Goals of care discussions in hospitalised patients: systematic review of randomised trials.

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported in abstract; GOCD documentation CI excludes 1.0 (statistically significant); resuscitation preferences CI crosses 1.0 (not statistically significant)

• Effect Size: OR 1.46 (communication tools vs. comparator for GOCD documentation); OR 1.84 for resuscitation preferences (not statistically significant)

• Primary Outcome: GOCD documentation rate in hospitalised patients

• Nnt Or Sensitivity: NNT not calculable from abstract data alone; OR 1.46 for documentation represents a modest but statistically significant improvement; OR 1.84 for resuscitation preferences is imprecise and non-significant

• Confidence Interval: GOCD documentation: 95% CI 1.04 to 2.05; Resuscitation preferences: 95% CI 0.95 to 3.60

Clinical Application

Interventions identified as most effective combine structured patient-facing and clinician-facing prompts (videos, guides, EHR alerts). These are feasible in well-resourced hospital settings with EHR infrastructure. Implementation requires interprofessional training and system-level support, which may pose resource and workflow challenges in smaller or under-resourced facilities. Goals of care documentation is a recognised priority in Australian acute care settings, supported by RACGP and ANZICS guidelines for advance care planning. The findings are directly relevant to Australian hospitals implementing My Health Record-integrated advance care planning tools and state-based GOC frameworks (e.g., NSW Health Goals of Care policy, Victorian Advance Care Planning). The TGA does not regulate communication tools or decision aids, so implementation is not subject to regulatory barriers. PBS implications are indirect — improved GOCD documentation may reduce futile high-cost interventions and ICU admissions, with potential cost savings to the healthcare system. The moderate certainty of evidence supports incorporation into quality improvement initiatives but does not yet mandate a change in standard of care. Hospitalised adults across general medical, surgical, and critical care settings, and their substitute decision makers. Most applicable to patients with serious illness, advanced age, or high-risk admissions where goals of care conversations are clinically indicated.

Abstract

IMPORTANCE: Structured communication tools and decision aids are recommended to facilitate goals of care discussions (GOCDs) in hospitalised patients, but their impact remains unclear. OBJECTIVE: To determine the effectiveness of communication tools and decision aids on GOCDs between healthcare providers, patients and substitute decision makers. DATA SOURCES: PubMed, Web of Science, CINAHL and ClinicalTrials.gov were searched from January 2015 to July 2025, with backward citation tracking to identify additional trials. STUDY SELECTION: Randomised trials of communication tools or decision aids for hospitalised adults or substitute decision makers were eligible, regardless of primary outcomes. DATA EXTRACTION AND SYNTHESIS: Trial characteristics, primary outcomes and methodological quality were extracted and assessed using the Core Grading of Recommendations, Assessment, Development and Evaluation framework. Random-effects meta-analyses were conducted when appropriate. RESULTS: 22 trials were included. Communication tools increased GOCD documentation (OR 1.46, 95% CI 1.04 to 2.05). Effects on resuscitation preferences were inconsistent (OR 1.84, 95% CI 0.95 to 3.60). Mixed effects were observed for concordant care, psychosocial outcomes and healthcare utilisation. Evidence certainty was moderate for most outcomes; several small pilot trials were rated low due to bias, imprecision or heterogeneity. Interventions were most effective when combining structured patient-facing or clinician-facing prompts such as videos, guides or electronic health record alerts. CONCLUSIONS AND RELEVANCE: Communication tools and decision aids improve GOCD documentation in hospitalised patients but show uncertain effects on other patient-centred outcomes or healthcare utilisation. Interprofessional training and system-level support may enhance impact, and future large trials should evaluate the effectiveness of facilitated GOCDs on important patient and health system outcomes.

References

1. 1.DiDiodato, C., Martin, C., Austgarden, D., McLean, J., & DiDiodato, G. (2026). Goals of care discussions in hospitalised patients: systematic review of randomised trials. BMJ Supportive & Palliative Care. https://doi.org/10.1136/spcare-2025-005827