How do we deal with multiple goals for care within an individual patient trajectory? A document content analysis of health service research papers on goals for care

Abstract

Objectives: Patients with complex long-term needs experience multiple parallel care processes, which may have conflicting or competing goals, within their individual patient trajectory (iPT). The alignment of multiple goals is often implicit or non-existent, and has received little attention in the literature.

Research questions: (1) What goals for care relevant for the iPT can be identified from the literature? (2) What goal typology can be proposed based on goal characteristics? (3) How can professionals negotiate a consistent set of goals for the iPT?

Design: Document content analysis of health service research papers, on the topic of 'goals for care'.

Setting: With the increasing prevalence of multimorbidity, guidance regarding the identification and alignment of goals for care across organisations and disciplines is urgently needed.

Participants: 70 papers that describe 'goals for care', 'health' or 'the good healthcare process' relevant to a general iPT, identified in a step-wise structured search of MEDLINE, Web of Science and Google Scholar.

Results: We developed a goal typology with four categories. Three categories are professionally defined: (1) Functional, (2) Biological/Disease and (3) Adaptive goals. The fourth category is the patient's personally defined goals. Professional and personal goals may conflict, in which case goal prioritisation by creation of a goal hierarchy can be useful. We argue that the patient has the moral and legal right to determine the goals at the top of such a goal hierarchy. Professionals can then translate personal goals into realistic professional goals such as standardised health outcomes linked to evidence-based guidelines. Thereby, when goals are aligned with one another, the iPT will be truly patient centred, while care follows professional guidelines.

Conclusions: Personal goals direct professional goals and define the success criteria of the iPT. However, making personal goals count requires brave and wide-sweeping attitudinal, organisational and regulatory transformation of care delivery.

Figure 1

The health services involved in ‘Alfred's’ individual patient trajecotory (iPT) and the main focus of care according to the electronic medical record at the hospital and with the general practitioner, Tromsø Norway, 2012.

Figure 2

Goal framework I, inspired by Verbrugge and Jette.

Figure 3

Goal framework II—The personalised hiearchical healthcare goal model.