Person-Centred Decision-Making: A Resource for Healthcare Providers

In Ontario, advance care planning, goals of care, and treatment decisions and informed consent are situated along a person-centred decision-making continuum. Person-centred decision-making gives patients and their care partners a voice in the design, delivery and evaluation of their care. This approach to care helps improve the patient experience and the quality and safety of care. It also delivers better outcomes and greater value through wiser use of resources.

Goals of Care Conversations

These are discussions between a provider and a capable patient (or an incapable patient’s substitute decision maker) that focus on:

• ensuring the patient understands the serious (often incurable and progressive) nature of their illness
• helping the healthcare provider to understand the patient’s values and the goals they have for their care
• the current clinical context

Outcome: Patients and healthcare providers have a shared understanding of the patient’s goals for their care. These goals are then used to support treatment decisions and informed consent.

Having a Goals of Care Conversation

1. Illness understanding: Confirm the patient’s understanding of their diagnosis and prognosis.
2. Elicit values and define goals:
   • Explore the patient’s past experiences, hopes, values and priorities.
   • Discuss the patient’s perception of quality of life.
   • Ask the patient to describe the goals they have for their future care.
3. Questions: Encourage questions and resolve outstanding concerns.
4. Document: Document the identified goals of care. Use these goals to inform the treatment decisions that need to be made and the resulting development of a treatment plan with the patient.
5. For more details and conversation starters, see Approaches to Goals of Care Conversations.

Advance Care Planning Conversations

Advance care planning involves the patient (while capable):

• confirming their future substitute decision maker (SDM) by accepting the automatic SDM or assigning a power of attorney for personal care
• discussing their wishes, values and beliefs with their SDM for their future care

Treatment Decisions and Informed Consent

Informed and contextualized treatment decisions are made by the patient (or their substitute decision maker [SDM] if incapable).

Consent requires providing the patient with information about the nature of treatment, benefits, risks, side effects, alternative courses of action, and likely consequences of not receiving treatment.

The conversation is focused on the current clinical (treatment-oriented) context.

Examples of treatment decisions in multi-care kidney clinics include:

• whether to have dialysis or conservative care
• if dialysis, which modality and location (home or hospital)
• if hemodialysis, which vascular access, when to start dialysis
• whether to be assessed for transplant and if eligible
• code status

During goals of care (GOC) and treatment decision conversations, it is important that the patient or their SDM do most of the talking. They should be making the decisions and not the health provider, whose task should be education and clarification of what the patient truly wants, given their circumstances.

The development of a treatment plan may take multiple appointments and conversations. Education sessions should be considered as an ongoing process with lots of scope for changes in both GOC and the treatment plan. For this reason, we recommend that GOC and the treatment plan be revisited annually for patients in both multi-care kidney clinics and dialysis. Conversations should also be revisited after any major change in health status.