Mastering Evidence-Based Goals of Care: Your Guide to Structured, High-Quality GOC Discussions and EHR-Driven Equity

In this episode of Hospital Medicine Unplugged, we cut through goals-of-care (GOC) conversations—who to flag, what to say, how to document it so the whole team actually uses it.

We open with the do-firsts: identify the right patients (surprise question “Would I be surprised…?”, acute deterioration, high-risk admits, ≥2 recent hospitalizations). Prep before you walk in: scan prior ACP notes/POLST/advance directives, locate the surrogate, check capacity, order an interpreter if needed, and secure a quiet space (+ tissues, sitter coverage). Set the agenda up front: “I want to understand what matters to you and make a plan that fits.”

The conversation flow (simple, repeatable):
• Ask–Tell–Ask: start with “What’s your understanding of what’s going on?” → share a concise medical summary and prognosis → check understanding.
• Elicit values/goals/fears: “What are you hoping for?” “What worries you most?” “What abilities are essential to your quality of life?”
• Explore trade-offs: function vs longevity, home vs ICU, burdens you’d accept for benefits you want.
• Make a recommendation (values-based): “Given how important being at home and independent is to you, I recommend….”
• Code status in context, not in isolation. Use plain language; avoid menu-listing procedures.
• Time-limited trials for uncertainty: set goals, time frame, and exit criteria.
• Close with teach-back & next steps: summarize decisions, confirm surrogate, plan to revisit.

Communication moves that work (and keep you human):
• NURSE your empathy—Name, Understand, Respect, Support, Explore.
• Short sentences, zero jargon, one idea at a time; pause for emotion.
• Calibrate detail to health literacy; invite family, but center the patient.
• When capacity is impaired: confirm surrogate hierarchy, reflect known values; involve ethics early if conflict.

Special scenarios—how we handle them fast:
• ICU or rapid decline: early palliative consult; consider a time-limited trial of ICU-level care with defined milestones.
• Conflict or ambivalence: normalize, re-align to stated values, schedule a second touch with key stakeholders present.
• Language & culture: professional interpreters only; ask about cultural or spiritual needs that influence decisions.
• Equity: proactively offer GOC to all eligible patients; don’t wait for “readiness”—our system prompts it.

What not to do (aka classic fail points):
• Opening with “Full code or DNR?” before exploring values.
• Info dumps without check-ins; euphemisms (“do everything”) and statistics without context.
• One-and-done conversations—goals evolve; your notes should too.

Documentation that drives care (and survives handoffs):
• Use the GOC template with discrete fields: capacity, surrogate/contact, values & priorities, prognosis discussed, recommendations, code status, time-limited trials (goals/criteria/timeline), hospice/palliative referrals, revisit date.
• Enter aligned orders (code status, limits of treatment, DNI/DIALYSIS preferences) before you leave the floor.
• Title your note “Goals of Care” and pin it to the header/inbox so ED/ICU can find it in 10 seconds.

We close with the system moves: a GOC bundle that (1) auto-flags candidates via the surprise question + high-risk diagnoses; (2) fires an EHR prompt + conversation guide in the admission navigator; (3) standardizes the GOC note and links it to code-status orders; (4) routes to palliative care for triggers (ICU admit, refractory symptoms, complex conflict); (5) builds training + feedback loops (review a short audio or template at noon conference); (6) dashboards equity metrics so every patient gets the offer.

Clear, compassionate, and actionable—everything your team needs to run patient-centered goals-of-care talks that actually change the plan at the bedside.