once the patient is goals and values have been elicited
a plan of care can be developed
when the goal is to have comfort for the final weeks of life the plan of care will be very different than when the goal is prolong survival
even if it requires burdensome intervention.
strong physician or practitioner input in developing the plan of care is critical
one error that is sometime made in discussing the plan of care is to focus solely on what will not be done (no intubation , no cpr, no hospitalization)