Electronic Documentation of Goals of Care Designation Discussions Among Alberta-based Geriatric Patients

Goals of Care Designations are important medical orders that are used to determine the appropriate level of medical intervention for individuals in the event of life limiting illness. Canada has an aging population and individuals are living with higher levels of chronic illness and comorbidity. As patient autonomy increases, it has become increasingly important to have accurate and up-to-date documentation of a patient's medical wishes for life sustaining care.

This was a retrospective chart review of 400 randomly selected patients 65 years of age and over, seen at the University of Alberta Hospital outpatient clinic for Comprehensive Geriatric Assessment from July 1, 2022 to June 30, 2023. We extracted the frequency of Goals of Care Designation (GCD) documentation determined by historical data available within selected patient charts, the setting of each discussion, and the specialty of each provider completing Goals of Care documentation.

Only 49.3% (197/400) of patients had any documented GCD entered on their electronic medical record (EMR). Of the 356 completed GCD forms, 267 (75%) were completed in an inpatient setting; the majority of GCD forms were completed by a specialist in Internal Medicine (39.89%, n=142) or Family Medicine (37.64%, n=134).

Our study revealed that less than half of patients had any GCD documentation in the provincial EMR. As accurate Goals of Care documentation is vital to patient care and autonomy, every opportunity should be taken by health-care professionals to complete this essential documentation.