NR-578 · Week 7 of 8 · Goals of care and advance planning

NR-578 Week 7 Goals of Care Conversations: How to Write It

By Corinne Ashdown, MSN, RN Primary Care Management of Older Adults 8-week session Manual reviewed August 2026
The short answer

A family meeting held over video, with one son in a car park on his lunch break and a daughter on a laptop three states away, is now an ordinary way for a goals-of-care conversation to happen, and the written record of it is graded on the same things a bedside conversation would be. Late in an older-adult practicum the written work usually turns to this territory: eliciting what matters to a person, translating it into treatment decisions, and documenting the reasoning so that a clinician who has never met them can act on it at three in the morning. The competency being tested is the conversation, written down. Your section may print this as NR 578 or NR578; it is the same course. Chamberlain publishes no syllabi outside Canvas. The placement here is our teaching judgment from the course's catalog arc; your section's rubric decides what your week actually asks. Clinical hours, encounter logs, site documentation, signed forms and preceptor evaluations are your own record and are never drafted, reconstructed or estimated with help.

NR-578 Week 7 grading scale at Chamberlain, the criterion levels this assessment is scored on, from Chamberlain Tutors
How Chamberlain grades NR-578 Week 7, visualized by Chamberlain Tutors.

What a goals-of-care document has to capture

The first requirement is values elicited before options are offered. The order matters more here than anywhere else in the course. A conversation that opens with a list of interventions produces answers about interventions, which is why so many documented preferences are a set of yes and no boxes that nobody can apply to the situation that eventually arises. A conversation that opens by asking what a good day looks like, what the person is most worried about, what they would find unacceptable and what they would trade for more time produces values, and values can be applied to circumstances nobody anticipated. In the write-up, the values paragraph comes first and the treatment decisions are visibly derived from it.

The second is an understanding check that is written as an exchange rather than asserted. Before preferences can mean anything, you need to know what the person believes about their own situation, and that belief is frequently different from what is in the record. Asking what they understand about their condition, what they have been told, and what they expect to happen next produces the starting point. Where their understanding differs from the clinical picture, the document should say so plainly and describe what was done about it, since a preference formed on a mistaken premise is not an informed one. This paragraph is also where students most often substitute a summary for the actual content, and the actual content is what earns the row.

The third is the translation step, which is the analytic centre of the document. Values do not automatically produce decisions; somebody has to reason from one to the other, and writing that reasoning out is the graded work. If a person says the thing they fear most is being kept alive without recognizing their family, that has implications for several categories of decision, and the document should trace them. If someone says they would accept a difficult treatment for a realistic chance of returning home but not for time in a facility, that is a decision rule that can be applied to a situation nobody has thought of yet. Writing the derivation, rather than jumping from a quoted value to a completed form, is what distinguishes this paper.

The fourth is the surrogate layer handled properly. Who would speak for this person, whether that person knows they have been named, whether they have been told what matters to the patient, and what legal instrument exists in this state are four separate facts, and the second and third are the ones that determine whether any of it works in practice. A surrogate named on a form who has never had the conversation will make decisions under pressure with no idea what the person wanted. Writing that gap where it exists, and the plan to close it, is practical clinical work rather than paperwork commentary.

The practicum boundary is at its sharpest in this territory and deserves stating precisely. You may have participated in these conversations under supervision, and everything institutional that resulted, including any advance directive, portable medical order, surrogate designation or signed form, is a legal or clinical document belonging to the patient and to the clinicians who executed it. None of it is drafted, completed, reconstructed or edited with writing help of any kind, and neither are your hours, your encounter log or your preceptor's evaluation. Your academic document is an analysis of your own reasoning about a conversation you genuinely had, fully de-identified. If a discussion accompanies the assignment, treat the post as final copy, since posts do not reopen after submission in Canvas.

The NR-578 Week 7 method, step by step

Six moves for writing a goals-of-care conversation so it can be acted on.

  1. 1. Record what the person understood before you explained anything

    Their account of their condition, what they have been told, and what they expect. Write it as they said it. Where it diverges from the clinical picture, say so and describe how the gap was addressed.

  2. 2. Elicit values with open questions and quote the answers

    What a good day contains, what worries them most, what they would find unacceptable, what they would trade time for. Short direct quotations are the strongest evidence available in this document.

  3. 3. Establish who is in the room and who is missing

    Who attended, by which route, and whose absence matters. A conversation that omits the person who will be called at three in the morning has a structural problem, and naming it is part of the analysis.

  4. 4. Derive decisions from values in visible steps

    Take each stated value and reason forward to what it implies for a category of treatment. Write the derivation. A jump from a quotation to a conclusion leaves the reasoning invisible and unscoreable.

  5. 5. Test the decisions against a scenario nobody named

    Apply the stated values to a plausible situation that was not discussed and see whether they produce a clear answer. Where they do not, that is the question for the next conversation, and saying so is stronger than pretending completeness.

  6. 6. Write what happens next and who holds it

    Which clinicians need this information, how it travels between settings, when it is revisited, and what event would trigger an earlier review. Preferences that live in one clinic's note do not reach the setting where they will be needed.

A layout and word budget for a goals-of-care document

Our frame for a conversation write-up, sized for roughly 1,300 to 1,600 words. It is our own outline rather than anything the university issues, and your week's rubric outranks it wherever the two disagree.

ElementWhat belongs in itWord target
Context and triggerDe-identified situation, functional and disease trajectory, and what prompted the conversation now rather than later.150 to 200
Participants and settingWho attended, by what route, who was absent and why that absence matters to the outcome.110 to 150
Understanding establishedWhat the person believed about their situation before anything was explained, and how any divergence was handled.190 to 240
Values elicitedThe open questions asked and the answers in the person's own words, kept short and in quotation marks.220 to 280
Derivation to decisionsEach value reasoned forward to what it implies for a category of treatment, in visible steps.250 to 320
Surrogate and documentation statusWho would speak, whether they know, whether they have been told what matters, and what instrument exists in this state.170 to 220
Travel and reviewWho needs this information, how it moves between settings, the review interval and the trigger for an earlier one.150 to 200

Evidence craft for goals-of-care writing

Use a named communication framework and cite it. Structured approaches to serious illness conversation exist, have been tested and provide the question sequence your document is following. Naming one with its year lets a grader evaluate your method rather than your instincts.

Cite your state's legal framework rather than describing it generally. Advance directives, surrogate hierarchies and portable medical order programmes differ substantially between states. Name the jurisdiction and cite its statute or health authority guidance where a legal fact affects your reasoning.

Quote the person briefly and exactly. A sentence in their own words about what they want or fear is worth several paragraphs of paraphrase, and it is the evidence that a values conversation actually occurred. Keep it short, keep it in quotation marks, and make sure it is doing analytic work.

Write prognosis without inventing precision. Where trajectory bears on a decision, describe it in terms of function and direction, cite what supports the description, and state the uncertainty. Manufactured timeframes are both inaccurate and, in this territory, a serious error.

Keep the register neutral about the decisions people reach. Preferences that differ from what you would choose are recorded as findings, not evaluated. Words like unrealistic and refused carry judgment, and they are marked in professional communication rows.

Five mistakes that cost points at this stage

  • Interventions offered before values were asked. A conversation that opens with a menu produces answers about the menu, and the resulting document cannot be applied to any unforeseen situation.
  • A form treated as the outcome. Completing paperwork is not the competency; the reasoning that would let another clinician act correctly at three in the morning is.
  • Values quoted and decisions asserted with nothing in between. The derivation is the graded step, and skipping it leaves the argument invisible.
  • Understanding never checked. Preferences formed on a mistaken premise are not informed, and a document that never asks what the person believed has skipped the foundation.
  • The surrogate named but never spoken to. A designation with no conversation behind it will not function under pressure, and the gap belongs in the document with a plan attached.

Before you submit

  • What the person understood is recorded before anything you explained
  • Values were elicited with open questions and appear in the person's own words
  • Every treatment decision is derived from a stated value in visible steps
  • A named communication framework is cited with its year
  • The state legal framework is cited where a legal fact affects the reasoning
  • The surrogate's awareness and knowledge of the person's values is addressed
  • Prognosis is described without invented timeframes
  • The plan says how this information travels and when it is revisited
  • No advance directive, portable order or signed form has been drafted or reproduced

Writing the NR-578 goals-of-care case?

Send the rubric and your de-identified notes out of Canvas. A premium original draft comes back in 24 to 48 hours with values elicited before options, the derivation from values to decisions written in visible steps and the surrogate gap named with a plan, and revisions run until the grade lands. Directives, portable orders, hours, logs and evaluations stay entirely yours.

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Questions students ask about this stage

The family wanted everything and the patient had said otherwise. How is that written?
Carefully, accurately, and with the reasoning that governs the situation stated rather than implied. Record what the patient had expressed, when, to whom and in what form, since the strength of that evidence matters. Record what the family expressed and, more usefully, what was driving it, because in most of these situations the disagreement is not really about the intervention. Common drivers are guilt, an expectation that a relative would want them to fight, a belief the clinical picture is better than it is, a religious or cultural obligation, or simply not having been told plainly what is happening. Write what was done to address the actual driver. Then state the framework: where a person with capacity has expressed a preference, that preference governs; where capacity is absent, a surrogate is asked to represent what the patient would have wanted rather than what the surrogate wants. Keep the register neutral throughout, because a document that positions the family as an obstacle loses in the communication row even when its clinical reasoning is sound.
My patient did not want to discuss any of it. Is there still a paper here?
Yes, and it can be a good one, because the way you respond to a deferral is itself a competency. Write what you asked, how it was framed and exactly how they declined, since there is a great deal of difference between not now, not ever and I want my daughter to handle all that. Each of those points somewhere different. Then write what you did: whether you established permission to raise it again, whether you asked the narrower question of who should speak for them if they could not, whether you addressed a worry that was driving the avoidance, and what you documented so the next clinician does not open cold. A great deal can be accomplished without a full conversation, and identifying a surrogate is often achievable when a discussion about treatment is not. Finish with the plan for revisiting and the event that would make it urgent. What the paper should not do is present a conversation that did not happen, in any form.
Does a goals-of-care conversation work over video, or should I wait for an in-person visit?
It works, with adjustments, and waiting has its own cost since these conversations are most often held too late rather than too early. Video has real advantages for family involvement: relatives who could never attend a clinic appointment can be present, which matters when the people who will be called in a crisis live elsewhere. It also has real constraints. You cannot read a room the same way, silences are harder to hold when a connection lags, and you cannot tell who else is listening off camera, which is worth establishing at the start. Practical points belong in the write-up: whether the patient could hear adequately, whether they had a private space, how you managed multiple participants, and how you checked reactions you would normally have seen. Then say what you would still want to do in person and when it is scheduled. A document that names the modality's effect on the conversation reads as far more thoughtful than one that reports a video meeting as though it were a room.
How do I write about a conversation with someone who has cognitive impairment?
By treating participation as a spectrum rather than a switch, which is the clinically accurate view. Many people with mild or moderate impairment can express values reliably even when they cannot reason through a complex treatment decision, and values are exactly what the conversation is trying to elicit. Write what you did to support participation: shorter sessions, simpler framing, a time of day when they were at their best, a familiar person present, and questions about what matters rather than about technical options. Record what they were able to express and mark it as their own words. Then write the surrogate layer alongside rather than instead, and be explicit about which parts of the plan rest on the person's own expressed values and which rest on substituted judgment. Where you assessed decision-specific capacity, describe it in those terms rather than as a global statement. A document that writes someone out of their own conversation because of a diagnosis has made a clinical error as well as an ethical one.

Keep going

NR-578 course hub Week 8: the closing competency portfolio The AGPCNP track help page
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