• Julie W Childers, Douglas B White, and Robert Arnold.
• Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, The University of Pittsburgh, Pittsburgh, Pennsylvania, USA. Electronic address: childersjw2@upmc.edu.
• J Pain Symptom Manage. 2021 Apr 1; 61 (4): 864-869.

AbstractWhen assuming care for a seriously ill hospitalized patient, we should find documentation of previous decisions about goals of care so that our conversation takes advantage of previous discussions and reduces decision-making burden on the patient, particularly when the patient is clinically declining and time is short. This article presents a framework to help clinicians incorporate prior goals of care conversations into decision-making for an acutely ill patient. When there is strong evidence that a previous decision still applies, clinicians should, after a brief check-in about the previous decision with the patient, then present a plan consistent with their previous decision as a default option, to which they can opt out. If there is less evidence of the basis for a previous decision, clinicians should explore the thinking behind the decision and, if there is clarity about patient preferences, propose a treatment plan. If there is conflict or uncertainty about the patient's preferences, clinicians should engage in a more comprehensive goals-of-care conversation, which involves exploring the patient's understanding of their illness, patient values, and reasonable treatment options, before offering a plan. By giving the patient the ability to opt out of a previous decision they made about goals of care, rather than another choice, we make it more likely that they will receive care consistent with their known wishes.Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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