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 DocumentationNo documented goals-of-care discussion.
Family UnawareFamily unaware of patient’s wishes.
No DNR/DNINo documentation of DNR/DNI status.
Litigation linkage: Lack of documentation or misalignment between stated goals and care delivery creates critical breach evidence in end-of-life care cases.
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” — lack of communication with family members.
Documentation GapsNo documentation of updates after significant changes.
Care Plan InflexibilityCare plan not adjusted despite changes in condition.
Litigation linkage: Frequent complaints of “lack of communication” are common in hospice care cases, making proper documentation and timely updates critical.
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
Unaware FamilyFamily unaware of symptom escalation or intervention plans.
Delayed CommunicationFailure to communicate symptom escalation to family promptly.
No ReassessmentNo documented reassessment of symptoms after interventions.
Litigation linkage: Families must be kept informed of symptom escalation and reassessment must be documented. A breakdown here often leads to claims of preventable suffering.
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
Unprepared FamilyFamily reports being unprepared for end-of-life signs despite education.
Infrequent VisitsNo increase in visit frequency during active dying.
Missing EducationNo documentation of end-of-life education provided to family.
Litigation linkage: Families must be properly prepared for the final days. Failure to communicate openly and consistently often results in claims of emotional distress or wrongful death.
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
Missing NotesIDT notes missing or incomplete.
Care Plan InactionCare plan not updated despite changes in condition.
Team DisconnectTeam members unaware of care changes or patient status updates.
Litigation linkage: Inadequate IDT communication leads to fragmented care and misaligned interventions. Missing documentation or failure to update the care plan contributes to breach claims.
Common Goals-of-Care Breach Themes
These are the strongest breach indicators in hospice care and should be a focus of both care coordination and documentation scrutiny.
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
