Goals of Care · A Conversation Guide
Decisions about your health — and about the end of life — belong to you and the people you love. We are here to give you honest information so those decisions reflect what truly matters to you, especially when hopes and reality don’t line up.
“The only surefire terminal disease is life itself.”
Why we have this conversation
Death and taxes — the two certainties. We all understand, in our heads, that life does not go on forever. Accepting it in the heart is another thing entirely, and no one should have to do that alone or under pressure in a hospital hallway.
A goals-of-care conversation is not about giving up. It is about getting clear — while there is time and calm to think — on what a good day looks like for you, how much you are willing to go through for more time, and where you draw the line. When we know that, we can shape every decision around your goals instead of guessing later.
We will tell you the truth, plainly. Then the choices are yours.
Talking about prognosis
When patients and families ask about time, they deserve a real answer. Part of that real answer is this: doctors are not very good at predicting it — and we almost always guess too high.
20%
of physician survival predictions for terminally ill patients were actually accurate
5×
how much doctors overestimated survival, on average (by a factor of 5.3)
63%
of predictions were too optimistic — far more than were too pessimistic
Christakis & Lamont, BMJ 2000 — 343 doctors, 468 terminally ill patients (median actual survival: 24 days). Notably, the longer a doctor had known the patient, the less accurate the estimate became — affection quietly tilts the guess toward hope.
Even patients with a known terminal illness frequently die not from that illness directly, but from a sudden, separate event the body can no longer absorb — a fall, a stroke, a heart attack, or a lower respiratory infection (pneumonia). Frailty narrows the margin for all of these. Understanding this helps families prepare for the real shape of decline, which is often a series of steps and sudden drops rather than a slow, predictable slide.
Understanding CPR
On television, CPR looks like a brief, clean rescue: a few compressions, a gasp, and the patient sits up. Real CPR is something else, and the difference matters enormously when you are deciding whether you want it.
CPR prevents dying. It is gentle, usually works, and the person returns to the life they had before.
CPR is attempted after the heart and breathing have already stopped — after death has begun. It is a forceful effort to restart a body, not a way to keep one from dying. Most of the time it does not succeed, and when it does, recovery is far from guaranteed.
Where the arrest happens — and how old and how sick the person is — changes the odds dramatically.
~9%
Survival to leaving the hospital after cardiac arrest in the community (all adults)
~17–18%
Survival to discharge after cardiac arrest inside a hospital (older adults)
~4%
Survival to discharge for community arrest in adults over 70
~5%
Survival for community arrest at age 85+ (vs. ~10% at 65–74)
0–11%
Survival to discharge for nursing-home and assisted-living residents
Sources: American Heart Association 2021 OHCA data (9.1% to discharge); pooled survival in adults >70 with out-of-hospital arrest ~4.1% (Resuscitation systematic review); in-hospital survival in older adults 11.6–18.7% (Age & Ageing review; NEJM Medicare cohort 18.3%); facility-resident outcomes 0–10.5% across studies. Outcomes are lowest when the rhythm is non-shockable, which is the most common situation in frail elders.
Around 44% of in-hospital attempts restart a heartbeat for a while, but only about 17% live to go home — and many survivors leave with new disability. Long-term outcome depends heavily on the brain: among older survivors of in-hospital arrest, roughly 59% were alive a year later if they left with little or no brain injury, but only about 10% if they left in a coma or vegetative state. The question is therefore not only “will it work?” but “what would survival look like, and is that a life I would want?”
NEJM 2013 (elderly in-hospital arrest survivors): 58.5% alive at 1 year overall; 10.2% alive at 1 year if discharged comatose/vegetative. National Registry of CPR: ~44% immediate survival, ~17% survival to discharge.
When CPR is done correctly
This is not a sign of something done wrong. Effective chest compressions push the breastbone down nearly two inches, dozens of times a minute. In an older chest, where cartilage has stiffened and bones are thinner, that force commonly breaks ribs and the sternum. The resuscitation guidelines themselves describe broken ribs as a common and accepted consequence of properly performed CPR.
Up to 89%
of patients have rib fractures found after CPR in autopsy studies
~8 ribs
broken on average in one controlled study of standard CPR
~50%
of those cases had additional internal chest injuries
Autopsy and CT series report rib fractures in roughly 13–89% of cases and sternal fractures up to ~47%; injury rates rise with advanced age, female sex, and longer resuscitation. Older adults with reduced bone density are at the highest risk. (Sources: JAHA 2022; Resuscitation autopsy studies; AHA/ILCOR consensus.)
The role of other conditions
Survival statistics describe groups of people. Your own odds depend on your particular situation — and a heavier burden of chronic illness lowers them further. In the large registry studies, patients with more comorbidities (measured by tools like the Charlson index) and those whose arrest happened at home rather than in public were significantly less likely to survive.
Conditions such as advanced heart failure, kidney disease, COPD, dementia, frailty, and cancer each reduce the body’s ability to recover from a major event like cardiac arrest — and they compound when combined. This is why two people the same age can face very different realistic outcomes, and why our recommendations are always tailored to you, not to an average.
Putting you back in the driver’s seat
Sometimes what a patient or family is hoping for and what medicine can realistically deliver are two different things. That gap is not a failing on anyone’s part — it is the most human thing in the world. Our role is to close it gently, with information, so your decisions rest on the truth rather than on the version of events we wish were true.
Geriatric care, palliative care, and hospice
These terms are easy to mix up, and the differences genuinely matter. Here is how each one works and where our practice fits.
This is who we are. We manage your overall health — chronic conditions, medications, function, memory, fall risk — and we lead these goals-of-care conversations. We coordinate the other services below and stay your physician through them.
A specialty focused on relieving symptoms — pain, breathlessness, nausea — at any stage of a serious illness, even alongside treatments meant to cure. Complex symptom management is its own area of expertise, so for difficult cases we refer to a palliative specialist rather than stretch beyond our lane. It does not require a six-month prognosis.
An added layer of care for the final stage of life, built around comfort. It brings in a hospice nursing team, medications, medical equipment (DME), and supplies related to the terminal illness — delivered wherever you live. Importantly, hospice does not replace us: we can remain your attending provider while the hospice team supports you and your family.
Under Medicare, hospice is available when:
Reference: 42 CFR §418.22; CMS Hospice benefit; CMS LCD L34538 (Determining Terminal Status). Hospice is not a one-way door — if someone stabilizes or improves, they can be discharged and re-enrolled later if they decline again. A wide range of conditions qualify, not only cancer: advanced heart, lung, kidney, and neurologic disease all commonly meet criteria.
Where we go from here
You do not have to decide everything today, and nothing here is set in stone — goals can change as life does. What we ask is simply that we keep talking honestly, so that whatever comes, your care reflects what matters most to you.
Bring your questions. Bring the people you love. We will give you the truth, and then we will help you carry it.