Takeaway
Make goals of care an ongoing priority—start early, revisit often, and align care with what matters most to the patient.
Connecting with Patients | January 7, 2026 | 2 min read
By Eric Last, DO, Zucker School of Medicine & Department of Writing Studies, Hofstra University
Throughout her remarkable NEJM podcast series “Not Otherwise Specified,” Dr. Lisa Rosenbaum has been chronicling the challenges and travails of primary care. The concept of the dreaded “checkbox” is a recurring theme. We’re endlessly required to check boxes about vaccines, about smoking, about drinking, and about the multitude of cancer screenings that cycle through a person’s lifespan. One often overlooked “checkbox” relates to a person’s goals of care.
Of all our “tasks,” frank discussions about goals of care, and a person’s unique priorities, can have the most impact. Yet, such discussions are often treated in a superficial way or not held at all on the assumption that other clinicians on the patient’s care team have had them. This can have devastating consequences. Worse still is the concept that the patient’s goals are static and unchanging. In truth, through the course of an illness, a person’s goals can change just as their illness can progress, prognosis vary, and concepts of hope evolve.
As primary care clinicians, we’ve likely all been in this situation: a patient, most often with cancer, is being treated by multiple subspecialists. There may be a medical oncologist, a surgical oncologist, a radiation oncologist, and numerous other subspecialists treating conditions in multiple organ systems in the illusory vacuum of compartmentalized care. With each setback comes another treatment offered, another therapy discussed, another potential trial for which the patient may qualify. It’s a clinical pattern discussed brilliantly and painfully throughout Dr. Atul Gawande’s book, “Being Mortal.”
For a primary care clinician, especially one who has nurtured relationships with patients over a long span of time, through challenges faced and trust earned, it’s awful to see patients faced with these scenarios. Not the multiple treatments tried, but the pattern of endless interventions without ever discussing what our patients truly want.
It’s not enough to ask, “What are your goals,” check a box, and move on. We all have the capacity to be the person to have this conversation with patients: “You’re doing pretty well now. But we need to think about this: if a time comes when it seems that your treatment is causing you more distress than any benefit it could offer, what should we do together?” Emphasize that the patient’s goals are paramount, that hope for improvement still exists, and that we’ll be there to help them through whatever process is to come.
There’s no checkbox that can adequately memorialize that conversation, nor any billing code that could financialize that level of relationship-requiring trust. We must have these conversations anyway, so that they aren’t held hours before a patient’s often predictable death.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.