Inpatient Goals of Care/Serious Illness Conversation Note

Encounter Details

Date/Time: [Date and time of conversation]

Location: [Inpatient unit/room or setting]

Modality: [in-person / phone / video] (If interpreter used, specify language and modality.)

Trigger: [Reason for conversation: clinical deterioration, new diagnosis, ICU transfer consideration, family request, pre-procedure, discharge planning, etc.]

Participants: [Patient presence: yes/no (if no, state reason); decision-maker(s) with relationship; clinical team members present; remote participants]

Prior GOC Notes: [Reference date(s) and summarize what has changed since prior discussion] (Only include if this is a follow-up conversation.)

Decision-Making Authority

Capacity: [has capacity / lacks capacity / fluctuating / not assessed] (Include brief basis for assessment. If not assessed, write "Not yet determined" and include plan to clarify.)

Surrogate: [Name, relationship, and basis for authority: patient with capacity, DPOA-HC, guardian, next-of-kin per hierarchy, etc.] (If not identified, write "Not yet determined" and state plan to identify. Do not infer authority.)

Decision Standard: [substituted judgment / best interest] (Include only if a surrogate is deciding.)

Discussion Summary

[Clinical situation and prognosis as communicated] (If patient/surrogate declined prognostic information, clearly state that.)

[Patient/surrogate understanding of illness]

[Values and priorities expressed: goals, hopes, fears, minimum acceptable quality of life, willingness to accept treatment burdens] (Include brief direct quotes for key value statements.)

Values Summary: [Concise synthesis of values guiding decisions] (Include when treatment limits are being considered, e.g., "Prioritizes remaining interactive; willing to accept time-limited ICU trial but not prolonged ventilator dependence.")

[Options and tradeoffs reviewed, with clinician recommendation if given]

Decisions

Goals of Care: [curative/restorative / life-prolonging with full escalation / selective escalation with limits / comfort-focused / mixed]

Code Status: [Full Code / DNR / DNI / DNR-DNI / other] (State whether order was placed/updated, by whom, and when. If discussed but unchanged, state current status remains in effect and when it will be revisited.)

Treatment Preferences: [Specific decisions about interventions discussed—ICU transfer, intubation, vasopressors, dialysis, artificial nutrition, procedures, antibiotics, etc.—noting what was accepted, declined, or conditionally accepted with details]

Time-Limited Trial: [Interventions included, time frame, success/failure milestones, and plan if milestones not met] (Include only if applicable; be explicit and unambiguous.)

Undecided/Deferred: [Items deferred with reason and plan to revisit, including date/time or clinical trigger for follow-up] (Include only if applicable.)

Follow-Up Plan

Orders: [Orders placed now; orders pending and by whom]

Communication: [Who will notify bedside nurse, overnight team, consultants, and outpatient providers]

Next Conversation: [Date/time, required participants, and pending decisions]

Contingency Triggers: [Actions if clinical status changes; who to contact prior to time-sensitive decisions]

(Document decisions as decisions and discussions as discussions. For safety-critical items—decision-maker, capacity, code status—use "Unknown/Not yet determined" with a plan rather than leaving blank.)