Goals-of-Care Conversations in the First 72 Hours After Admission

Many unwanted hospital transfers happen at night, in a hurry, because no one knows what the resident would want. The resident is short of breath or confused, the family cannot be reached, and the code status in the chart says "full code" by default.

A goals-of-care conversation in the first few days after admission does not prevent every transfer, and it should not. Its purpose is to make sure that when a hard moment comes, the plan reflects the resident's wishes rather than a default.

Why Timing Matters

Federal rules already set an early clock. CMS requires a baseline care plan within 48 hours of admission, and it requires facilities to inform residents in writing of their right to accept or refuse treatment and to formulate an advance directive. Residents also have the right to request, refuse or discontinue treatment.

Many teams set a target of a first goals-of-care conversation within about 72 hours. That is a practical goal, not a federal rule. It lines up with the baseline care plan, catches residents while families are often present for admission, and happens before the first weekend or after-hours change in condition.

What the Research Shows About End-of-Life Transfers

A large national study in the New England Journal of Medicine looked at 474,829 nursing home residents with advanced cognitive and functional impairment who died. About 19% had at least one "burdensome transition." The authors defined that as a transfer in the last three days of life, multiple hospitalizations in the last 90 days, or a hospital stay followed by return to a different nursing home.

Rates varied widely by state, from 2.1% in Alaska to 37.5% in Louisiana. Residents without an advance directive had higher adjusted risk. In regions with the most burdensome transitions, residents were also more likely to have feeding tubes, ICU stays in the last month of life and late-stage pressure injuries.

The study does not prove that advance directives prevent transfers. It does show how often hospital care near the end of life happens without clear, documented wishes behind it.

Who Leads the Conversation

Goals-of-care work is a team effort, but roles should be clear.

• Attending physicians and nurse practitioners lead conversations about prognosis, treatment options and code status, and they sign medical orders such as a POLST form where your state uses one.
• Social workers often start the conversation, identify the legal decision-maker, locate existing documents and schedule family meetings.
• Nurses notice when a resident or family raises questions, report changes that should prompt a revisit, and make sure the current code status is easy to find on every shift.

Everyone should know where the documents live in the chart and who to call when a family asks a question the nurse cannot answer.

Advance Directives and POLST

An advance directive records the resident's wishes and, often, who should speak for them. A POLST form is different. POLST describes itself as a portable medical order for people with serious illness or frailty, turning their wishes into orders that medical teams can follow when the person cannot speak for themselves. POLST.org has a state-by-state map of forms and resources, so check what applies in your state.

Good documentation means the code status, the decision-maker, and any medical orders match each other. When they conflict, flag it for the provider right away.

Tools That Make the Conversation Easier

You do not have to invent a script.

• INTERACT includes Advance Care Planning tools as one of its four tool types. Earlier INTERACT materials included a guide to help social workers and primary care providers start conversations with residents and families when health declines, including moves toward comfort care or hospice.
• The Serious Illness Conversation Guide from Ariadne Labs is designed for physicians, nurses, social workers, chaplains and other clinicians. It is built around questions such as how much a person wants to know about what is ahead, what their most important goals are if health worsens, their biggest fears, and what tradeoffs they would accept for more time. In an outpatient oncology trial, the program led to earlier and more complete documented conversations.

Both tools focus on listening first. The goal is to understand what matters to the resident, then let the provider translate that into a care plan.

What to Do This Week

• Pull a list of residents admitted in the last two weeks and check whether a goals-of-care conversation is documented.
• Confirm that code status appears in the same place in the chart for every resident.
• Agree on who schedules the first conversation (often social work) and who leads it (the provider).
• Add "revisit goals of care" as a prompt after any hospital return or major change in condition.
• Share the Serious Illness Conversation Guide or your INTERACT advance care planning tools with your interdisciplinary team.

A daily admission screen can flag residents whose risk profile suggests the care team may want to prioritize an early conversation, which is one way Keystone supports facility teams.

This article is general education for skilled nursing teams. Follow your facility's policies and the direction of your medical director and providers.