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Shared goals of care
Shared goals of care are when clinicians, patients and whānau explore patients’ values, the care and treatment options available and agree the goal of care for the current episode of care and if the patient deteriorates.
Shared goals of care is targeted advance care planning for an episode of care and comprises of a discussion and a decision.
We currently offer two shared goals of care plan templates
Shared goals of care for hospital admissions
Shared goals of care for aged residential care/long term care facilities.
These are nationally agreed templates that clinicians can use to record the shared goals of care discussions and document the shared goals of care decision for an episode of care.
The shared goals of care is the third stream of work in the patient deterioration programme (after New Zealand Early Warning Score and Kōrero mai).
The work is underpinned by the shared goals of care principles described here. The principles outline what is required for providers to have shared goals of care discussions with adult patients and their whānau.
Following the principles will ensure these important discussions occur with patients and whānau and are in line with their Te Tiriti o Waitangi responsibilities.
Why shared goals of care are important
When shared goals provide the basis for clinical treatment plans, there is less risk of a patient receiving unwanted or unwarranted treatments which is especially important if their condition deteriorates.
Evidence shows that engaging patients and whānau results in better health and care outcomes. The patient and whānau are more likely to feel valued and involved in their treatment, and their experience in hospital is better.
Providing excellent clinical care underpins clinicians’ values and drives their work ethic. Valuing shared goals of care discussions should become part of this care provision by all clinicians and links closely with choosing wisely. For some, this may mean a change in practice. It can be difficult and confronting to have these discussions but the outcomes warrant having them. There are guides and training that can help with these discussions, for example, the Serious Illness Conversation Guide.
Clinicians who communicate effectively, through sharing information and listening to seek understanding, can draw out patients’ values and preferences for care. This forms the basis for informed decisions about complex medical treatment options, should the patient’s condition deteriorate.
Read the case for change here. This document contains information about recognising and responding to acute deterioration and the importance of having shared goals of care discussions with patients and their whānau.
When shared goals of care discussions should take place
Current status
Shared goals of care are best explored when a patient is well, for example outpatient or when planning treatment or investigations are ideal settings to start these conversations.
However, during an unplanned episode of care shared goals of care discussions should take place early - before episodes of acute deterioration so everyone can engage fully without the pressures of an evolving clinical crisis. Discussions should be documented with all adult patients, ideally within 24 hours of admission and be reviewed and documented during the admission if there are changes in the patient’s condition. If patients have advance care plans and/or advance directives, these need to support the discussion.
The discussion may be straightforward and brief if the patient and whānau understand the clinical situation, and therefore may be appropriately discussed on admission or on a ward round. For others, the situation may be more complicated and involve several discussions before a decision can be made. Through listening, clinicians will be able to pick up subtle cues from patients and whānau that indicate more time may be needed for these discussions.
All Te Whatu Ora districts have engaged with shared goals of care for hospitals. Some have fully implemented, others have recently launched, while a third group are piloting in selected sites or are focussing on educating staff in the use of the Serious Illness Conversation Guide to support the shared goals of care kaupapa.
Shared goals of care for aged residential care is promoted by New Zealand Dementia Foundation as one of three evidence-based tools recommended to support high-quality, person-centred end-of-life and palliative care for our residents living with dementia mate wareware. The three-tool resource is available on the New Zealand dementia website.
Shared goal of care - frequently asked questions
This section provides clear, practical answers to common questions to support clinicians to use the shared goals of care process confidently and consistently.
Understanding shared goals of care
Roles and responsibilities
Advance care planning and shared goals of care
Timing and setting
Legal and ethical considerations
Clinical decision-making and review
Treatment options
Communication tools and support
Continuity of care
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Shared goals of care are clinical plans created through a structured, clinician‑led discussion with a hospital patient or aged residential care (ARC) resident, their whānau, and the healthcare team. They explore what matters most to the person, discuss available care and treatment options, and document the agreed goal of care for the current episode of care, including what should happen if the person deteriorates.
The shared goals of care process includes both:
A discussion, and
A clinical decision documented on the Shared Goals of Care Plan.
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Shared goals of care help ensure that treatment is wanted, warranted, and aligned with the person’s values. They support informed decision‑making, guide timely responses during deterioration, reduce unwanted or non‑beneficial interventions, and promote consistent, culturally responsive, person‑centred care across services.
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An episode of care is the defined period in which a person receives treatment and clinical oversight. For hospital patients, this is the duration of their admission; for ARC residents, it is the period they are living in the facility.
A new Shared Goals of Care Plan is required for each episode of care.
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Shared goals of care provide a structured way to understand what matters most to the person before a crisis occurs. By having these conversations early, clinicians can make timely, clinically appropriate decisions that reflect the person’s values and avoid unwanted or non‑beneficial treatments during deterioration.
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Yes. The principles of shared goals of care apply to all adult hospital patients and ARC residents, although how fully the process is implemented may vary across hospitals and facilities.
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Yes. In hospitals and ARC facilities that have implemented share goals of care, the Shared Goals of Care Plan replaces the older Do Not Attempt CPR (DNACPR) form.
The Shared Goals of Care Plan provides broader, person‑centred clinical direction - going beyond a CPR decision to outline the overall goals of care, which treatments are likely to benefit the person, and which may not be appropriate.
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Shared goals of care is a team-based process. The members involved may vary depending on the setting (hospital or ARC), the person’s condition, and the complexity of the decisions being made.
The team may include:
The treating clinician (senior doctor, GP, or nurse practitioner) – responsible for ensuring that the shared goal of care discussion occurs and is undertaken appropriately. They are accountable for the clinical decision and for signing the Share Goals of Care Plan. The treating clinician often leads the discussion, although in some settings – such as ARC – nurses or other trained team members may lead the discussion.
Nurses – prepare the person and whānau, contribute day‑to‑day clinical insights, and support the discussion. In some settings (e.g. ARC), nurses may lead the shared goals of care discussion.
Junior doctors – contribute clinical information, support assessment and discussions, and help prepare for the shared goals ofc are process under senior clinical guidance. In some organisations, junior doctors may be authorised to confirm a Goal of Care A. Always check your organisational policy.
Allied health professionals (e.g., social workers, occupational therapists, physiotherapists, cultural support workers) – contribute to the discussion and provide functional, psychosocial, cultural, and environmental insights that help shape the Shared Goals of Care Plan.
Specialist teams (e.g., palliative care, ICU, geriatric medicine) – involved when additional expertise is needed or decisions are complex.
While the treating clinician is responsible for finalising and signing the Shared Goals of Care Plan, the wider team’s perspectives help ensure decisions reflect the person’s values, goals, and overall clinical picture.
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The treating clinician (senior doctor, GP, or nurse practitioner) is responsible for ensuring that a shared goals of care discussion occurs and is undertaken appropriately. They lead the discussion in most settings, helping the person and their whānau understand the clinical context, treatment options, and likely outcomes. In some settings - such as ARC - nurses or other trained team members may lead the discussion, but the treating clinician remains accountable for the clinical decision.
The treating clinician is responsible for finalising and signing the Shared Goals of Care Plan, ensuring the decision is clinically appropriate, legally compliant, and aligned with the person’s values and preferences.
They must also review, update or develop a new Share Goals of Care Plan if the person’s condition or care setting changes.
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Nurses and allied health professionals play a vital role in shared goals of care. They bring day‑to‑day clinical, functional, psychosocial, and cultural insights that help ensure the Shared Goals of Care Plan reflects a holistic understanding of the person.
Their contributions may include:
Preparing the person and their whānau for shared goals of care discussions.
Contributing clinical, functional, and contextual insights that support decision‑making and help clarify concerns.
Advocating for the person’s values, preferences, and cultural needs.
Documenting relevant observations and discussions within their scope of practice.
Supporting follow‑up actions and helping ensure continuity of care.
In some settings - particularly ARC - nurses may lead the shared goals of care discussion, drawing on their close, ongoing relationship with the resident and their whānau.
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Nurses and allied health staff can document shared goals of care-related conversations on the discussion side of the Shared Goals of Care Plan or in the clinical record. Documentation should note who was present, key themes from the discussion, and any follow‑up actions.
Where possible, documenting on the Shared Goals of Care Plan is encouraged, as it keeps the information central, easy to locate, and readily accessible - particularly during deterioration events or when care is handed over to another team. Information recorded only in clinical notes may be harder to find.It is important that the discussion is communicated to the treating clinician responsible for finalising the shared goals of care decision.
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Organisational policies vary. Each hospital or facility sets its own rules about which clinicians are authorised to sign the Shared Goals of Care Plan, particularly when CPR or other resuscitation decisions are involved.
Key points to remember:
Always check your local policy on shared goals of care, CPR, and resuscitation documentation.
If you're unsure whether you're authorised to sign, seek guidance from your supervisor or clinical lead.
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Shared goals of care discussions should be documented on the Shared Goals of Care Plan wherever possible. Doing this ensures the information is easy to find, supports continuity of care during the current admission, and makes it readily accessible if the person is admitted in the future.
Documentation may also be recorded in the clinical notes; however, this information is harder to locate quickly during a deterioration event or transfer of care.
Whether documenting on the Shared Goals of Care Plan or in the clinical record, include:
Who was present
Key points from the discussion
Any follow-up actions required
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Advance care planning is person-led and generally future-focused. It may include creating an advance care plan, documenting an advance directive, or appointing an Enduring Power of Attorney (EPOA) to guide decisions if the person loses capacity across any future care setting.
Shared goals of care are clinician-led and specific to the current episode of care, whether in hospital or aged residential care. Shared goals of care discussions focus on what matters most to the person now, in the context of their current health status and potential for deterioration. Shared goals of care can be thought of as targeted advance care planning for this current episode of care.
Previous advance care planning conversations, documented advance care plans, advance directives, and any information from discussions with an activated EPOA should be reviewed and used to inform shared goals of care discussions and decisions.
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An advance care plan outlines what matters most to a person - now and in the future. A shared goals of care discussion focuses on treatment preferences for the current episode of care.
Before the shared goals of care conversation:
Review the person’s advance care plan and any advance directives (Section 6 of My Advance Care Plan and Guide or standalone directives).
Consider any stated values, goals, cultural needs, or treatment preferences that may guide current decision making.
If the person has capacity:
They should participate fully in the shared goals of care discussion.
Their advance care plan can support and inform their current preferences.
Any existing advance directives (e.g. DNACPR wishes) should be acknowledged and documented if the person intends them to apply to this episode of care.
If the person does not have capacity:
The advance care plan should be used to guide care, as it provides legally recognised documentation of the person’s values and preferences.
Clinicians are required to adhere to any valid advance directives (developed voluntarily by a person when they were competent and informed and they intended it to apply to the current situation).
Include the activated EPOA and whānau and other support people to ensure discussions reflect the person’s known values, preferences, and cultural needs.
Document the reason the person cannot participate in the shared goals of care process.
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Yes. Shared goals of care discussions often uncover a person’s values, preferences, and priorities. These insights can be used to initiate or update an advance care plan at the time of discharge or transfer.
Health care staff are encouraged to support patients or residents to complete or revise an advance care plan - especially if shared goals of care discussions have highlighted new or evolving goals or changes in their health situation.
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Shared goals of care discussions should take place early in the person’s care journey to support timely, appropriate decision-making.
Hospital: Ideally within the first 24 hours of admission, and reviewed during the admission if the person’s condition changes. Discussions may also occur in outpatient or pre-admission settings where appropriate.
ARC: On admission, during six-monthly care plan reviews, or when there is a significant change in the person’s health status.
Early discussions allow the person and their whānau to participate meaningfully and help the clinical team plan care that is wanted, warranted, and aligned with what matters most to the person should deterioration occur.
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A Shared Goals of Care Plan is valid for the duration of that episode of care. It should be reviewed and updated if the person’s clinical condition changes or if their values or treatment preferences evolve.
Hospital: The Shared Goals of Care Plan applies for the current admission and should be reviewed whenever there is a significant change in the person’s condition.
ARC: The Shared Goals of Care Plan applies for the period the person is living in the facility. It should be reviewed at least every six months during routine care plan reviews, or sooner if the person’s health status changes.
Regular review ensures the Shared Goals of Care Plan remains clinically appropriate and aligned with what matters most to the person.
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A Shared Goals of Care Plan decision is specific to a single episode of care and does not carry over to future admissions.
However, documentation from previous hospital or ARC shared goals of care can provide valuable context — offering insights into the person’s values, preferences, and clinical history that may inform the current conversation.
Always start a new shared goals of care plan for each episode of care to ensure the plan reflects the person’s current situation, goals, and priorities.
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If the person is unable to participate due to lack of decision-making capacity:
Refer to any existing advance care plan or advance directive to guide or direct care.
Consult with the activated EPOA for personal care and welfare, if one is in place, and/or speak with whānau to understand the person’s known values and preferences.
Document the clinical decision and rationale clearly, including the reason the discussion could not be held. Complete and sign the Shared Goals of Care Plan for the current admission and include any relevant supporting documentation in the clinical record.
All decisions must be clinically appropriate and aligned with legal and ethical standards. If the person regains capacity, the shared goals of care discussion should be revisited with them directly.
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Despite careful shared goals of care discussions, there may be situations where the person’s or whānau expectations differ from the clinical opinion of the healthcare team about what treatment is medically indicated.
In these situations:
Seek support from senior colleagues and refer to your organisation’s policies and procedures.
Document clearly the discussions that have occurred, including the clinical rationale and any concerns raised.
Remember that clinicians are not obligated to provide treatments that are not clinically indicated. For example, a person does not have a right to demand CPR if it is not medically indicated.
In hospital settings, consider consulting ICU, outreach, palliative care or older persons health teams — they are experienced in supporting these conversations and can help clarify appropriate care before a rapid response or acute deterioration occurs.
In ARC settings, involve the facility’s clinical lead or GP, and consider engaging the wider healthcare team, including nurse practitioners or geriatricians, if available. These teams can help navigate complex decisions and support respectful, person-centred care planning.
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Ideally, shared goals of care decisions are made through a conversation with the person and/or their whānau or legal decision maker. However, if the person is unable to participate due to lack of decision-making capacity and no support person is available, it may be necessary to document and sign the Shared Goals of Care Plan as a clinical decision. In this case, clearly record the reason why the discussion could not take place, and ensure the conversation is held with the appropriate people as soon as possible.
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Yes. The shared goals of care discussion can take place before the episode of care - for example, in a pre-admission clinic. Having the conversation ahead of time often leads to calmer, more considered discussions where patients and whānau can participate more fully.
If the discussion is held before admission, it’s important to ensure:
Permission has been sought to initiate the conversation.
Patients and whānau are supported before, during, and after the process.
Appropriate support people are present, including cultural or spiritual advisors if needed.
Cultural needs are acknowledged and respected.
Facilities are appropriate - outpatient settings like pre-admission clinics often offer more privacy and dignity than inpatient wards, which can better support meaningful conversations.
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Not necessarily. The depth and scope of the shared goal of care conversation should be guided by clinical context and patient factors. The CPR Decision guide for shared goals of care discussions provides a helpful framework to determine when a full shared goals of care conversation is appropriate.
If the patient is not at risk of deterioration during this admission and has no serious underlying co-morbidities, a brief, focused discussion may be sufficient.
However, if the patient is at risk of deterioration, has complex health needs, or if CPR is not clinically indicated or unlikely to be beneficial, a comprehensive shared goals of care conversation is recommended.
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No. A Shared Goals of Care Plan is a clinical tool used to guide decision-making for a specific episode of care. It reflects a conversation between the healthcare team and the person (or their legal decision maker), with input from whānau, about what care is appropriate, wanted, and warranted in the current context.
An advance directive is different: it is a legal document created by an individual to express their treatment preferences for future situations in which they may lack capacity. If a valid advance directive applies to the current clinical situation, it must be followed and the shared goals of care decision should reflect it.
In most circumstances, a valid advance directive cannot be overridden by a shared goals of care decision.
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Shared goals of care supports clinical decision-making but does not replace clinical judgement. If the person’s condition has changed or you have concerns about the appropriateness of the documented shared goals of care decision, it should be reviewed in line with clinical protocols and judgement.
If the shared goals of care decision no longer reflects the current clinical situation, a new decision should be discussed, agreed, and documented. The previous Shared Goals of Care Plan must be clearly crossed out (if paper) or updated (if electronic), with the rationale for the change recorded.
However, if the shared goals of care decision reflects a valid advance directive that applies to the current clinical situation, it cannot be overridden. Clinicians are legally and ethically required to follow valid advance directives.
All decisions should be made in partnership with the person (or their legal decision maker if they lack capacity), and whānau and guided by clinical appropriateness, legal frameworks, and the person’s expressed values and preferences.
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An EPOA for personal care and welfare becomes active only when the person has been assessed as lacking decision-making capacity and the EPOA has been legally enacted.
Once active, the EPOA should be included in shared goals of care discussions and can make decisions on the person’s behalf. Their role is to represent the person’s known values, preferences, and wishes - not to make decisions based solely on their own views. Any advance care plan should guide the conversation, and any valid advance directive relevant to the current situation must be followed.
It’s important to note that EPOAs:
Cannot refuse standard lifesaving treatment that is clinically appropriate.
Cannot demand treatments that are not medically indicated.
All decisions must align with clinical judgement, legal frameworks, and ethical standards. Clinicians should support EPOAs to understand the person’s clinical situation and ensure decisions remain person-centred and appropriate.
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If the person has decision-making capacity, their choices must be respected - even if whānau disagree. Whānau cannot override a competent person’s decision. Use tools like the Serious Illness Conversation Guide to support understanding and facilitate respectful dialogue.
If the person does not have capacity, decisions should be guided by any existing advance care plan and/or valid advance directive and made in partnership with the legally authorised decision maker (e.g. activated EPOA for personal care and welfare). In these cases, whānau input is important and helps provide an understanding of the person’s ascertainable preferences, but decisions must still be clinically appropriate and in line with legal and ethical standards.
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Shared goals of care should be reviewed regularly to ensure they remain clinically appropriate and align with the person’s current goals, values, preferences and circumstances. Examples include:
there was a time-limited decision to treatment
the person’s condition changes significantly
the person/whānau/legal decision-maker asks for a review of the discussion and decision
there is a transfer of care within the organisation (e.g. between hospital teams or wards)
At regular review intervals (e.g. six-monthly in ARC).
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A new Shared Goals of Care Plan should be created for each new episode of care. This includes:
On admission to hospital or ARC
When there is a transfer of care to another facility or provider (e.g. hospital to ARC, or between Health NZ providers, from ARC to hospital)
Shared Goals of Care Plans are not carried over between episodes of care. Even if the overall goal of care remains the same, escalation processes will differ across care settings. Regular review ensures plans remains clinically appropriate and aligned with the person’s current goals, values, preferences and care setting.
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A Shared Goals of Care Plan is valid only for the specific episode of care in which it was created. If a person is transferred to another setting - such as from hospital to aged residential care or vice versa - a new Shared Goals of Care Plan needs to be created. Even if the overarching goal of care remains the same (e.g., comfort-focused care), the escalation processes and available interventions will differ between settings.
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If the person’s condition has changed or the shared goals of care decision seems inappropriate, escalate to the treating clinician - this may be a doctor in hospital, or a GP or nurse practitioner in ARC.
If a change is made, the previous Shared Goals of Care Plan must be clearly crossed out (if paper) or updated (if electronic), and the new decision documented with the rationale.
Valid advance directives applicable to the situation must still be followed and cannot be overridden.
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A – Curative/restorative with CPR. Treatment aims to prolong life. Full treatment and ICU-level interventions.
B – Curative/restorative care without CPR. Treatment aims to prolong life. May include ICU and resuscitation-level interventions as appropriate.
C – Quality of life-focused care; symptom control and well-tolerated treatments. No CPR.
D – Comfort while dying; end-of-life care guided by Te Ara Whakapiri. No CPR.
Click to view the hospital shared goals of care form relevant to your emergency escalation approach (777/MET/RRT)
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The goals are aligned with the Hospital Shared Goals of Care Plan but adapted for ARC settings:
A – Restorative care with CPR and hospital transfer.
B – Restorative care without CPR; hospital transfer may be appropriate.
C – On-site active care to enhance quality of life; not for hospital transfer unless comfort cannot be maintained. No CPR.
D – Comfort while dying; no CPR or hospital transfer (unless comfort cannot be maintained). End-of-life care guided by Te Ara Whakapiri.
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No, but it’s a helpful framework. It supports compassionate, structured conversations and is endorsed nationally.
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Shared goals of care and serious illness conversations can be confronting, and your organisation may have trainers who can provide appropriate training. You can also see the Tō tātou Reo advance care planning website for more details of the Aotearoa guide and some online training (e-learning) modules. (Visit Serious illness conversations — Advance care planning)
Most organisations also have a variety of existing processes to provide employee support, such as the Employee Assistance Programme (EAP).
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If a clinician avoids these types of discussion, it is possible they feel ill equipped and unprepared to have them. Find out locally who provides training in serious illness conversations and consider running group training together.
Consider viewing these discussions as a quality marker in morbidity and mortality sessions or peer review to raise colleagues’ awareness.
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Acknowledge this is not the ideal environment for the discussion and offer apologies.
Seek an alternative space for either the patient and whānau or the adjoining patients if possible, during the discussion and decision time.
Ask a colleague to join you – they may be able to deal with potential distractions like catering staff or other patients and whānau without you leaving the discussion.
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Documenting shared goals of care discussions on the Shared Goals of Care Plan helps ensure the information is easy to locate, consistent, and readily accessible during the current admission and in any future admissions.
The form provides a single, central place where the goals of care discussion and decision can be quickly retrieved - which is especially important during a deterioration event or when care is handed over to another team.
While documenting in the clinical record is acceptable, information recorded in clinical notes can be harder to find.
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Yes. Shared goals of care supports continuity of care across settings. Key shared goals of care discussions and the documented decision should be included in discharge summaries and transfer documentation so the receiving team understands what was discussed and agreed.
A new episode of care will require a new shared goals of care decision, but previous shared goals of care discussions and decisions provide valuable context about the person’s values, preferences, and clinical history. Using secure communication channels helps ensure this information is transferred safely and supports coordinated, person‑centred care.
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Shared goals of care in ARC supports proactive care planning aligned with the resident’s values. Discussions should occur on admission, during reviews, or when health changes. Documentation must be clear, culturally safe, and shared across settings if transfer occurs.
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Yes. Providing the hospital with the resident’s Shared Goals of Care Plan at the time of transfer helps ensure care aligns with the person’s values and preferences from the outset.
Include:
the completed Shared Goals of Care Plan
any relevant clinical notes or supporting documentation
information on recent discussions with the resident and whānau
Use secure communication methods whenever possible. Clear, early sharing of this information allows hospital teams to respond quickly and appropriately during the new episode of care.
You can also download this content as a Word document [add doc link when finalised]
Get in touch
Please let us know if you require any assistance. Our email is acp@tewhatuora.govt.nz
Resources available
Podcast: The semantics of CPR
Factsheet: capabilities for recognising and responding to acute deterioration
Clinical governance recommendations
Note: A clinical governance committee is needed to provide oversight and expert advice about the safety, effectiveness, and ongoing improvement of the recognition and response system.
This paper is intended for project teams responsible for implementing and improving recognition and response systems in New Zealand hospitals. It briefly outlines recommendations for ongoing clinical governance of recognition and response systems.
Stakeholder assessment template
Note: This template forms a part of the patient deterioration preparation and implementation guide. It can be used to document the level influence and interest your stakeholders have in the success of the project, then identify how you will engage with them
Shared goals of care using the serious illness conversation guide e-learning module
If you do not have a Health NZ e-learning account, you will need to create one to access these materials. Health NZ e-learning log in instructionsPlease note: Health care staff who are not employed by Health NZ can request a Health NZ e-learning account to access this course.
Related Resources
ARC-specific resources
It has never been more important to understand what matters most to your residents and their whānau, to be prepared for any future change in their health and to know what their priorities, concerns and preferences might be if their health did deteriorate.
In addition to the resources elsewhere on this webpage, we have developed some specific aged residential care resources to support you and other staff working in aged residential care (ARC) to use the Serious Illness Conversation Guide and capture any shared goals of care for residents
When to have shared goals of care discussions
Shared goals of care discussions are part of the overall assessment and planning for residents.
We recommend that you aim to have this discussion during the first two or three weeks of a resident’s stay as part of the admission process and development of their long-term plan.
The discussion is not a one-off discussion. It would be ideal to revisit the shared goals of care decision with the resident and whānau as part of regular care plan reviews or where there has been a significant change in the resident’s health.
We recommend that shared goals of care discussions are led by a senior clinician after they have gathered as much information as possible from the wider care team working with the resident.
Demonstration video
We have created a 25-minute-long video demonstrating how to prepare for, talk about and capture goals of care for your residents. This demonstration video is just one example of a shared goals of care discussion. We created this example using Zoom as we were under COVID level 3 at the time of recording. Ideally these discussions would take place in person.
We have used the Aotearoa Serious Illness Conversation Guide to support this shared goals of care discussion.
This video is a supplement to the Serious Illness Conversation Guide training video and we recommend that before you watch this ARC video that you watch the Serious Illness Conversation Guide communications skills training video and have copies of the Aotearoa Serious Illness Conversation Guide and ARC shared goals of care form in front of you.
ARC shared goals of care form
We have created an ARC-specific shared goals of care form, to capture the discussion and document the shared goals of care for residents.
Shared goals of care aged residential care form (fillable PDF)
There are two fact sheets that will help you with this form:
Fact sheet for nurses and Allied health workers supporting shared goals of care decisions (PDF)
The form is a fillable PDF you can add your facility’s logo to. If you do use it and want to save it as a final version that cannot be edited, you will need to 'Print to PDF' before you save or share it. See the PDF below for instructions on how to do that.