Symbolic image of an oncologist and patient engaged in a goals-of-care discussion.

Navigating End-of-Life Discussions: A Practical Guide for Oncology Professionals

Rhea Morgan in Health & Wellness December 2025 • 4 min read.

"Empowering oncologists with tools and strategies to facilitate goals-of-care conversations, improve patient understanding, and enhance end-of-life care."

Goals-of-care conversations, expertly led by oncologists, are vital for enhancing prognostic awareness among patients and their families. However, these discussions frequently fall short, failing to adequately prepare individuals for advance care planning and appropriate end-of-life arrangements. Recognizing this critical gap, our institution initiated a Phase 3 trial, integrating palliative care into the standard treatment protocols for Phase 1 clinical trial participants. This initiative provided a unique opportunity to develop and implement an electronic medical record (EMR)-based goals-of-care template designed to facilitate more effective and comprehensive discussions.

This goals-of-care template allows healthcare professionals to complete all or selected sections in consultation with patients, ensuring comprehensive coverage of essential topics such as transitioning to hospice care and addressing legacy concerns. A key benefit of this approach is that it ensures all providers are aligned and 'on the same page' regarding treatment plans. Integrated within our EMR as a SmartPhrase, the template can be easily accessed and completed, proving instrumental in clarifying patient understanding. Furthermore, the template serves as a valuable tool for documenting advance care planning, supporting both clinical care and accurate billing practices.

While this tool has not undergone formal testing, its effectiveness in day-to-day practice and research has been evident. This article shares our experiences and insights, offering a practical, doable template with the hope that others will find it equally beneficial in enhancing their approach to end-of-life care discussions.

Why Goals-of-Care Conversations Matter: Improving End-of-Life Care

Symbolic image of an oncologist and patient engaged in a goals-of-care discussion.

Goals-of-care conversations, when skillfully conducted by oncologists, present a pivotal opportunity to enhance advance care planning and end-of-life care. However, it's concerning that many patients do not fully grasp the essentials during these discussions. A study focusing on patient expectations regarding chemotherapy revealed that a significant proportion of patients with lung or colorectal cancers held the misconception that palliative chemotherapy, radiation, and/or surgery could lead to a cure. Such misunderstandings underscore the urgent need for improved patient education.

The failure to effectively educate patients about their condition and realistic treatment outcomes can result in end-of-life experiences characterized by diminished quality of care. This includes instances of overly aggressive interventions, reduced quality of life due to inadequate symptom management, heightened caregiver distress, and other preventable complications. Palliative care, as a standard practice, incorporates goals-of-care (GoC) discussions as an integral component of patient care.

Reduced Readmission Rates: Palliative care consultation led to lower 30-day readmission rates in a large urban hospital.
Improved Outcomes with GoC: Patients receiving consultations that included GoC discussions, alongside symptom management, experienced even lower hospital readmission rates.
Study Findings: Research indicates that incorporating GoC discussions results in better patient outcomes and reduced aggressive end-of-life care.

Integrating a GoC planning session close to the time of diagnosis can significantly decrease the use of aggressive end-of-life care. This highlights the importance of initiating these conversations early in the treatment process.

Empowering Patient-Centered Care Through Enhanced Communication

Our approach to integrating goals-of-care discussions emphasizes a patient- and family-centered approach, aligning with our TEAM (Time, Education, Assessment, and Management) framework. By prioritizing open communication and shared decision-making, we strive to enhance the quality of care and support patients in making informed choices that reflect their values and preferences. Ultimately, this comprehensive approach fosters a more compassionate and effective healthcare experience for individuals facing serious illnesses.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.12788/jcso.0355, Alternate LINK

Title: Goals-Of-Care Discussions

Subject: Oncology

Journal: The Journal of Community and Supportive Oncology

Publisher: Frontline Medical Communications, Inc.

Authors: Catherine Saiki

Published: 2017-08-01

Everything You Need To Know

What are goals-of-care conversations, and why are they important?

Goals-of-care conversations are discussions, skillfully led by oncologists, to enhance prognostic awareness among patients and their families, improve patient understanding, and support informed decision-making. These conversations are essential to make sure that patients are aware of their condition and its realistic treatment outcomes. They are an integral component of patient care and crucial for advance care planning and end-of-life care, preventing overly aggressive interventions and improving overall quality of life.

What is the significance of the EMR-based goals-of-care template?

The importance of the electronic medical record (EMR)-based goals-of-care template is its ability to facilitate effective and comprehensive goals-of-care discussions. This template, integrated as a SmartPhrase within the EMR, ensures all healthcare providers are aligned on treatment plans. It's also a valuable tool for documenting advance care planning, helping both clinical care and accurate billing practices. The template allows healthcare professionals to complete all or selected sections in consultation with patients, ensuring comprehensive coverage of essential topics such as transitioning to hospice care and addressing legacy concerns.

Why is it important to effectively implement goals-of-care discussions?

Implementing goals-of-care discussions is vital because many patients have misunderstandings about their conditions and treatment outcomes. For example, many patients with lung or colorectal cancers believed that palliative chemotherapy, radiation, and/or surgery could lead to a cure. These misunderstandings underscore the need for improved patient education. By integrating goals-of-care planning early in treatment, healthcare professionals can decrease the use of aggressive end-of-life care and improve end-of-life experiences.

How does the TEAM framework influence goals-of-care discussions?

The TEAM framework (Time, Education, Assessment, and Management) focuses on a patient- and family-centered approach, which is used when integrating goals-of-care discussions. By prioritizing open communication and shared decision-making, this framework enhances the quality of care and supports patients in making informed choices. This comprehensive approach fosters a more compassionate and effective healthcare experience for individuals facing serious illnesses.

Why is it crucial to initiate goals-of-care conversations early in treatment?

Initiating goals-of-care conversations early in the treatment process is significant because it can lead to better patient outcomes and reduced aggressive end-of-life care. These conversations are an integral component of patient care and can significantly decrease the use of aggressive end-of-life care. Research indicates that incorporating goals-of-care discussions results in better patient outcomes and reduced aggressive end-of-life care, including lower hospital readmission rates and improved symptom management.