Goals of care are the aims for a person’s medical treatment, as agreed with their family, carers and healthcare team. Goals of care will change over time, particularly as the person enters the terminal phase. Medical goals of care may include attempted cure of a reversible condition, a trial of treatment to assess reversibility of a condition, treatment of deteriorating symptoms, or the primary aim of ensuring comfort for a dying person. A person’s goals of care may also include non-medical goals, for example, reaching a particular milestone or participating in a family event. 
Goal setting involves a process of negotiation between a person and health care professional or a multidisciplinary team about an agreed target which will be worked towards.
Very few systematic reviews and guidelines exist for goals of care in relation to palliative care for residents of aged care facilities (RACFs) or for older people receiving care in the community. 
Goal setting in palliative care is complex, challenging and should be multidisciplinary and flexible in nature. The process of setting and working towards specific goals can be an important part of adapting to a life-limiting illness. As illness progresses, the emphasis of goal setting can change from physical independence to leaving a legacy.  In the assessment of palliative care interventions of RACFs, there exists very little evidence as to the role and importance of goals of care. 
The literature indicates that discussions with people about goals of care and end-of-life planning do not increase levels of anxiety, depression or feelings of hopelessness for the person or their family, and they can minimise the hesitation, stress or guilt felt by surrogate decision-makers. These discussions should explore the person's expectations of treatment options, fears and concerns regarding their disease and their future, and should include physical and psychosocial (psychological, social, spiritual, existential, cultural) factors.  Timing of goals of care discussions is particularly important for people diagnosed with dementia. Early discussion enables the person to state their wishes for the later stages of their condition when they may no longer have the competency or capacity to speak for themselves. 
A care plan should integrate, where reasonable, the wishes of the person and their family, be responsive to the change in the person’s conditions, and include clear, respectful and empathetic communication, [1-5] medication review to discontinue unnecessary medication, [3,5] and anticipatory prescribing for people in the last days of life. [3,5] It is particularly important that the person and their family understand the burdens of treatment and the likely loss of quality time and the likely gain in quantity of time.  Care should be taken so that a person and their family understand the underlying disease status and prognosis, treatment options, likely outcomes and likely adverse effects so that goals are realistic and person-centred.
Decision aids, in particular electronic video education tools and patient-clinician communication are both important means to improve understanding and knowledge of treatment choices and assist in GoC decision-making and accurately reflecting a person’s preferences and values. [7,9,10] Decision aids should be used with caution for people with multimorbidity as single chronic disease is often the focus of development. 
For people with low English proficiency, discussions about goals of care and end-of-life planning, should, where practical, include a professional interpreter. 
Overall, the evidence is scant with a mix of low, moderate and high-quality evidence.
Page updated 28 June 2021