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Back to Module 7: Goals of Care Goals of Care

7-Step Protocol to Negotiate Goals of Care
Identifying Goals to Hope For
Cultural Considerations
Communicating Prognosis
Use of Language
Setting Goals and Priorities for Treatment and Care

• Clarify Goals and Treatment Priorities
• Determining Priorities for Treatment and Care
• When the Physician Cannot Support the Patient's Choices

Decision-Making Capacity

Setting Goals and Priorities for Treatment and Care

Clarify Goals and Treatment Priorities

• The patient’s goals for care should guide the therapies and care that patients and families choose and receive

• In addition to helping them to establish overall goals, physicians can assist patients and families to clarify priorities for treatments and care as they negotiate an initial plan of care together

• Subsequently, whenever the patient’s goals (or parents’ when the patient is a child) are uncertain or might be expected to change, goals and treatment priorities should again be clarified

• Review is recommended at several types of juncture:

• significant change in health status (e.g., worsening prognosis or unexpected recovery)


• change in life expectancy (e.g., advanced age or serious life-threatening illness)


• change in setting of care (e.g., from hospital to nursing home or vice versa)


• change in treatment preferences (e.g., decide to discontinue dialysis or other therapies)

• If the prognosis allows you to delay this conversation, give the patient time to acclimatize to his or her new circumstances

• With a little time to settle, patients are more likely to again stabilize their goals and priorities

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Determining Priorities for Treatment and Care

• Once overall goals have been determined, the physician can help the patient (or parents if the patient is a child) to determine his or her priorities for treatment and care

• Priorities should be based on individual patient values and preferences as guided by specific clinical circumstances

• Priorities will be influenced by information from the physician and other health care professionals

• The physician will want to describe the possible priorities and be open to the feasibility of others

• Values and preferences will be elicited and clarified through physician-patient discussions (see Module 1: Advance Care Planning and Module 2: Communicating Bad News)

• Questions that can be used to elicit patients’ values and goals for medical care at the end of life:

• What are you expecting?
• What do you most want to accomplish?
• What is most important in your life right now?
• What are you hoping for?
• What do you hope to avoid?
• What do you think will happen?
• What are you afraid will happen?
• What do you expect the end to be like?

• Examples of patient values and preferences:

• No matter what happens, I want us to stay at home, No more hospitals
• I’m worried what all of this will cost my family
• What I fear most is pain
• I would like to be alert and aware as long as possible
• I just hope I have time to finish my memoirs
• If I live to see my daughter married, I’ll die happy
• When death comes, I want my family around me
• I don’t want my wife to have to quit her job to take care of me
• My wish is never to be hooked up to machines
• It’s important to me to live as long as possible, and to go out fighting
• It is important to me to try everything there is to cure my child
• I don’t want my child hooked up to machines

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When the Physician Cannot Support the Patient's Choices

• Typically occurs when goals are unreasonable, illegal

• Set limits without implying abandonment

• Make the conflict explicit

• Try to find an alternate solution

Example of Physician Responses

"I understand that your first priority is to live as long as possible by having a heart transplant. Unfortunately, I’m not able to do that because of your other health problems. Is there an alternative way that I can help you achieve your goal of living as long as possible?" or "I understand your goal is not to be a burden to your family and you would like me to assist you to die. Unfortunately, I cannot do that. Is there an alternative way that I can help you so that you will not be a burden?" More intractable differences are addressed elsewhere. (see Module 1: Advance Care Planning; Module 5: Physician-Assisted Suicide; and Module 9: Medical Futility)

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