Se t ting G oa l s at the End
of Life: The Importa nce
of Communication
The broad goals and methods of comfort care
near the end of life should reflect the informed
patient’s wishes. Table 1 briefly summarizes
communication techniques that can be used to
help terminally ill patients identify their values,
goals, and preferences. The plan of care can
then be aligned with the patient’s wishes.12 Such
conversations about goals of care are essential
when the withholding or withdrawing of lifesustaining
interventions (e.g., dialysis or cardiopulmonary
resuscitation) is being considered
and as an aid in choosing appropriate diagnostic
tests (e.g., positron-emission tomography–computed
tomography or monitoring of vital signs).
Discussions about setting goals at the end of life
are associated with greater congruence between
patients’ wishes and the care that they receive
during that time, and such discussions are correlated
with the use of fewer aggressive, life-extending
interventions (e.g., mechanical ventilation
and resuscitation), as well as with end-of-life
care that is consistent with the patient’s prefer
ences, fewer deaths in the intensive care unit,
and earlier referral to a hospice.17,18
Understanding Comfort Care
Comfort care requires the meticulous palliation
of troubling symptoms and offering of skilled
psychosocial and spiritual support to the patient
and the patient’s family (Table 2). However, the
term is often used in a misleading or imprecise
manner — for example, when such care is automatically
considered equivalent to a do-not-resuscitate
order and, perhaps even without discussion
with the patient,23 is extrapolated to mean
the exclusion of a full range of palliative measures
appropriate for a dying patient. Rather
than simply writing orders for “comfort care”
(or “intensive comfort measures,” the term that
we prefer), the medical team should review the
entire plan of care and enter explicit orders to
promote comfort and prevent unnecessary interventions.
Infrequently, a focus on comfort care may
include the use of potentially life-sustaining
measures, when these are consistent with a patient’s
goals (e.g., when the patient wants to be