Knowing when to start goals of care conversations

3 minute read

Knowing when to start goals of care conversations

< 1 minute read

UCSF recommends that care teams start goals of care conversations after three readmissions to explore alternatives to hospitalization.

The Issue

Heart failure is a serious chronic condition often accompanied by comorbidities. In the first year of our heart failure program, 25% of our patients died and that number has stayed pretty consistent. When we talked to patients about their condition, we realized that many of them didn’t understand the severity of their condition. They’d say “Oh, I have a little heart problem. I take Lasix and it takes care of it.” On the flip side, there were other patients who were getting readmitted three, four, or more times in a year, and they were just tired of constantly being in the hospital. We spoke to one woman and realized all she wanted was to stay at home, but her husband was her primary caregiver and he was so burnt out that he kept taking her back to the hospital for a break.


University of California Medical Center is a teaching hospital in San Francisco, CA. It has 660 beds and serves a diverse population with varying educational levels and languages spoken (including Cantonese, Mandarin, Russian, and Spanish). It is also an advanced heart failure and transplant hospital with patients traveling from across California for their health care. Their transitions program began in 2008 and is influenced by IHI’s Transforming Care at the Bedside.

What We Tried

We wanted to have open and frank conversations with patients about their condition to create a realistic care plan for them, but those are delicate conversations that we weren’t prepared to have. We decided to go on rounds with our palliative care team to see how they have these heartfelt and frank conversations with patients. Participating in rounds with PC was really helpful and we ultimately got ourselves ELNEC (End of Life Nursing Education Consortium) certified on how to have end-of-life conversations.

In addition to our goals of care conversations, we prompt referrals and additional conversations with the Palliative care team and medical team. Now when a patient is on their third readmission within a year, we recommend in our emails to the care team that they consult palliative care to begin goals of care conversations, if not already stated. We also use a dedicated chaplain who is part of our Heart Failure team to assist in these goals of care and end of life discussions.


These conversations have had a huge impact on the way we work with patients. Patients deserve to understand how serious their condition is so they and their caregivers can make informed decisions about their care. Many of our goals of care conversations end with patients deciding they would rather go to a hospice or home with hospice than keep getting readmitted.

Additional Benefits

Since goals of care conversations happen with the patient and their caregivers, they have also helped us identify caregiver fatigue and concerns. Addressing the caregiver needs allows us to better plan for the patient and a safe disposition.


Many people in the care team will argue that goals of care should only happen near the end of life or when a patient starts to consider hospice—but, when patients have serious chronic diseases that will only worsen, we believe that the earlier you can have these conversations the better.

Patient and Family Challenges: Empowering Patients

Topics: After-hospital care, Identifying causes of readmission, Using resources effectively

Collaborator (Non-Members): Eileen Brinker

Organizational Background

Organization Name: UCSF Parnassus

Location: 500 Parnassus Avenue, San Francisco, CA, United States

Organization Type: Hospital