Goals of Care After Severe Neurologic Injury

KEECC-A Evaluation

Element 1: Build the Relationship

Evidence: The clinician opens with a warm self-introduction ("we are here to support you as best we can"), acknowledges the difficulty of the journey, and uses empathic language throughout ("I understand," "I do not think that you're giving up on him"). The clinician responds to Mrs. Lopez's emotional distress (e.g., her fear of "giving up") with direct, validating reassurance. Tone is consistently compassionate and patient-centered. However, there are limited explicit verbal acknowledgments of emotion in the moment (e.g., no direct "I can see how painful this is for you" type statements), and non-verbal cues cannot be fully assessed from transcript alone.

Rating: 4: Very Good

---

Element 2: Open the Discussion

Evidence: The clinician introduces themselves and acknowledges the context. When Mrs. Lopez asks what is happening with Mateo, the clinician invites her to share her thoughts and concerns ("Can you share with me what some of your thoughts or concerns are, and we can take them one by one?"): a good agenda-setting move. However, there is no explicit "is there anything else?" to elicit a full set of concerns before proceeding, and the agenda is only partially negotiated rather than fully co-constructed.

Rating: 3: Good

---

Element 3: Gather Information

Evidence: The clinician uses open-ended questions effectively ("Can you share with me what some of your thoughts or concerns are?"; "What are your goals for him if he lives a very different life?"). The clinician listens actively and follows the mother's lead, allowing her to express concerns about prognosis, CPR, and Mateo's pain. However, there is limited use of clarifying or summarizing techniques: the clinician does not explicitly reflect back or summarize what has been gathered before moving forward. The information-gathering is functional but not deeply structured.

Rating: 3: Good

---

Element 4: Understand the Patient's and Family's Perspective

Evidence: This is a strong area. The clinician explicitly elicits Mrs. Lopez's goals for Mateo ("What are your goals for him if he lives a very different life?"), which draws out rich information about Mateo's values (independence, sports, not wanting to suffer). The clinician acknowledges the mother's fear of "giving up" and directly addresses it. The exploration of Mateo's prior expressed wishes ("he told me he would not want to suffer for a long time") is elicited skillfully. Cultural/contextual factors (e.g., family structure, spirituality) are not explicitly explored, which is a minor gap.

Rating: 4: Very Good

---

Element 5: Share Information

Evidence: The clinician explains the clinical situation in accessible language (e.g., describing CPR as "chest compressions and breathing," noting it can break ribs and be intense). The prognosis is communicated honestly but compassionately ("I worry that he will not wake up"). However, there is no teach-back or explicit check for understanding (e.g., "Can you tell me what you've understood so far?"), and encouragement of questions is implicit rather than explicit. Information-sharing is clear but lacks verification of comprehension.

Rating: 3: Good

---

Element 6: Reach Agreement on Problems and Plans

Evidence: The clinician actively involves Mrs. Lopez in the decision-making process, framing care choices around Mateo's values and her goals. The mother arrives at a decision (no CPR) and the clinician affirms it ("I think that's the right thing for him in your family"). However, the clinician does not explicitly check Mrs. Lopez's willingness or ability to follow through, does not identify additional supports or resources (e.g., palliative care team, chaplain, social work), and does not confirm the plan in concrete terms (e.g., documenting a DNR order). The shared decision-making process is present but incomplete.

Rating: 3: Good

---

Element 7: Provide Closure

Evidence: The conversation ends with the mother expressing understanding and acceptance, and the clinician affirms her decision. However, there is no explicit summary of the plan, no discussion of next steps (e.g., "We will put this in writing," "Here is what happens next"), no mention of what to expect going forward, and no invitation for further questions or concerns. The emotional closure is present, but the practical closure is largely absent.

Rating: 2: Fair

---

Summary Table

---

Overall Narrative

This clinician demonstrates genuine compassion and skill in the relational and perspective-eliciting domains of the encounter. The goals-of-care conversation is handled sensitively, and the mother reaches a meaningful, values-aligned decision. The primary gaps are in the structural elements: no teach-back, no explicit agenda-setting, no identification of support resources, and a notably incomplete closure that lacks next steps, follow-up planning, or a final invitation for questions. Strengthening these structural habits would elevate an already empathic performance to an excellent one.