directive,
(b) the maker satisfies the Public Guardian that no other person is able and willing to act as agent, and
(c) the Public Guardian consents to being designated as agent.
Under what conditions can someone request the Public Guardian to act as their Agent?
Can someone write a Personal Directive naming the Public Guardian to be their agent, without consulting the office, and if they lose capacity, will the Public Guardian be compelled to act as their agent?
No. The Public Guardian will decline to act as their agent, as the Public Guardian did not have the opportunity to discuss the individual’s wishes in advance. The Personal Directive may be considered invalid without the Public Guardian’s consent. The Public Guardian will respond to the service provider or designate, who made the office aware of their situation and ask them to send in a referral for Specific Decision Making or guardianship, should a decision or ongoing decisions be required on their behalf.
Can someone ask the Public Guardian to be an alternate Agent, in case their primary Agent is unable to fulfil their role?
No. As per the legislation and policy: the Public Guardian will not consent to be named as a co-agent or as an alternate agent.
If the Public Guardian consents to be an individual’s agent, can someone select the Public Guardian to assess their capacity along with a Physician/Psychologist to determine whether or not their Personal Directive should be enacted?
No. Pursuant to policy, the Public Guardian will not assist in assessing the maker’s capacity; 2 service providers (one being a physician or psychologist) can determine capacity
How can someone contact the Office of the Public Guardian and Trustee to request the Public Guardian to act as their Agent?
Office location and phone numbers can be found on the OPGT website (see link below): https://www.alberta.ca/contact-office-public-guardian-trustee.aspx
Information about personal directives and the personal directives registry can be found on the OPGT website.
If you have questions about personal directives or the personal directive registry, email: personal.directives@gov.ab.ca
Can an RN take a verbal Goals of Care Designation (GCD) order?
In certain circumstances a person may require a change in their GCD order. Where the Most Responsible Health Practitioner (MRHP) is not on site and is only available by telephone the RN may take a verbal telephone GCD order. In this urgent situation, the RN documents the verbal telephone order on the GCD order form. The RN is to make a checkmark within the relevant GCD order box and place his/her initials in the relevant line below the selected GCD order. The MRHP must then co-initial on this line and sign the order at the earliest possible opportunity.
Clinical example:
Mrs. Hill is a 78-year-old lady residing at home and has a history of advanced cancer and has become bedbound and requires 24-hour care. Her current GCD order is M2 reflecting her earlier desire to be cared for in that facility without transfer to hospital; she has made it very clear to her home care nurse and her family that she now wishes to transfer to hospice for her end-of-life care.
Her home care nurse phones her FP to obtain a C1 GCD in preparation for transfer to hospice. The FP provides a telephone order for a C1 GCD and informs the RN that she will fax a new signed C1 GCD to the home care RN at the end of clinic.
When can people with a M2, C1 or C2 GCD order transfer to acute care hospital?
Transfer to hospital may be considered when symptoms cannot be managed in the person’s current care setting. If the patient has an M2 GCD, transfer can be considered if the patient agrees after an ACP/GCD conversation. If the patient has a C1 GCD, transfer should occur if symptoms can be better managed elsewhere and if the patient agrees. If the patient has a C2 GCD, transfer should occur in rare circumstances, considering where it will be best for the patient to die and if the care team is confident the patient is unlikely to die during transport.
Clinical example:
Mrs. Smith is an 84-year-old lady who has been residing in a supportive living facility for the last 5 years. She has a history of ovarian cancer and no further treatments are available; her GCD is C1. She has been requiring regular weekly paracentesis for her abdominal ascites and symptom management. Her family transports and escorts her to the standing outpatient appointment. Over the last month she is requiring the drainage more frequently and the frequent appointments are becoming difficult for her. She wishes to continue to have the drainage as it gives her relief from pain and nausea. The outpatient department has arranged for her to come to hospital to have a paracentesis catheter inserted into the abdomen so that the frequent drainings could be continued. The drain will be managed by the home care RN. Patient is transferred to hospital for the procedure and is then discharged home.
Mr Kumar is an 82-year-old man, residing in a facility, with a history of severe CHF, COPD and is quite frail. His current GCD order is M2; he has made it very clear to his doctor and his family that he wishes to have his symptoms managed as best as possible at his facility and does not wish to go to hospital. However he trips and appears to have fractured his leg, he is in pain that cannot be managed at that facility. He is transferred to hospital for surgical repair of his fracture. (see also surgery FAQ below)
If chest compressions are started in someone who is choking, when can chest compressions be stopped?
One fear a person, their family, and/or staff may have is that emergency help will not be offered for a choking episode if GCD does not allow for resuscitation. Interventions by healthcare providers when a person is choking may start with abdominal thrusts and/or chest compressions depending on the situation. If attempts to alleviate the obstruction are not effective and the person becomes pulseless and breathless the known GCD order will provide direction for further intervention and care, including whether CPR should be initiated.
If chest compressions are utilized to alleviate an obstruction in a choking situation they can be stopped when the obstruction is relieved or there is confirmation of ventilation (when a breath is provided and the chest rises).
Some individuals state they would not want chest compressions if they choked, even if the choking episode results in death. For some, that is because chest compression may cause significant harm. Where individuals do not want chest compressions for this circumstance, documentation is required on the GCD order form under the specific clarifications section, and conversations are to be recorded on the ACP Tracking Record Goals of Care Discussion form.
Examples of special circumstances:
It is important to discuss the potential use of chest compressions with persons who are at a high risk of aspiration (choking). In facility living, care teams are encouraged to have these conversations at the initial and annual care conferences.
Clinical example:
Mrs. Bosey is an 82- year-old lady residing in a facility. While having lunch in the common dining room she begins to cough and show signs of choking. Staff who are present initially perform abdominal thrusts to attempt to alleviate the obstruction. EMS is called and staff are directed to bring the chart containing her Green Sleeve with the current GCD order. She then becomes unresponsive, staff initiate chest compressions in order to alleviate the obstruction. The obstruction is relieved as confirmed when a breath is provided the chest rises. In accordance with her current GCD order (non R1), chest compressions are stopped.
Additional Resources:
Can non-invasive ventilation (such as BiPAP/ CPAP) be used in individuals with a non-R GCD order?
Yes, non-invasive ventilation, such as Bilevel positive airway pressure (BiPAP)or continuous positive airway pressure (CPAP) or High flow Heated Humidified Oxygen (HHHFO e.g. “optiflow,” can be used in individuals with a non-R GCD Order – if the intent of the treatment aligns with the GCD order.
Non-invasive ventilation is the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway. Non-invasive ventilation is used for life sustainment, life prolongation and may be used to alleviate symptoms and /or suffering.
The use of non-invasive ventilation is based on physician recommendations, the availability of resources in the current environment (e.g. respiratory therapist and/or equipment), and the GCD order based on discussions with the person and their family/ADM.
Clinical examples:
Life prolonging (appropriate for R GCDs) – Individual admitted with pneumonia person cannot maintain 02 saturations BiPAP is utilized.
Life sustaining (appropriate for M GCDs) - Individual with IPF admitted with hypoxia and High flow Heated Humidified Oxygen is used to improve oxygenation and manage dyspnea.
Symptom control (appropriate for all GCDs) – Individual with sleep apnea utilizes CPAP nightly for 6-8 hours resulting in increased alertness during the day.
Can the Medical Emergency Team (MET) /Code 66/ Rapid Response Team be called for patients with non-R GCD orders?
Yes – Depending on site-specific practices, these teams can respond for patient deterioration and support the health care team and the attending physician outside of the ICU.
e.g. A patient with an M1 GCD becomes seriously unwell with a sudden drop in blood pressure and reduced level of consciousness on an evening shift. The attending physician is on-call from home, 20 minutes away. A code 66 is called to provide rapid response while the attending travels into the hospital.
When a person with a M1, M2 or C1 GCD undergoes surgical interventions, what pre-operative discussions need to occur?
Major surgery can be considered for patients with M1, M2 or C1 GCDs to either fix a correctable problem or prevent suffering from an unexpected trauma or illness. For such patients, the surgical and anesthetic teams require clarity on the use of resuscitative measures to best assure operative success. Possible transfer to ICU for peri-operative complications or post-operative (recovery room) support should be discussed with the patient/ADM. ICU transfer may be considered for short-term physiological and mechanical support in order to return the patient to prior level of functioning. The possibility of intra-operative death should also be discussed with the patient/ADM.
Clinical example:
Mr. White is a 58-year-old male with a diagnosis of multiple myeloma with extensive myelomatous bone involvement. He is living independently in his home with his wife. He can no longer receive cancer-modulating therapies. He still wants to accomplish some things in the five remaining months he is expected to live. He wishes all future investigations and interventions to be directed towards comfort. His current GCD order is C1.
While walking his dog, Mr. White slips on the ice, injuring his ankle. He proceeds to an urgent care clinic for assessment and is found to have an unstable tri-malleolar fracture. The patient consults with an orthopedic surgeon to discuss surgical options. Mr. White decides to proceed with operative repair. He is informed by the surgeon that he may require a period of observation in ICU post-operatively. Mr. White understands the risks and agrees to a short-term stay if it is believed that he will return to a previous level of functioning. The discussion is well documented on the Advance Care Planning Tracking Record Goals of Care Discussion form and is also documented on the GCD order form under “specific clarifications”. At surgery his GCD is reviewed as part of the “safe surgical checklist” A new GCD does not need to be written as long as all the surgical, post-op and anesthesia teams are aware of the special clarifications on his GCD order
Are patients with an M or C GCD order ever considered for ICU admission?
No patient is absolutely excluded from ICU care simply as a result of a previously determined GCD order. "In the moment" decision-making by the current care team may lead to revocation of a GCD order and potential admission for ICU care, if that is felt to be necessary and appropriate.
However, in general, adult patients with M and C GCD orders are not candidates for ICU admission because they are not expected to benefit from and are not desiring of treatments that would be provided in that environment.
Considerations for ICU use for patients with an M or C GCD:
In which of the Goal of Care Designations can an Automated External Defibrillator (AED) be utilized?
An AED lead placement may be used in patients with R1, R2 and R3 GCDs because it will assist in diagnosing, especially during the time required to call a code team for assistance (assistance does not imply resuscitation).
R1 - Full CPR, including the potential for an AED shock, can be used for R1 designated people.
R2 - In the rare circumstances that a shock alone will revive someone, it is reasonable to try AED for people with R2 and R3 GCDs, recognizing that without the benefits of full CPR, chances for success are limited.
A limited attempt (e.g. a shock) would usually be in compliance with the R2 GCD order and the patient's wishes (even if that attempt fails).
R3 - A person with an R3 GCD order is really not looking for resuscitation attempts for cardiorespiratory arrest. The concept of R3 was to allow for situations where patient is already in a critical care area but either would not want or would not benefit from chest compressions or ventilation. However, occasionally, such patients with known conditions could benefit from controlled cardioversion with electricity, drugs and dialysis in an ICU. In this highly monitored environment a malignant arrhythmia can be acted on quickly enough that a patient has a reasonable chance of survival without CPR.
If an R3 designated patient on non-CCU/ICU unit or out-patient area develops a malignant arrhythmia, they are most likely to survive only with the benefit of all resuscitative measures – but they and their care teams have placed limits preventing the use of all those technologies. A shock, if available, can be tried, but should not be repeatedly employed at risk to the dying patient’s dignity.
How does the Interventional Cardiology service in acute care respond to referrals for angioplasty when the patient has an M1 GCD?
There is a risk that persons with an M1 GCD order might be inappropriately turned down for angioplasty simply due to their GCD. A GCD designation of M1 should not be the sole reason a patient would be turned down for angioplasty (PCI).
M1 GCD definition includes the following language about major surgery:
“Major surgery – is considered when appropriate. Resuscitation during surgery or in the recovery room can be considered, including short-term physiologic and mechanical support in an ICU, in order to return the patient to prior level of function. The possibility of intra-operative death (option: life-threatening intra-operative deterioration) should be discussed with patient in advance of the proposed surgery, and general decision-making guidance agreed upon.”
As always, good conversation, considering functional status/risk/benefit and patient goals, will help determine suitability for the procedure. This conversation must include the risk that peri-procedural arrest could occur, and must determine guidance regarding what, if anything, will be undertaken to resuscitate a patient in the event of an arrest.
M1 designated patients can receive attempts at resuscitation, with their advance agreement, along with the limitation that an ICU stay or prolonged dependence on life-support would not be considered. Eventual withdrawal of life support interventions, after appropriate conversations, would be considered ethically and legally permissible. Such instructions should be clearly indicated on the health record and on the GCD order form under “specific clarifications”.
Some patients will direct that no attempt at resuscitation should occur and the cardiology team may be uncomfortable attempting angioplasty in that context.
Some general concerns with accepting an M1 patient for a Percutaneous Coronary Intervention (PCI) procedure that would need to be discussed/ addressed include:
Is cardioversion (provision of electricity) linked with chest compressions in all resuscitation attempts?
No – resuscitation attempts can sometimes include cardioversion without chest compressions. The R3 GCD order was specifically designed for patients in heart monitored situations whose malignant rhythm disturbance might be correctable by electricity and/or cardiac drugs, but who have chosen not to receive chest compressions and mechanical ventilation.
If a person with an R3 GCD order has a monitored rhythm disturbance requiring appropriate cardiac interventions, those interventions are undertaken when required.
If such a person is found pulseless, appropriate and limited cardiac interventions can be undertaken (electricity and/or cardiac drugs). It is understood by the patient and the team that the restriction against chest compressions might limit the chances for success. If return of a functional output to re-establish a pulse is not achieved, the person has died.
In an unmonitored situation (on the street or on a general care unit), a pulseless person with a R3 GCD order prohibiting chest compressions and mechanical ventilation has died. It would be exceedingly unlikely to revive such a person with only electricity.
That said it would not be unreasonable for a code team or a first responder to place leads, assess the displayed rhythm and attempt electricity, without going further. However, it is also reasonable for a first responder in the community not to place leads or an AED on such a patient if it was known and undisputed that the patient carried a nonR1 GCD order. This is a clinical judgment call.
Should an M2 GCD order be prescribed for an individual in the acute care setting?
An M2 GCD order is intended to be prescribed in non-hospital settings or when the person is being transitioned to another location of care from acute care hospital. An M2 GCD order communicates that the person wishes available medical treatment and interventions in their non-hospital location of care. On occasions when a patient with an M2 order is transferred to acute care e.g. for symptom support, it may be appropriate to keep that order during their acute care stay.
When recreation therapy workers accompany residents on an outing why do they need to take a resident’s Green Sleeve or Goals of Care Designation (GCD) order?
When friends and family members take the resident out, they usually do not carry the resident’s GCD order.
Residents living in continuing care facilities commonly have many complex health issues and are at greater risk of potential medical events. When participating in off-site activities organized by the facility, AHS staff are responsible for carrying personal health information needed to maintain care (medications, emergency contacts, allergy information) including the GCD order in the event that a resident experiences a critical health event.
Carrying the residents’ Green Sleeve plastic pocket containing all advance care planning documents is considered best practice. In the event of a medical event, all ACP/GCD documentation (ACP/GCD Tracking Record, Personal Directive) is necessary for EMS and acute care clinicians to understand the reasons for the current GCD order.
If it is not possible to have the original Goals of Care Designation order with the resident then a photocopy of the most recent Goals of Care Designation order may be relied upon to guide treatment. The GCD order photocopy must have a notation stating “true copy of the current Goals of Care Designation order for this patient” with the staff member’s signature, date and printed name.
Which team member is responsible for making a GCD order photocopy?
A regulated health care provider such as an RN or LPN who prepares other documentation (client list, medication administration records) that accompanies the resident should also prepare the Green Sleeve or GCD order. Follow local procedure for documentation.
When might the resident’s GCD order be needed on an outing?
Any event where EMS is called would require referencing the residents’ most current GCD order. Potential examples include a choking or airway event, a fall, a change in level of consciousness or an allergic reaction.
If EMS is called and the resident is transported to hospital, what do I do with their Green Sleeve/GCD order?
The resident’s Green Sleeve or GCD order should be given to EMS clinicians to accompany the resident to hospital.
If an emergency occurs on an outing, who do I tell? What should be documented?
Follow your local procedure that includes contacting the facility/unit to advise them. Documentation should include a description of the event/circumstances, actions taken and the response/outcome i.e.: was the patient transported to hospital? Document that the Green Sleeve or GCD order was provided to EMS and accompanied the patient.
How do we keep the GCDs secure?
On an outing, Green Sleeves or GCD orders should be held in safekeeping with other confidential information in a secure but easily accessible location. A resident’s Green Sleeve should be treated in the same manner as other confidential client information taken on a recreational outing, e.g. medication administration records, allergies.
What do we do if the GCDs get lost, stolen or defaced/damaged?
Follow the policy for loss of confidential information. Report as a breach of privacy. Inform the care unit so that steps may be taken to have the GCD order rewritten. Complete an online RLS report (for AHS staff) and any additional required incident reports. Review circumstances of the loss to reduce the chance of reoccurrence.
Which GCDs are appropriate for advanced airway management such as supraglottic airway (SGA) device?
Advanced airways management, such as with SGA and intubation are considered life support measures usually used in critical care settings that provide ventilator support and as such are appropriate for patients with an R1 or R2 GCD. Patients with other GCDs (R3, M and C) are not expected to benefit from and /or do not desire ventilation support.
Basic airway support using oral pharyngeal airway and nasal pharyngeal airway devices can be appropriate for patients with any GCD when the intent is to temporarily support a patient’s airway and to align with a patient’s treatment goals.
See AHS intranet for Policy: HCS-202
A patient is admitted to acute care with information that they have a Green Sleeve however it is in their home/care facility. Reviewing previous/existing charts (electronically or hard copy) shows a previous GCD order of M1. How should the health care team proceed?
Without a confirmed current GCD order available, past GCD orders must be interpreted with caution. Past ACP documentation offers clues to informed decision making however previous GCD orders cannot be assumed as the patient’s current GCD order.
Upon admission the receiving care team should always validate the presence of a GCD with the patient. If no known GCD exists, a new GCD should be ordered by the patient’s most responsible health professional (MRHP) considering the patient’s current clinical status and their wishes and values.
Knowing how to act appropriately in the event of a medical emergency is crucial, since in the absence of a known GCD order, this patient defers to receive R1 care. It is important that the patient / substitute decision maker knows this possibility and this information may expedite an ACP GCD conversation and updated GCD order.
If the patient has capacity, and is able to communicate:
If the patient lacks capacity or is unable to communicate:
A patient with capacity and a non R1 Goal of Care Designation from an acute care site without cardiac catheterization facilities has been offered interventional cardiac procedure at an urban cardiac care center. Eg: Central Zone patient transported to Edmonton Zone. What steps should the referring healthcare team take to ensure the patient is appropriate for the procedure/transfer in light of the patient’s most current non R1 GCD?
This FAQ only applies to patients who have capacity and are their own decision makers.
When a patient with a non R1 GCD is referred for interventional cardiology procedure, it is essential that the referring healthcare team document a patient centered and clinically appropriate procedure plan should a cardiac arrest occur during the procedure.
First Step: Document on GCD order Special Clarifications (and Tracking Record) arising from conversation with patient. The referring physician first discusses with the patient potential risks and benefits of the procedure, especially in light of their current underlying medical condition and history. Cardiology or Interventional Cardiology may be consulted if the referring physician requires clarification of specific procedure risks. The purpose of this conversation is to understand and document the wishes of the patient regarding what, if anything, should be undertaken if procedure resuscitation is needed.
Some patients may direct that, aligning with their values and wishes, no attempt at resuscitation, no intubation should occur. The cardiology team may be uncomfortable performing an invasive procedure in that context, therefore this will need to be flagged and discussed with the cardiology team prior to the procedure being booked and the patient being transported (see Step 2).
Questions to consider: Why does the patient have non R1 GCD in the first place, and what does this say of the risk/benefit ratio of invasive cardiac procedures in such a patient? What are the underlying wishes of the patient with regards to their treatment goals? Is the patient accepting of short-term life supporting therapies or a short trial of care within an ICU?
The current non R1 GCD remains unchanged and a summary of the pre-procedure conversation is documented on both the patient chart and the GCD order under special clarifications. It is important to fully discuss and document the patient’s intentions and wishes in order to avoid potential future conflict (e.g., in case the patient loses capacity and their loved ones are having conversations with the care team regarding the patient’s future care).
Sample Special Clarifications charting
Risks and benefits of interventional cardiology procedure discussed with patient and their significant other. In the event of an arrest during the procedure patient is agreeable to CPR being initiated, possible intubation and is accepting of a short term trial in ICU. The patient sees “short term” as meaning 30 days and does not wish their life to be sustained or prolonged by medical interventions beyond that period of time if the patient’s treatment team recommends withdrawal of care or feels care is not clinically appropriate, is potentially harmful, or is futile.
Second Step: PRIOR to transport the referring health care team communicates GCD special clarifications with BOTH:
Cardiology/interventional cardiology staff and Paramedic transport team.
Prior to the actual procedure, the interventional cardiology physician is the most appropriate person to describe the procedure, the risks and address intubation, ICU etc. They will also review and obtain informed consent, reaffirm the patient wishes and reviewing the Goal of Care Designation/ plan of care including special clarifications. The interventional cardiology physician may decline to offer the procedure, in which case the referring physician would need to consider alternate courses of care for the patient.
Third Step: Post procedure the patient’s GCD order should be revisited. The patient’s values and goals may have changed and this change should be reflected in a new GCD order.
In a home care environment, what is the process for a health care professional to upload an electronic version of the client’s current GCD order and/or ACP GCD Tracking Record?
In the absence of a mobile printer/scanner a health care professional can take a photo of ACP/GCD documents using their AHS mobile device. The following guidelines are recommended:
Is a GCD order that has been generated in Connect Care with an e-signature valid?
For example, when a GCD order shows “signed electronically on Connect Care” some Paramedics have questioned whether an electronic GCD is valid without a hand written signature from the ordering physician or nurse practitioner.
A GCD order generated from Connect Care, like all medical orders, is considered valid. When the following phrase is seen “signed electronically in Connect Care” they can trust this information is valid just like a hand written signature would be. The information is stored within Connect Care on a secure AHS server. If authenticity required verification, anyone with access to Connect Care is able to view the document on the ACP/GCD navigator.
