Person Centred Decision Making (PCDM): Advance Care Planning, Goals of Care Discussion and Health Care Consent Tool Kit

We know that patients want to have discussions about their current and future care, about their values and goals, and they want support and guidance from their healthcare practitioners. Over the past few years, these conversations have become increasingly complex. Changing terminology, with unclear definitions and outcomes, add to the confusion. This leads to common challenges and questions:


How can I engage my patients Advance Care Planning conversation and

Goals of Care conversations?

What is the difference between Advance Care Planning conversations and

Goals of Care conversations?

Shouldn’t other providers have these conversations with my patient?


This set of resources assist clinicians to engage patients in Patient-Centred Decision-Making conversations. It helps providers understand the conversations most appropriate to their practice setting and context.


   PCDM Framework & Definitions

 The Framework provides definitions of and the differences between Advance care  planning  (ACP), Goals of care conversations (GOCC) and consent.

   PCDM Clinician Algorithm

This algorithm directs the clinician to the right conversation.  In this model we identify that     SDMs for patients who are incapable of health care decisions also need preparation for future   decisions. For example, an SDM for a patient with dementia deserves to learn what   complications are expected in the future (swallowing difficulties, aspiration, infections) so that   they are more prepared to make decisions when needed.


   PCDM E-Learning Modules

   These five modules advance clinician’s knowledge & attitudes through:

  • Interactive case scenarios
  • Reflective questions
  • Videos of both simulated & real clinical encounters
   PCDM Quick Reference Guide

 This guide acts as a quick reference for a busy clinician, or, for administrators looking for a   summary of activities required for Patient-Centred Decision-Making.  The columns are linked   directly to the algorithm actions. The content is summarized from the e-learning modules.

   PCDM Implementation Guide 

 The purpose of the Guide is to help Ontario health care institutions implement person-centred   decision-making (advance care planning, goals of care conversations and consent). Using the   structure of quality improvement, the guide lists several resources for administrators and   clinicians to use to enhance awareness, desire for change, knowledge, ability and   reinforcement/capacity building.


For more information or further assistance, please contact Nav Dhillon –