Core Elements of Goals of Care Initiatives Across Eight Health Systems.

Journal: Journal of pain and symptom management
Published Date: Jan 16, 2026

Abstract

For patients with serious illnesses, goals of care conversations improve quality of life and patient and family satisfaction and may reduce healthcare costs. However, these conversations often happen late in a serious illness or not at all. To better integrate goals of care into routine clinical practice, health systems across the country have implemented initiatives to increase and document these conversations. In this paper, we describe the landscape of goals of care initiatives across eight large health systems in the United States and identify core elements for effective programs: 1) Defining the purpose of the initiative; 2) Identifying the target patient population using patient diagnoses, artificial intelligence algorithms, or length of stay; 3) Engaging key stakeholders, including patient, caregiver, frontline provider, and leadership; 4) Encouraging the conversation through clinician and patient education and electronic health record prompts; 5) Documenting conversations within the electronic health record; 6) Measuring data by building electronic health record and information technology infrastructure; and 7) Planning for sustainability and scalability through leadership and funding support. These core elements can help inform how health systems plan goals of care initiatives, build infrastructure, and garner support to successfully implement these initiatives.

Authors

  • Jessica E Ma
    Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
  • Gina Piscitello
    Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
  • Jane Schell
    Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
  • Kiira Lyons
    Division of Geriatrics and Palliative Care, Department of Medicine, Duke University School of Medicine.
  • Robert M Arnold
    Brookedale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
  • Erin Eckert
    Duke AHEAD, Medical Education Administration, Duke University School of Medicine.
  • Erin K Kross
    Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
  • Lisa M Gibbs
    University of California Irvine, Irvine, CA.
  • Matthew J Gonzales
    Institute for Human Caring, Providence, Renton, WA.
  • Molly Kantor
    Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.
  • Nathan Moore
    Hampshire Hospital NHS Foundation Trust, United Kingdom.
  • Sarah Nouri
    Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.
  • Michael W Rabow
    Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.
  • Yael Schenker
    Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
  • Rebecca L Sudore
    Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.
  • Deborah Unger
    Institute for Human Caring, Providence, Renton, WA.
  • Anne M Walling
    6 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
  • Neil Wenger
    Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA.
  • Patrick H White
    Department of Medicine, Washington University School of Medicine in Saint Louis, St Louis, MO.
  • David Casarett
    Department of Medicine/Division of General Internal Medicine/Palliative Care, Duke University, Durham, North Carolina, USA.

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