Goal Setting and Interdisciplinary Support and Care Planning

Abstract

Abstract In this case, the importance of goal-setting and interdisciplinary support and care planning for people with advanced disease is discussed. Drawing on the practice of a hospice interdisciplinary breathlessness clinic, the case highlights issues such as the need to consider ‘concerns’ rather than just ‘problems’. The practice of person-centred goal-setting is explained, and evidence about patient experiences of this within palliative care is provided. Tips are given to help practitioners consider how to orientate their services so that establishing patient goals becomes the central focus for interdisciplinary care teams. Positive risk-taking and parallel planning are highlighted as ways to shift practice to improve the rehabilitative approaches in palliative care. This case includes video content from Lucy, who was known to hospice services due to her advanced chronic obstructive pulmonary disease. Lucy was keen for her experiences to be used in the education of healthcare professionals and the content is freely accessible via YouTube.