Goals of Care Form Northern Territory: What Hospitals Need From You

The Gap Between Your Wishes and Clinical Orders

You might know exactly what you want — no machines, no resuscitation, comfort care only. But writing "I don't want to be kept alive on machines" in your Advance Personal Plan does not translate directly into a clinical order. Hospital staff need specific, actionable direction: which treatments, under which circumstances, with what boundaries.

In the NT Health Top End Region, that translation happens through the Goals of Care process. It is a structured clinical conversation between the treating team and the patient (or their decision-maker) that produces a documented set of treatment parameters the ward can follow.

How Goals of Care Work in the NT

Goals of Care conversations typically happen during hospital admission or when a patient's condition changes significantly. The treating doctor sits down with the patient or their substitute decision-maker and works through:

• What the current clinical situation is and what outcomes are realistic
• What the patient values most — prolonging life, maintaining independence, comfort, being at home
• Which specific treatments the patient consents to and which they refuse
• The overall treatment intent — curative, restorative, or comfort-focused

The outcome is documented in the patient's medical record and drives clinical decisions across the care team. It is not a standalone legal document — it is the clinical operationalisation of the patient's documented wishes.

The Advance Personal Plan Connection

Your APP feeds directly into the Goals of Care conversation. If you have recorded an Advance Consent Decision refusing specific treatments — mechanical ventilation, CPR, artificial nutrition — those refusals are binding and must be reflected in the Goals of Care documentation.

Advance Care Statements (your general values and preferences) guide the conversation without binding it. If you wrote that quality of life matters more than longevity, the treating team uses that to inform their recommendations, but they are not legally required to withhold every life-prolonging treatment.

The stronger and more specific your Advance Consent Decisions, the less interpretation is needed during the Goals of Care conversation. Vague wishes create ambiguity; specific refusals create clarity.

What Clinicians Actually Need

Hospital staff in the NT Health Top End Region need language they can act on. There is a difference between what most people write and what clinicians need to see:

What people write: "I don't want to suffer." What clinicians need: "I refuse mechanical ventilation if I have a condition with no realistic prospect of meaningful recovery."

What people write: "No heroic measures." What clinicians need: "I refuse cardiopulmonary resuscitation. I consent to palliative sedation if required for comfort."

What people write: "I want to die naturally." What clinicians need: "I refuse artificial nutrition and hydration if I am in a persistent vegetative state. I consent to all pain management including medications that may hasten death as a secondary effect."

This translation is the hardest part of advance care planning. Most people do not know the clinical vocabulary, and most clinicians do not have time to guide a distressed family through every permutation during a crisis.

When Your Decision-Maker Steps In

If you lose capacity and your APP includes healthcare authority for a decision-maker, that person participates in the Goals of Care conversation on your behalf. They are expected to make decisions consistent with your documented wishes and known values — not based on what they would want for themselves.

The decision-maker should come prepared to the conversation. That means having a copy of the APP, understanding what the Advance Consent Decisions say, knowing the maker's values from the Advance Care Statement, and being ready to answer the clinical team's questions about what the maker would have wanted in the specific situation.

Getting Prepared

The Goals of Care conversation goes better when you have done the clinical translation work before the crisis. Writing down your wishes in plain English, then converting them into specific treatment consents and refusals, gives your decision-maker and the hospital team a clear starting point instead of an emotional negotiation.

Our Northern Territory Advance Directive & Living Will Kit includes a Goals of Care worksheet that walks through common clinical scenarios and helps you translate your values into the specific language hospital staff can act on immediately.

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