What this moment may signal
understanding, hopes, acceptable burdens, values, relationships, decision preferences, and legacy
Point-of-care scenario
Goals of care
Possible themes include understanding, hopes, acceptable burdens, values, relationships, decision preferences, and legacy.
Respectful opening
“This may be affecting more than the medical plan. What feels most important or difficult right now?”
Questions to explore
What matters most right now? What gives strength? What has changed in meaning, identity, relationships, or hope? Are beliefs or practices affecting care? What support would fit?
Clinical considerations
Clarify symptoms, cognition, mood, safety, capacity, voluntariness, treatment understanding, practical barriers, social context, and institutional requirements. Do not diagnose from a single statement.
Spiritual, emotional, and social considerations
Follow the patient’s language across meaning, purpose, worldview, grief, guilt, hope, relationships, community, culture, identity, and practical needs.
Support and referral
Use generalist presence and permission-based inquiry. Offer professional chaplaincy for deeper assessment, ritual, religious struggle, reconciliation, complex grief, or treatment conflict. Add behavioral health, social work, palliative care, ethics, interpretation, safeguarding, or emergency services according to findings.
Urgency indicators
Escalate suicidal thoughts, inability to remain safe, acute psychiatric symptoms, severe delirium, abuse, coercion, time-critical treatment conflict, or imminent death with urgent ritual needs through established professional pathways.
Documentation language
Patient described concerns related to goals of care in their own words. Explored meaning, strengths, preferences, healthcare implications, and desired support. Appropriate referral or accommodation offered; follow-up planned.
Follow-up
Revisit the concern after the immediate decision or care transition. Confirm whether the referral occurred, whether the response fit the patient’s preference, and whether new clinical or family needs emerged.