How should I conduct a goals-of-care discussion with a patient (or surrogate) to align treatment with their values?

How to Conduct Goals-of-Care Discussions

Begin by asking the patient or surrogate what they already understand about the medical situation before providing any new information, then elicit the patient's values and goals through patient-focused questions, engage in back-and-forth deliberation about treatment options, and provide a clear recommendation that integrates medical facts with the patient's values. 1

Prepare and Set the Stage

• Avoid all medical jargon when communicating—terms like "NPO," "pulse ox," "intubation," and "hypertension" are frequently misunderstood by patients and families. 1
• Ask patients/surrogates whether they are confused by any terms used and define any words they do not understand. 1
• Provide emotional support by acknowledging strong emotions and expressing empathy, as fear and anxiety impair the ability to process information and make decisions. 1

Assess Current Understanding First

• Start by asking: "Can you tell me what you've heard about what is going on?" rather than delivering an opening monologue. 1
• This allows you to gauge comprehension level and tailor your information delivery accordingly. 1
• Use the "Ask-Tell-Ask" approach: ask permission to discuss prognosis, convey the information, then assess understanding. 1

Explain Medical Condition and Prognosis Clearly

• Discuss key prognostic domains including risks of short and long-term mortality, ventilator dependence, functional impairment, and cognitive impairment. 1
• Recognize that patients and surrogates often have overly optimistic expectations about prognosis, and clinicians frequently fail to clearly convey important prognostic information. 1
• Ask the patient/surrogate to explain the medical facts in their own words, then correct any misunderstandings or misperceptions. 1

Elicit Patient Values, Goals, and Preferences

• When patients can communicate, even if they lack decision-making capacity, elicit values and preferences directly from them—do not assume they are too confused or sedated to contribute. 1
• Obtain and review advance directives, POLST/MOLST forms, and durable power of attorney documents. 1
• Communicate with family members, primary care providers, or other caretakers to understand any prior oral expressions of values and preferences. 1

When Working with Surrogates

• Ask patient-focused questions such as: "If your father could speak for himself right now, what do you think he would choose?" 1
• This is critical because surrogates often mistakenly use their own values rather than the patient's values when making choices. 1
• Seek input from family and friends to understand the patient's core values, even if specific wishes were never expressed—loved ones often have reasonable understanding of core values. 1

Explain Treatment Options Without Jargon

• Provide clear and complete information regarding the range of medically appropriate treatment options, including risks and benefits of each option. 1
• Present options within the boundaries of accepted medical practice—you are not obligated to provide interventions outside accepted standards of care. 1

Engage in Active Deliberation

• Participate in back-and-forth discussions of pros and cons of various diagnostic and therapeutic options. 1
• Elicit and discuss openly the thoughts and concerns of the patient, surrogate, family members, and healthcare team. 1
• Through open dialogue, both parties can correct misunderstandings—not only can you correct the family's misperceptions, but the family can correct yours. 1

Provide a Clear Recommendation

• Offer a recommendation based on both medical facts and the patient's values, and explain the rationale underlying it. 1
• Clearly articulate which recommendations are based solely on medical facts and experience versus which are based on personal beliefs and values. 1
• Do not underestimate the weight of your recommendations—ensure you do not inadvertently pressure or intimidate patients as choices are made. 1
• Your recommendation should account for the patient's values, goals, and preferences while including your clinical judgment about what options are medically appropriate. 1

Critical Pitfalls to Avoid

• Never assume physical weakness equals lack of decision-making capacity—post-critical illness weakness does not indicate inability to make decisions. 2
• Do not force a single decision-making model on all patients—preferences vary significantly and change over time based on the clinical scenario. 1
• Avoid beginning with an "opening monologue" of information—this prevents you from gauging baseline understanding and tailoring your approach. 1
• Do not delay implementing a patient's wishes while trying to convince a disagreeing surrogate, as this violates patient autonomy. 2