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Learning modules

Activity 3: Establishing goals of care

End-of-life goal setting is a key palliative care skill. Discussions to establish goals of care ideally begin soon after the diagnosis of a life-limiting condition. Health care professionals need to work with the person to develop goals of care that target individual needs, values and preferences. This requires you to have good communication skills.

These skills include:

Listening and enquiring: To begin with, ascertain the individual’s level of understanding and reactions to their situation and prognosis. The types of open questions that may be helpful to understand an individual’s goals and preferences may be:

  • What are you hoping for now?
  • What is important to you?
  • What do you need to accomplish?
  • Who do you need to see in the time that is left? [1]

Checking and clarifying: An individual’s goals are likely to change as their illness progresses. It is important to state your understanding of the individual’s goals and check this with how the individual sees his or her situation.

Two strategies that may be useful when establishing end-of-life goals of care are:

1) Family meetings

A family meeting is a discussion with involved family members and the caring team to exchange information and improve communications. The patient can be included. These meetings provide an opportunity for family members to express and share their feelings within a safe and structured context.

Family meetings:

  • require a skilled facilitator
  • are offered by the service provider based on individual family need
  • promote a proactive approach to care
  • may provide a clearer picture of the goals of care to patients and families
  • are mutually beneficial.

Family meetings are documented in the clinical record to maintain communication among professionals. Record who attended and a clear summary of significant conversations and decisions.

Family meetings are not:

  • a platform for clinical debate about a patient’s condition
  • a tool saved for crisis situations only.

Guidelines have been developed to help health care professionals to conduct effective family meetings. [2]

2) Advance Directives

An Advance Directive is a document that:

  • contains instructions that consent to, or refuse, specified medical treatments
  • clearly states patient care goals and preferences
  • may be completed by a legally competent patient or by a legally appointed proxy e.g. enduring power of attorney
  • may be completed as part of the advance care planning process
  • has legal status
  • must be available when the individual’s place of care is being changed i.e. admission to hospital from home
  • varies according to each Australian state or territory.

If an individual does not make an Advance Directive, the treating team will continue to provide care based on clinical judgement, the individual’s wishes and family liaison. [3]

Review module 2 for the principles of effective communication in palliative care.

Thinking points


1. Ambuel, B. (2009). Establishing End-of-Life Goals: The Living Will Interview. Fast Fact #65. Fast Facts and Concepts. Retrieved March 16, 2015, from

2. Hudson, P., Quinn, K., O’Hanlon, B., Aranda, S. (2008). Family meetings in palliative care: Multidisciplinary clinical practice guidelines. Biomed Central; 7;12. Retrieved September 15, 2010, from

3. Palliative Care Australia. (2009). Advance Care Planning position statement.