Goals of Care - Serious Illness Conversations with Older Adults

Key Points

• Start with the patient's understanding and values, not with a list of procedures.
• Prognostic communication should be clear, compassionate, and honest about uncertainty.
• Decision-making capacity is specific to the decision at hand.
• Use substituted judgment when a surrogate speaks for a patient who lacks capacity.
• Clinicians should make treatment recommendations linked to the patient's stated goals.
• A time-limited trial can help when prognosis or treatment benefit is uncertain.
• Code status is only one part of a broader plan.
• Document values and reasoning, not merely DNR or full code.

Algorithm

1. Identify a clinical trigger for serious-illness planning.
2. Assess understanding and decision-making capacity.
3. Ask permission to discuss prognosis and future care.
4. Explore hopes, worries, essential abilities, and unacceptable health states.
5. Identify the surrogate decision maker and existing advance-care documents.
6. Recommend treatments that fit the expressed goals.
7. Use time-limited trials when appropriate and define success and failure criteria.
8. Document decisions and revisit them after major clinical change.

Clinical Synopsis & Reasoning

Serious-illness communication is a clinical skill used when disease, frailty, or recurrent hospitalization creates uncertainty about whether future interventions will achieve outcomes the patient values. Begin by assessing understanding and asking permission to discuss what may lie ahead. Use clear language about prognosis while acknowledging uncertainty. Statements such as time may be shorter than we hope can introduce prognosis compassionately, but whenever possible provide a meaningful range or functional trajectory rather than vague euphemisms.

Elicit values before asking about procedures. Important questions include what abilities are essential for an acceptable quality of life, which states would be unacceptable, what the patient hopes for, what they fear, and how much burden they would accept for a chance of more time. For some people, longevity is the priority. Others prioritize remaining at home, maintaining cognition, avoiding hospitalization, or controlling symptoms. These values then guide recommendations about CPR, intubation, surgery, dialysis, artificial nutrition, hospitalization, antibiotics, or hospice.

Decision-making capacity is task-specific. A patient may be able to name a surrogate yet lack capacity for a complex treatment decision. If capacity is absent, use the legally authorized surrogate and apply substituted judgment based on the patient's known values whenever possible. Advance directives, prior conversations, POLST or equivalent medical orders, and statements from family can help reconstruct preferences. Avoid asking a surrogate what they personally want for the patient; ask what the patient would choose if able to speak now.

Treatment Strategy & Disposition

After eliciting values, clinicians should make a recommendation rather than leaving families to choose from a menu without guidance. Link the recommendation explicitly to stated goals: because staying comfortable at home is most important and ICU treatment is unlikely to restore independent function, a home-focused plan with hospice may fit better than repeated hospitalization. When prognosis is uncertain, a time-limited trial can define what treatment will be tried, for how long, what improvement would count as success, and what will happen if the goal is not reached.

Discuss CPR in context. Explain what cardiopulmonary arrest would mean in the setting of the patient's underlying illness and the likely outcomes of attempted resuscitation. Code status should not substitute for broader planning about hospitalization, ICU transfer, intubation, or other interventions. Document the conversation in accessible language, including participants, capacity, surrogate, values, prognosis discussed, decisions made, and unresolved issues. Translate decisions into actionable orders when appropriate.

Revisit goals after major changes such as hospitalization, new functional dependence, cancer progression, recurrent infection, or transition to long-term care. Palliative care consultation can support complex symptom management and communication at any stage of serious illness and is not limited to patients choosing hospice. Hospice is a specific benefit for patients with a qualifying terminal prognosis who elect comfort-focused services rather than disease-directed Medicare coverage for the terminal condition.

Epidemiology / Risk Factors

• Serious illness and multimorbidity become more common with age, increasing the need for advance care planning.
• Preferences may change as function, symptoms, and prognosis change.
• Many patients want clinicians to discuss prognosis but differ in desired level of detail.
• Poor communication contributes to goal-discordant treatment and family distress.

Investigations

Key Questions

Pharmacology

Prognosis / Complications

• Conversations can improve alignment between care and patient priorities.
• Clear surrogate identification reduces uncertainty during crises.
• Time-limited trials can prevent indefinite burdensome treatment when benefit is uncertain.
• Earlier palliative involvement can support symptom control and decision quality.

Patient Education / Counseling

• Encourage patients to name and talk with a surrogate before a crisis.
• Ask patients to share advance directives and medical orders with clinicians and family.
• Explain that goals can be revised as circumstances change.
• Clarify the difference between palliative care and hospice.
• Invite questions about prognosis and what treatments can realistically accomplish.
• Provide a written summary when major decisions are made.

Notes

Goals-of-care documentation should be easy to find and specific enough to guide an overnight or emergency clinician. A note that says family aware of prognosis is less useful than one that records the patient's priorities, acceptable outcomes, surrogate, and the rationale for recommended limits. Revisit rather than copy forward old language when the clinical situation changes.

References

1. American Geriatrics Society: 2023 AGS Beers Criteria — Link
2. American Geriatrics Society: Guidelines and Recommendations — Link
3. CMS: Hospice Care Coverage and Eligibility — Link
4. CMS: Hospice Determining Terminal Status — Link