Effective Strategies for Operationalizing Goals of Care Documentation: Lessons, Advice, and Key Messages

Key Message: Proven strategies for routinizing goals-of-care conversations with seriously ill patients across a heterogeneous multistate health system will be presented, with discussion of system change methods, organizational policies, EHR and clinical workflow innovations, and advice for implementing similar programs within other institutions.

Abstract: Introduction/Context

Goals-of-care (GOC) conversations ensure clinical teams and health systems know what matters to patients and align treatment plans with patients’ goals and priorities (1-3). However, patients with serious conditions often lack documented GOC conversations in the electronic health record (EHR) because either the conversations did not occur or were not recorded (4-5).

Implementation and Measuring Success

We describe a multiyear systematic effort that substantially increased documentation of GOC conversations across 51 hospitals (6). In 2024, 8,533 out of 10,063 (84.8%) of patients who were in an ICU for 5 or more days had a documented GOC conversation in the EHR during the course of that admission. By contrast, at baseline in 2016, only 555 out of 8,143 (6.8%) met this quality metric. Overall, documented GOC conversations in adult non-obstetric acute care admissions rose from 2% (8,296 of 382,067) in 2017 to 27% (102,066 of 376,586) in 2024.

Strategic Drivers of Success

Our success rested on five strategic drivers: aligning goals-of-care with our health system’s mission; adopting evidence-based quality standards; deploying real-time interactive performance dashboards to monitor progress; delivering scalable clinician communication training; and streamlining EHR and clinical workflows to reduce clinician documentation burden. For each, key lessons and anecdotes will be presented. Additionally, we will share new tactics for simplifying our approach even more, using generative artificial intelligence.

Conclusion

Implementing these five drivers increased GOC documentation for ICU patients from 6.8% in 2016 to 84.8% in 2024, and overall acute-care GOC documentation from 2% in 2017 to 27% in 2024. This systemic strategy and scalable framework improves EHR documentation of goals-of-care conversations and provides a reproducible roadmap that can be adapted and applied in other health systems.

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3. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, D.C.: National Academies Press. 2015. https://doi.org/10.17226/18748.

4. Yadav KN, Gabler NB, Cooney E, et al. Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care. Health Affairs 2017;36:1244–1251.

5. Paladino J, Sanders J, Kilpatrick LB, et al. Serious Illness Care Programme—contextual factors and implementation strategies: a qualitative study. BMJ Support Palliat Care 2024;14:e1503–e1511.

6. Gonzales MJ, Unger D, Byock I, et al. Successful Strategies for Operationalizing Goals-of-Care Documentation. NEJM Catalyst 2025;6.