JD, a 79-year-old woman with pulmonary fibrosis and cervical cancer metastatic to the lungs, was hospitalized with acute pulmonary embolism and aspiration pneumonia. We knew her goals of care: to breathe comfortably, to live seven weeks longer until her 80th birthday, to write two more chapters of her book, and to be able to die at home on her terms. Despite appropriate medical therapy, including high-flow oxygen that confined her to the ICU, she still struggled to breathe.
Widely recommended as a key priority in medicine, goal-concordant care represents medical care aligned with patients’ priorities for treatment intensity, functional outcomes, and longevity.1–3 As clinicians, we strive to understand each patient’s goals of care and to either achieve those goals or to readdress them as illness trajectory evolves.
However, many factors threaten goal-concordant care. First, patients and their families may misunderstand their prognosis: clinicians cannot predict every disease trajectory; existing care processes do not always facilitate clear communication of prognosis; and psychosocial distress may impair many patients or families from fully processing a poor prognosis. Without prognostic understanding, patients and their families may not realistically prioritize their goals of care.3
Second, patient goals and preferences change over time, sometimes in contradictory ways. In a systematic review, 10 of 25 studies found that most patients had inconsistent end-of-life care goals.4 The more clinicians checked on patient goals, the more patients changed them.4 Even with clear treatment limits, as in JD’s case, priorities shift: For example, prioritizing comfort increased when JD experienced severe dyspnea. Furthermore, coping with serious illness often includes pendulum swings between hope and worry, optimism and realism.5 JD could oscillate between optimism that she would finish her book alongside realism planning for her impending death. Goal-concordant care therefore cannot be a status achieved by a single conversation, with results written in stone. Clinicians must repeatedly revisit what matters most to patients as illness evolves.
Third, and perhaps most important, contradictory goals often make goal-concordant care challenging. Like many patients, JD had legitimate and coexisting goals. She wanted to breathe comfortably, to live, to write, and to be able to die at home when the time was “right.” She could attain all goals simultaneously before critical illness—but in the reality of her ICU admission, her goals conflicted with each other. Opioids relieved her dyspnea but clouded her writing; high-flow oxygen kept her alive but in the ICU. Unable to achieve all of her goals, our ICU team navigated evolving trade-offs between comfort, function, and treatment burden.
Evolving trade-offs create an insidious risk: that clinicians may inadvertently create the illusion of choice where none exists. Who decides when a goal—for JD, finishing her book—is no longer worth pursuing? As JD’s respiratory failure worsened and her hoped-for milestones receded, comfort rose above physical longevity as her most important goal. Her transition to comfort-focused care reflected not only the increasing importance of comfort but also the increasing impossibility of living longer. As clinicians, we must be careful of inadvertently offering patients and families options to choose from when, in reality, only one is medically feasible.
If clinicians frame decisions solely as a matter of patient or family preference, we risk unintentionally shifting responsibility for medical decisions to families, potentially absolving our responsibility of making medical recommendations. Medical recommendations are difficult but necessary and can be centered on a patient’s values (eg, independence, dignity) even if inconsistent with their stated goals (eg, writing a book or living to 80). We should ground recommendations in patient values while acknowledging when medicine can no longer realistically achieve stated goals. Without clear recommendations, we risk asking families to tell us when to stop nonbeneficial care rather than us telling family if a specific treatment is no longer indicated or beneficial. In one prospective ICU study, families who actively participated in end-of-life decisions were more likely to develop symptoms of posttraumatic stress disorder than families who were told their loved one was dying.6
Because goals are dynamic, plural, conflicting, and sensitive to unspoken pressures, we should approach discussions about goal-concordant care with curiosity, humility, and responsibility. JD died before reaching her 80th birthday, finishing her book, or getting home. But she achieved one goal that remained feasible: comfort at the end of her life. Comfort was not the only goal she had, but it had become the one we could honor through clear recommendations and care, without asking her family to choose from impossible options.
References
1. Bernacki RE, Block SD; American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003. doi:10.1001/jamainternmed.2014.5271
2. Auriemma CL, O’Donnell H, Jones J, et al. Patient perspectives on states worse than death: a qualitative study with implications for patient-centered outcomes and values elicitation. Palliat Med. 2022;36(2):348-357. doi:10.1177/02692163211058596
3. Secunda K, Wirpsa MJ, Neely KJ, et al. Use and meaning of “goals of care” in the healthcare literature: a systematic review and qualitative discourse analysis. J Gen Intern Med. 2020;35(5):1559-1566. doi:10.1007/s11606-019-05446-0
4. Murali S, Poco LC, Malhotra C. Instability in end-of-life goals and preferences of patients who are seriously ill: a systematic review. JAMA Netw Open. 2025;8(11):e2541264. doi:10.1001/jamanetworkopen.2025.41264
5. Jacobsen J, Jackson V, Greer J, Temel J. What’s in the syringe? Principles of Early Integrated Palliative Care. Oxford University Press; 2021.
6. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171(9):987-994. doi:10.1164/rccm.200409-1295OC
