Goals of Care Communication: A Self-Study Guide

Why These Conversations Are Hard — And Why They Matter

Goals of care conversations — discussing what matters most to a patient as their health changes, and what treatment approaches align with those priorities — are consistently among the most avoided conversations in healthcare. Research shows these conversations often happen too late, frequently only in a crisis, when a patient may no longer be able to participate meaningfully. Having them earlier, while a patient can engage fully, improves both the quality of care received and family experience afterward, regardless of outcome.

The Serious Illness Conversation Guide Approach

Developed by Ariadne Labs, the Serious Illness Conversation Guide is one of the most widely studied and adopted frameworks for these discussions. Its core structure: set up the conversation, assess understanding and preferences, share prognosis honestly but compassionately, explore key topics (goals, fears, function, tradeoffs), and close by summarizing and making a recommendation aligned with what you heard. The guide is designed to take 15–20 minutes and works across a range of serious illness contexts, not just imminent end-of-life.

Key Questions That Open the Conversation

• "What is your understanding of where you are with your illness right now?"
• "How much information about what's likely to be ahead would you like from me?"
• "What are your most important goals if your health situation worsens?"
• "What are your biggest fears and worries about the future?"
• "What abilities are so critical to your life that you can't imagine living without them?"
• "If you become sicker, how much are you willing to go through for the possibility of more time?"

These questions work because they start from the patient's understanding and values rather than leading with clinical information the patient hasn't asked for yet.

Common Pitfalls to Avoid

• Leading with statistics before understanding what the patient wants to know. Some patients want detailed prognosis information; others explicitly don't. Ask first.
• Using euphemisms that obscure meaning. "Things aren't going the way we hoped" can be less clear than "The cancer has grown despite treatment" for a patient trying to make real decisions.
• Conflating "do you want everything done" with a real goals conversation. This framing forces a binary that doesn't capture what actually matters to most patients — comfort, time with family, avoiding a particular kind of suffering.
• Having the conversation only once. Goals of care can and do change as illness progresses; treat this as an ongoing conversation, not a one-time form to complete.

Navigating Family Disagreement

When family members disagree about a patient's care direction, the most effective approach centers the patient's own previously expressed wishes rather than the loudest or most present family member's preference. Ask directly: "What do you think [patient] would say if they could tell us themselves?" This reframes disagreement away from "who is right" toward "what would the patient want," which is often easier for families to align around.

Documenting Goals of Care

A goals of care conversation is only useful if it's documented somewhere the whole care team can access — not just in a note the specialist wrote that the primary care team never sees. Document in structured, retrievable format: the patient's stated priorities, the recommendation made, and the patient/family's response. Where available, formal documents like a POLST (Physician Orders for Life-Sustaining Treatment) should follow from — not substitute for — this deeper conversation.

A Practice Scenario

Scenario: A 79-year-old patient with advanced heart failure is being readmitted for the third time in six months. Her daughter wants "everything possible" done; the patient herself has said little in recent visits. Applying the framework: Start by assessing the patient's own understanding directly — "What's your understanding of how your heart is doing?" — even if the daughter tends to answer first. Explore what matters most to the patient specifically (time at home vs. aggressive intervention, tolerance for hospital stays). Document her stated priorities clearly, and use them — not just the daughter's stated wishes — as the anchor for the care team's recommendation going forward.