# Algorithm-triggered goals-of-care conversations before crisis

Source: https://onco.cc/ideas/idea-moon-goals-conversation-trigger/  
OnCo record `idea-moon-goals-conversation-trigger` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

When a prediction model says a patient has a high chance of dying within a year, their team is prompted to have a structured conversation about what matters to them, while there is still time to act on it.

## Summary

Most patients with advanced cancer do not have documented conversations about goals until the final weeks. A randomised trial at Penn used a machine-learning mortality prediction to nudge oncologists, quadrupling serious illness conversations. The proposal is to make this standard: validated risk model, default prompt with a Serious Illness Conversation Guide, documentation template, and measurement of goal-concordant care and end-of-life chemotherapy use.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Triggered conversations increase documented goals within 3 months of a high-risk flag from under 20% to over 50%, reduce systemic therapy in the last 14 days of life, and improve family-reported quality of dying.
- Rationale: Clinicians overestimate prognosis and avoid the conversation; a neutral prompt gives permission and a time. The behaviour change has been demonstrated; the outcomes now need scale.
- Proposed test: Multi-centre stepped-wedge implementation with end-of-life quality metrics and bereaved-family surveys as primary outcomes.
- Maturity: being-tested-at-scale
- Actor: clinic

## Sources

- Bottleneck evidence (Patients lack understanding, navigation and agency): Basch et al., Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment (JAMA 2017): https://doi.org/10.1001/jama.2017.7156

## Connected records

- institutions: [Abramson Cancer Center, University of Pennsylvania](https://onco.cc/institutions/penn-abramson/)
- bottlenecks: [Pain relief and palliative care are unavailable to most](https://onco.cc/bottlenecks/b-palliative/), [Patients lack understanding, navigation and agency](https://onco.cc/bottlenecks/b-patient-voice/)

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