How should I document a recommendation for a family discussion to determine goals of care for an elderly patient with failure to thrive, considering their values, preferences, and best interests, to decide between comfort care and full treatment?

Documentation of Goals of Care Discussion for Elderly Patient with Failure to Thrive

Document this as: "Family meeting held to discuss goals of care. Patient's current clinical status, prognosis, and treatment options (including comfort-focused care vs. full medical intervention) reviewed with family. Surrogate decision-maker identified. Patient values and preferences explored. Plan for [specific decision] based on patient's stated values. Will reconvene in [timeframe] to reassess." 1

Essential Documentation Components

1. Patient's Clinical Status and Prognosis

• State the headline clearly: Document one succinct sentence summarizing the patient's condition and trajectory (e.g., "Patient with progressive functional decline, recurrent hospitalizations, and multiorgan dysfunction consistent with end-stage failure to thrive") 1, 2
• Record specific functional impairments: inability to perform activities of daily living, cognitive status, nutritional status, and weight loss 2, 3
• Note that failure to thrive in elderly patients represents a "key decision point" that warrants explicit discussion of end-of-life care options 2

2. Surrogate Decision-Maker Identification

• Document by name and relationship: "Identified [name], [relationship] as healthcare proxy/surrogate decision-maker" 1
• Explicitly state: "Surrogate instructed that their role is to help us understand patient's values, goals, and preferences to make decisions the patient would have made for themselves" 1
• If no formal healthcare proxy exists, recommend completing medical power of attorney documentation 1

3. Patient Values and Preferences Explored

Document specific questions asked and responses received 1:

• "Asked family what patient would consider an unacceptable quality of life"
• "Discussed whether patient previously expressed preferences about life-sustaining treatment"
• "Explored what gives patient's life meaning and purpose"
• Record any previous advance care planning discussions 1

4. Treatment Options Presented

Frame as a choice, not a recommendation initially 1:

• Document: "Explained that different families make different choices in this situation; there is no single 'right answer'" 1
• Record specific options discussed:
  • Full treatment: "Discussed pursuing all interventions including ICU care, intubation, CPR, with understanding that outcomes may not align with patient's values given [specific clinical factors]" 1
  • Comfort-focused care: "Discussed transitioning to comfort measures focusing on symptom management, dignity, and quality of remaining time, with option of hospice referral" 1, 4
  • Selective treatment: "Discussed continuing current treatments but not escalating to ICU/intubation" 1

5. Benefits and Burdens Discussed

Document the proportionality discussion 1:

• "Reviewed that full treatment may include: frequent hospitalizations, invasive procedures, ICU stays, with potential outcomes of [specific functional limitations]"
• "Discussed that comfort care focuses on relief of suffering, maintaining dignity, and optimizing quality of remaining time"
• "Explained time-to-benefit considerations given patient's limited life expectancy" 1

6. Family Understanding Assessed

• "Asked family to explain back their understanding of patient's condition" 1
• "Family demonstrates understanding that [specific prognostic information]" 1
• Document any misunderstandings corrected 1

7. Decision-Making Preferences

Critical to document the family's preferred role 1:

• "Family prefers to share decision-making responsibility with medical team" OR
• "Family prefers to make decisions independently after receiving information" OR
• "Family prefers medical team make recommendations based on patient's values"

8. Emotional Responses Acknowledged

• "Family expressed [grief/fear/uncertainty]. Provided empathic response and supportive silence" 1
• "Reassured family that patient will not be abandoned regardless of treatment choice" 1

9. The Recommendation or Decision

Document the specific plan 1:

• If decision made: "Based on patient's stated values of [specific values], family and team agree to pursue [comfort care/full treatment/selective treatment]"
• If decision deferred: "Family requests time to process information. Will reconvene [specific date/time]"
• "Palliative care consultation requested to assist with [symptom management/goals clarification/conflict resolution]" 1

10. POLST/MOLST Documentation

If comfort care chosen, complete immediately 1, 4:

• "POLST form completed: DNR/DNI, comfort measures only"
• "Ensured documentation accessible across all care settings" 1
• Document preferred location of death if discussed 1

Specific Documentation Template

Use this structure 1, 5:

FAMILY MEETING - GOALS OF CARE DISCUSSION

Date/Time: [timestamp]
Participants: [names, relationships]

CLINICAL STATUS: [One-sentence headline of patient's condition and prognosis]

SURROGATE DECISION-MAKER: [Name, relationship] identified as healthcare proxy. Role of surrogate decision-making explained.

PATIENT VALUES EXPLORED: Family reports patient previously stated [specific values/preferences]. Patient would consider [specific conditions] unacceptable quality of life.

OPTIONS DISCUSSED:
1. Full treatment including ICU/intubation/CPR
2. Comfort-focused care with hospice
3. [Other options if applicable]

BENEFITS/BURDENS: Discussed that full treatment may prolong life but with [specific functional limitations]. Comfort care focuses on symptom relief and dignity.

FAMILY UNDERSTANDING: Family verbalizes understanding that [key prognostic points].

DECISION: Based on patient's values, family and team agree to [specific plan].

NEXT STEPS:
- [Specific interventions]
- [Palliative care consult if applicable]
- [POLST completion if applicable]
- [Follow-up timeframe]

EMOTIONAL SUPPORT: Acknowledged family's [emotions]. Reassured continued support regardless of decisions made.

Common Documentation Pitfalls to Avoid

• Never document vague statements like "goals of care discussed" without specifics 1
• Never fail to identify a specific surrogate decision-maker by name 1
• Never document only your recommendation without recording the family's understanding and preferences 1
• Never delay POLST completion if comfort care is chosen - complete during the same encounter 1, 4
• Never document the discussion without a specific follow-up plan and timeframe 5

When to Involve Palliative Care Specialist

Document consultation request when 1:

• Family having difficulty engaging in advance care planning
• Conflict between patient/family wishes and medical recommendations
• Uncontrolled symptoms requiring specialized management
• Patient/family distress despite support interventions