How should clinicians address inconsistent or changing goals of care over time?

• A. Reassess prognosis, communicate clearly, revise documentation, and involve the patient/family in decisions.
• B. Avoid changing the plan to prevent confusion.
• C. Wait for the next formal review before making any changes.
• D. Only document changes in private notes without sharing.

Answer: (A)

Goals of care change as the illness and information evolve, so clinicians should regularly reassess prognosis, communicate clearly about what is realistically achievable, revise the plan accordingly, and involve the patient and family in decisions. When the prognosis or patient values shift, a thoughtful conversation helps everyone understand the likely outcomes, benefits, and burdens of different options, which guides choosing interventions that align with what matters most to the patient. Updating documentation ensures the care plan reflects current goals and is understood by all members of the health team, preventing mixed messages during transitions. Involving the patient and family respects autonomy, supports informed choices, and reduces confusion or distress as care evolves.

Delaying changes or clinging to an old plan can lead to interventions that no longer match the patient’s goals or improve quality of life. Waiting for a formal review can stall necessary adjustments, and keeping changes in private notes prevents the rest of the care team and the patient from knowing the current direction of care.