ICU Family Meeting/Goals of Care Communication Note

Date/Time: [date and start time of meeting]

Location: [ICU unit/bed or indicate if remote]

Mode: [in-person / phone / video]

Reason for Meeting: [one-line summary of purpose]

Interpreter: [language and interpreter name if available] (Only include if interpreter used.)

Participants:

• Patient: [present and participation level, or not present due to...]
• Family/Surrogates: [names with relationships; identify legal decision-maker if applicable]
• Team: [attending, nursing, social work, palliative care, chaplain, others as present]

Clinical Context

[Brief narrative of what triggered this meeting] (2-4 sentences focusing on decision-relevant context: new clinical event, deterioration, need for major decision, prolonged course, or conflict. Include time sensitivity if relevant. Do not repeat the full ICU course.)

Decision-Making Authority

Patient Capacity: [has capacity / lacks capacity due to... / not formally assessed]

Decision-Maker: [name, relationship, and basis for authority—HCPOA, legal guardian, or default surrogate hierarchy]

Prior Directives: [summary of any advance directive, POLST, or prior documented wishes; or "not available—efforts to obtain and plan noted"]

[Brief note on capacity uncertainty or disagreement and plan to resolve] (Only include if capacity is uncertain or there is disagreement about decision-making authority.)

Discussion Summary

[Narrative synthesis of medical information shared and prognosis] (Summarize current status, life-sustaining therapies in use, recent developments, trajectory, and short- and longer-term outlook. Explicitly acknowledge uncertainty and what additional information could clarify the picture.)

[Narrative synthesis of values/goals elicited and options reviewed] (Describe what matters most to the patient, acceptable/unacceptable outcomes, and baseline function. Outline treatment paths discussed—full escalation, limits, time-limited trial, comfort-focused care—with high-level risks/benefits. Note options not recommended and why. Use brief direct quotes only for key value statements.)

Decisions Reached

(If no decisions were made, state "No decisions reached" with brief reason and omit the items below.)

• Goal of care: [life-prolonging with full escalation / life-prolonging with limits / comfort-focused]
• Code status: [Full code / DNR / DNR-DNI] (If partial, clarify specific preferences.)
• Treatment limits: [specific interventions to withhold or withdraw, or "none"]
• Time-limited trial: [therapy, duration, success criteria, reassessment date] (Only include if applicable.)
• Deferred: [topics not decided and reason, or "none"]

Corresponding orders [have been / will be] updated and bedside RN notified.

Follow-up Plan

• Orders: [code status order update, comfort care order set, other orders to place]
• Consults: [palliative care, ethics, chaplain, social work] (Only include if requested or planned.)
• Next communication: [family contact person, preferred method, next meeting date or trigger]
• Handoff: [instructions for covering team] (Only include if relevant.)

(Document uncertainty explicitly. Use direct quotes sparingly for key value statements. If information is missing, state "not available" and note plan to obtain.)