Goals of Care and Advance Planning

Goals of care are the overarching aims that a patient and care team agree should guide treatment given the patient's values, condition, and prognosis. Advance care planning is the ongoing process by which people consider, discuss, and document their preferences for future care in case they later become unable to speak for themselves. In older adults living with serious or progressive illness, both are central to person-centred care.

Definition

Goals of care are the agreed aims that guide medical decisions in light of a patient's values and clinical situation; advance care planning is a process of reflection and communication, supported where appropriate by advance directives, in which a person prepares for medical decision-making in the event of future incapacity.

Scope

This topic covers how goals of care are elicited and aligned with treatment, what advance care planning is and how it differs from a single advance directive document, and the legal instruments commonly used to record preferences. It treats these as concepts and processes for reference; it is not a script or protocol for conducting these conversations with a specific patient.

Core questions

• How are a patient's values translated into actionable goals of care?
• What is the difference between advance care planning as a process and an advance directive as a document?
• Which instruments record preferences, and what are their limits?
• Does advance care planning change the care people actually receive?

Key concepts

• Goals of care
• Advance care planning
• Advance directive and living will
• Durable power of attorney for health care
• Physician/Portable Orders for Life-Sustaining Treatment (POLST)
• Preparation for in-the-moment decision making
• Shared decision making

Mechanisms

A goals-of-care conversation typically explores a patient's understanding of their illness and prognosis, what matters most to them, and how those values translate into preferences about life-sustaining treatments; the resulting goals then guide specific decisions. A influential reframing argues that advance care planning should be understood less as completing a document specifying particular treatments and more as preparing patients and surrogates to make in-the-moment decisions, because future circumstances are hard to predict (Sudore, 2010). Documents such as living wills, durable powers of attorney for health care, and portable medical-order forms (e.g., POLST) are tools that record or operationalise these preferences.

Clinical relevance

Understanding goals of care and advance planning helps explain how treatment decisions are aligned with what patients value, particularly when illness is serious or prognosis limited. This entry describes the concepts and evidence for reference and education; it is non-prescriptive and not a substitute for individualised clinical and legal guidance.

Epidemiology

Completion of advance directives is far from universal: a systematic review of US adults found that roughly one in three had completed any type of advance directive, with somewhat higher rates among those who were older or seriously ill (Yadav, 2017).

Evidence & guidelines

A randomised controlled trial in older hospitalised patients found that facilitated advance care planning improved concordance between the care delivered and patients' end-of-life wishes and improved family outcomes (Detering, 2010). Quality frameworks for palliative care identify communication about goals and advance care planning as core elements of serious-illness care (Kelley, 2015).

History

Advance directives emerged in US law and practice in the late twentieth century, with the living will and durable power of attorney for health care formalising patients' rights to direct future care. Practice and scholarship subsequently shifted from emphasising standalone documents toward viewing advance care planning as an iterative communication process and toward portable medical-order programmes that translate preferences into actionable orders (Sudore, 2010).

Debates

Do advance directives reliably guide future care?

Because people cannot foresee every future circumstance, written directives may not match later situations; this motivated reframing advance care planning as preparation for in-the-moment decisions rather than as fixed instructions, though completed documents and surrogate designation still matter.

Key figures

• Rebecca Sudore
• Terri Fried
• Karen Detering
• Amy Kelley

Seminal works

• sudore-2010
• detering-2010

Frequently asked questions

What is the difference between an advance directive and advance care planning?

An advance directive is a document (such as a living will or designation of a health-care proxy) that records preferences for future care. Advance care planning is the broader, ongoing process of reflecting on values and discussing future care, which may or may not result in such a document.

Is a living will the same as a POLST?

No. A living will is a directive expressing a person's general wishes for future care. A POLST (Physician/Portable Orders for Life-Sustaining Treatment) is a portable medical order completed with a clinician, generally intended for people who are seriously ill, that translates preferences into actionable orders.