Goals‑of‑Care Communication Map
A structured guide outlining the required communication steps between providers, families, and interdisciplinary teams to ensure care aligns with the patient’s wishes.
Clear, consistent communication is the foundation of hospice and palliative care. Goals‑of‑care discussions ensure that treatment aligns with the patient’s values, preferences, and end‑of‑life wishes. When communication breaks down, families feel blindsided, symptoms go unmanaged, and care becomes misaligned with the patient’s intent.
This map outlines what should occur at each stage of care and helps attorneys identify communication failures, documentation gaps, and deviations from standards.
Use this tool during breach analysis, deposition preparation, and timeline reconstruction.
INITIAL GOALS‑OF‑CARE DISCUSSION (AT ADMISSION)
✔ Required Participants
• Patient (when able)
• Family or designated decision‑maker
• Hospice/palliative physician
• Nurse
• Social worker
✔ Required Discussion Topics
• Patient’s values and priorities
• Understanding of illness
• Expected disease progression
• Symptom‑management preferences
• Resuscitation status (DNR/DNI)
• Hospitalization preferences
• Preferred setting of care (home, facility, inpatient hospice)
✔ Required Documentation
• Summary of discussion
• Advance directives
• POLST/MOST forms
• Identified decision‑maker
• Patient’s stated goals
Red Flags
• No documented goals‑of‑care discussion
• Family unaware of patient’s wishes
• No documentation of DNR/DNI status
ONGOING GOALS‑OF‑CARE COMMUNICATION
✔ Required When:
• Symptoms worsen
• Condition changes
• New medications are introduced
• Hospitalization is considered
• Family expresses concern
• Patient enters active decline
✔ Required Communication Elements
• Update on condition
• Explanation of changes
• Options for comfort‑focused interventions
• Clarification of what to expect
• Reaffirmation of goal
✔ Required Documentation
• Time and content of communication
• Who was present
• Decisions made
• Changes to the care plan
Red Flags
• Family reports “no one told us”
• No documentation of updates
• Care plan not adjusted despite changes
COMMUNICATION DURING SYMPTOM CRISIS
✔ Required Actions
• Immediate notification of family
• Explanation of symptoms
• Discussion of comfort‑focused options
• Clarification of expected outcomes
• Reassessment after interventions
✔ Required Monitoring
• Pain
• Dyspnea
• Agitation
• Anxiety
• Distress level
✔ Required Documentation
• Time family was notified
• Interventions performed
• Response to interventions
• Any changes in goals
Red Flags
• Family unaware of symptom escalation
• Delayed communication
• No reassessment documented
COMMUNICATION DURING ACTIVE DYING
✔ Required Communication
• Clear explanation of signs of active dying
• What to expect in the final hours/days
• How to provide comfort
• When to call hospice
• Emotional and spiritual support
✔ Required Visit Frequency
• Increased visits
• More frequent reassessments
• Ongoing family support
✔ Required Documentation
• Family updates
• Symptom‑management interventions
• Emotional/spiritual support provided
Red Flags
• Family reports being unprepared
• No increase in visit frequency
• No documentation of end‑of‑life education
INTERDISCIPLINARY TEAM (IDT) COMMUNICATION
✔ Required IDT Responsibilities
• Review goals of care regularly
• Adjust care plan as needed
• Communicate changes to all team members
• Document decisions and rationale
✔ Required Communication Pathways
• Nurse → Physician
• Nurse → Social worker
• Physician → Family
• IDT → All disciplines
Red Flags
• IDT notes missing
• Care plan not updated
• Team members are unaware of changes
COMMON GOALS‑OF‑CARE BREACH THEMES
• Uncontrolled pain or dyspnea
• Delayed titration
• Unsafe opioid dosing
• Failure to monitor sedation or respiratory status
• Poor family education
• Medication errors
• Inadequate documentation
• Failure to align medications with goals of care
These are the strongest breach indicators in hospice medication‑related litigation.