Internal Medicine — Foundation of Discipline

F6 Discussing and establishing patients’ goals of care

Key Features:
- This EPA focuses on the documentation of a patient’s previous advanced directives and/or goals of care, and not those discussions that are directed at changes in goals of care (that is an EPA of the Core stage).
- This EPA includes discussing goals of care with a substitute decision-maker.
- This EPA may be observed in the clinical setting or in simulation (e.g. OSCE).

Assessment Plan:

Direct and/or indirect observation by supervisor

Use Form 1. Form collects information on:
- Category: stable acute condition; unstable acute condition; progressive chronic condition
- Setting: ambulatory; inpatient; simulation
- Substitute decision maker: yes; no
- Observer role: staff; senior resident

Collect 3 observations of achievement
- 1 from each category
- Not more than 1 in simulation setting
- At least 1 involves a substitute decision-maker
- At least 2 observations by staff
- At least 2 different assessors

Form

F1: Observation

Milestones

• COM 1.6. Identify patients who lack decision-making capacity and seek out their substitute decision maker

• COM 1.2. Optimize the physical environment for patient comfort, privacy, engagement and safety

• COM 1.4. Identify, verify and validate non-verbal cues

• ME 2.3. Discuss and clarify previously established advanced directives and goals or care

• ME 2.4. Discuss with the patient and family the degree of uncertainty inherent in all clinical situations

• ME 2.3. Work with patients and their families to understand relevant options for care

• COM 5.1. Document information about patients and their medical conditions in a manner that enhances intra- and interprofessional care

• P 3.1. Adhere to institutional policies and procedures relevant to advance directives and goals of care

• P 3.1. Apply the laws governing substitute decision making

Context Variables

• Setting (single-choice)
  • inpatient
  • ambulatory
  • simulation
• Category (single-choice)
  • stable acute condition
  • unstable acute condition
  • progressive chronic condition
• Observer role (single-choice)
  • staff
  • senior resident
• Substitute decision maker (single-choice)
  • no
  • yes

Requirements

• Collect 3 observations of achievement (minimum 3)
• 1 from each category (minimum 3)
  • Counted once per distinct Category
• No more than 3 in simulation setting (minimum 2)
  • Only counts when Setting is not simulation
• At least 1 involves a substitute decision-maker (minimum 1)
  • Only counts when Substitute decision maker is yes
• At least 2 observations by staff (minimum 2)
  • Only counts when Assessor kind is Faculty
• At least 2 different assessors (minimum 2)
  • Counted once per distinct Assessor