Goals of Care

Secunda and colleagues started from a problem that anyone who has been on rounds will recognize: the phrase is everywhere and its meaning is ambiguous. They searched MEDLINE, CINAHL, and Scopus for publications with the exact phrase in the title or abstract, analyzed the 214 texts that qualified, and found that use of the term climbed steeply over time, with 87 percent of the included texts published between 2009 and 2018. One finding is worth holding onto at the bedside: the phrase is rarely used to describe the specific personal goals a patient is pursuing in their own life.

The review also set out why the concept earns its place in serious illness care. Applying it supports patient autonomy and patient-centered care, it helps teams avoid care the patient does not want while identifying the care the patient does value, and it gives patients and families a form of psychological and emotional support that a purely procedural discussion does not.

The definition is a useful check on how the phrase gets used in practice, where goals of care can shrink into shorthand for a code status decision or for a plan to limit treatment. Aims that are informed by a patient's values have to be elicited before they can guide anything, and eliciting them is conversational work: asking what the patient understands, what they are worried about, what they would trade and what they would not, then reflecting it back in language they recognize.

This is why goals of care sits alongside a communication tool rather than replacing one. The Serious Illness Conversation Guide supplies the wording, and SPIKES covers the moment when bad news has to precede the goals discussion. What neither supplies is timing, and clinicians build that through repeated practice with patients and surrogates who hesitate, change their minds, or say something that does not fit the plan the team had already formed.