Goals of Care

Goals of care is a structured, collaborative process of communication between clinicians, patients and, where relevant, family members or surrogate decision-makers. It aims to establish an individualised care plan that aligns medical treatment with the patient's values, priorities and preferences.

It matters most in serious, life-limiting or progressive illness. Treatment decisions there carry substantial implications for quality of life and, in some cases, length of life.

Structured goals of care conversations are an essential component of high-quality care, though frequently underutilised and delayed. They apply across a broad range of settings, from chronic progressive conditions to acute, critical illness.

The underlying principle is that treatment decisions should be guided by what matters most to the individual patient. They should not default to a uniform, maximal intervention approach regardless of clinical context and patient preference.

Principles and framework

• Goals of care discussions are distinct from, though closely related to, advance care planning. Advance care planning is the broader, ongoing process of discussing and documenting an individual's future care preferences, ideally well before a crisis.
• They are also distinct from specific treatment decisions. Cardiopulmonary resuscitation status is one component, though not the only one, of a goals of care conversation.
• Goals of care are the overarching framework within which specific decisions are made. This keeps each decision consistent with the individual's broader values and priorities, rather than made in isolation.
• A structured approach to goals of care conversations generally has four parts.
  • Establish what the patient already understands about their condition and prognosis. Where the patient lacks capacity, ask the surrogate decision-maker.
  • Explore values, priorities and what matters most. This includes views on acceptable versus unacceptable outcomes, and the relative importance of length of life versus quality of life and functional independence.
  • Give clear, honest information on the likely trajectory and the realistic benefits and burdens of the treatment options.
  • Develop a care plan collaboratively that reflects this shared understanding.
• Hold these conversations proactively, before a crisis forces urgent decision-making under pressure.
• Revisit and update them as the clinical situation evolves and the patient's views change. Goals of care are a dynamic, ongoing process, not a single, fixed decision.

• Clinical triggers for a goals of care conversation:
  • diagnosis of a serious, life-limiting illness
  • significant clinical deterioration or a change in prognosis
  • transition between care settings, including hospital admission (particularly for a frail or significantly comorbid patient) or transfer to a new care facility
  • in the acute setting, any significant treatment decision with substantial implications, such as intensive care admission, major surgery in a frail or significantly comorbid patient, or starting a new, burdensome treatment for a progressive condition
• Patients and families understandably find these conversations difficult.
• Common barriers include clinician discomfort or lack of confidence, and time constraints in busy practice.
• Another barrier is deferring discussion until a crisis makes it unavoidable. It is then conducted under significant time pressure and emotional distress. This limits its quality and the patient's ability to participate meaningfully.
• A further barrier is a mistaken clinician assumption about what a patient would want, made without directly and explicitly exploring it with them.
• Cultural, religious and individual preferences vary on the desired level of involvement in decision-making. Some patients and families prefer a more directive approach from the clinical team. Others prefer a more collaborative or autonomous role.
• Specific values and priorities also vary, including acceptable outcomes and the relative importance of different aspects of care. Use a sensitive, individualised approach, not a standardised, one-size-fits-all structure.

• Goals of care is a communication and care planning process, not a diagnostic entity.
• Careful, ongoing assessment of the patient's current condition, likely trajectory and prognosis is an essential foundation for an informed, meaningful conversation.
• Honest prognostic information, delivered sensitively, allows the patient and family to make genuinely informed decisions aligned with their values.
• Assess decision-making capacity, following relevant local legal and professional frameworks, wherever there is any question about it.
• Identify the appropriate decision-maker clearly. This is the patient where capacity is retained. Where capacity is significantly impaired, it is an identified surrogate decision-maker, whether formally appointed or identified by the local legal hierarchy.
• This ensures the conversation and resulting care plan reflect the views of the person whose values should guide the decision.

• Structured, proactive goals of care conversations are the core intervention. An appropriately trained clinician should conduct them with adequate time, in a private, unhurried setting.
• Specific communication frameworks, widely taught and used across palliative and broader clinical practice, support a consistent, full and compassionate approach.
• Document the outcome clearly and fully. Record the agreed care plan and the underlying values and priorities that informed it.
• Documentation makes the information accessible to the broader clinical team. It guides care during any subsequent acute deterioration, when the original conversation may not be available to revisit in real time.
• Specific treatment decisions are made within the framework set by the goals of care conversation. They include cardiopulmonary resuscitation status, escalation to intensive care, and specific burdensome treatments for a progressive underlying condition. This keeps them consistent with the patient's expressed values and priorities.
• Reassess and revisit goals of care over time as the clinical situation evolves. This is an essential component of longitudinal management. A patient's views and priorities may change as the illness progresses and as they gain experience and understanding of its impact on their life.
• Integrate specialist palliative care early where available and appropriate. It adds expertise and support for complex or challenging conversations, plus symptom management and psychosocial support. It complements the ongoing role of the primary treating team.