One voice at the bedside: aligning goals of care and prognostic communication in trauma and acute care surgery

Abstract

High-acuity surgical and trauma care requires rapid decision-making under conditions of uncertainty, fragmented information flow, and competing physiological priorities. Patients frequently move across multiple services, each bringing distinct clinical expertise and discrete perspectives on prognosis, treatment goals, and acceptable outcomes. Within this dynamic environment, variation in prognostic framing and communication is common. Families often receive subtly different messages about the patient’s expected trajectory, which can foster confusion and mistrust. Clear, aligned communication is therefore not an adjunct to technical excellence; it is an essential component of high-quality trauma and surgical care.

Contemporary surgical practice increasingly intersects with palliative care principles. Surgical patients experience significant symptom burden, uncertain recovery, and frequent inflection points requiring reconsideration of goals of care. Surgeons occupy a central role in these early conversations. Early surgeon-initiated discussions about values and acceptable outcomes improve alignment between treatment plans and patient preferences, clarify expectations as clinical conditions evolve, and support family decision-making under stress. Yet, there is little formal training of surgeons in this area. Specialty palliative care is an essential partner when complexity, symptom burden, or decisional conflict exceed routine surgical management. Together, surgeon-led communication and selective palliative collaboration create a model in which trauma care remains both aggressive when appropriate and consistently grounded in what matters most to patients and families. This review, recently discussed at the American Association for the Surgery of Trauma online Grand Rounds, will address several of the most common obstacles encountered by acute care surgeons navigating multidisciplinary goals-of-care and prognostic discussions, as well as complex surrogate situations. Specifically, it examines how to create and deliver a cohesive and consistent message from a multidisciplinary team, the role of surgeon-led palliative care discussions with and without formal palliative care service consultation, and strategies for managing discordant surrogate decision-makers.

The surgeon’s role in early palliative care integration

The complexity of contemporary surgical care has increased substantially as surgeons care for older patients, individuals with significant comorbidities, and those who experience prolonged or uncertain postoperative courses. In this environment, early conversations about goals of care are essential. Such discussions help align interventions with patient values, provide clarity when clinical conditions change rapidly, and support decision-making in the face of uncertainty.

Across the surgical continuum, the surgeon frequently serves as the primary medical provider. Surgeons assess the appropriateness of operative intervention, explain risks and benefits, and help patients and families understand the expected course of recovery. This role is especially prominent in trauma and acute care surgery, where surgeons oversee evaluation, resuscitation, operative management, and critical care. ¹ Even within the elective setting, longstanding surgeon and patient relationships foster trust and allow for conversations about values before complications arise.

Surgical judgment is central in determining whether an operation is likely to relieve suffering or when its burdens may outweigh potential benefit. Ethical commentaries and surgical literature emphasize that surgeons play a critical role in identifying when operative intervention may meaningfully improve quality of life or if a comfort-focused or non-operative strategy is more consistent with patient goals.² When surgeons engage in early communication about values and priorities, they help guide treatment planning across the course of serious illness rather than only as death becomes more likely.^{3 4}

Evidence supports the integration of palliative care early in the course of serious illness. In a cluster randomized controlled trial of high-risk intensive care unit patients, early palliative care consultation increased transition to do not resuscitate or do not intubate status, increased hospice utilization, reduced ventilator days, and lowered readmission rates without increasing mortality.⁵ A retrospective cohort study also showed that early palliative involvement reduced intensive care interventions near the end of life.⁶ Although these studies were not limited to surgical populations, the findings are highly relevant as many surgical patients experience postoperative or trauma-related critical illness with similar prognostic uncertainty.

Surgical populations demonstrate substantial unmet palliative needs.^{7 8} For patients presenting with acute, life-threatening surgical emergencies, even brief discussions about patient values and acceptable outcomes can guide immediate treatment decisions and help shape postoperative expectations. These conversations do not delay lifesaving intervention but ensure care aligns with what matters most to the patient.

Trauma and emergency general surgery patients frequently present additional challenges. Many lack decision-making capacity due to neurological injury, intoxication, or their overall physiological status. Surrogates often make decisions under emotional stress and substantial uncertainty. The unpredictable course of traumatic and septic physiology, along with the risk of repeated complications or neurological decline, requires ongoing reassessment of goals. While early surgeon-led communication helps families anticipate a variable path to recovery, as complexity increases, specialty palliative care consultation may be needed to support symptom management, facilitate difficult discussions, and aid families who are distressed. Unfortunately, high-quality randomized data specific to trauma and emergency general surgery populations remain limited.^{9 10}

Despite the lack of specific surgical-based studies, professional organizations increasingly support structured approaches and ongoing research to integrating palliative care into trauma and surgical practice. The Eastern Association for the Surgery of Trauma performed an evidence-based review evaluating palliative care processes in geriatric trauma patients. They identified potential benefits of palliative care integration, such as improved documentation and reduced length of stay, while acknowledging significant gaps in the evidence.^{11 12} The review concluded that while palliative processes can improve the quality of care, additional research is needed before adopting universal palliative triggers in trauma settings. Other experts similarly advocate embedding palliative care principles into trauma center practice to strengthen patient-centered care without compromising surgical readiness.¹³ The AAST palliative care committee has developed a set of practical guidelines, which are available on the AAST website, with the goal of helping clinicians to incorporate palliative care principles into surgical practice.¹⁴ These guidelines cover specific traumatic injuries as well as commonly encountered surgical problems, and they are intended to support clinicians in leading goals-of-care discussions with patients and their families.

Deciding when to involve specialty palliative services requires careful clinical judgment. Specialty consultation is particularly valuable when patients experience persistent or worsening organ dysfunction despite aggressive therapy, prolonged and uncertain recovery trajectories, refractory symptoms that exceed routine surgical management, complex family dynamics or conflict, lack of patient capacity along with unclear prior preferences, or repeated major interventions without meaningful improvement. In trauma and surgical intensive care units, these situations are common. Specialty palliative care teams contribute expertise in symptom management, high-stake communication, shared decision-making, and supporting consensus building among multidisciplinary teams.

Despite clear potential benefits, barriers remain substantial. Surgeons often report discomfort with emotionally challenging conversations, concern about reducing hope, uncertainty regarding prognosis, and limited time in demanding clinical environments.¹⁵ These barriers are amplified in high-acuity settings where rapid decision-making is the norm. Overcoming these challenges requires institutional and cultural support, training in communication skills, and reinforcement that palliative communication complements rather than replaces life-sustaining intervention when appropriate.^16–18

A practical model combines early surgeon-initiated discussions with selective specialty palliative involvement. Surgeons begin foundational conversations as soon as risk becomes apparent. Specialty services are often involved when complexity, emotional burden, or symptom management exceed what the primary surgical team can provide. Clear documentation, routine reassessment of goals, and effective communication with the entire care team help ensure alignment with patient values throughout hospitalization. This approach is consistent with the recent conceptualization of subspecialty palliative care as synergistic with recovery-focused care, and it allows ongoing quality improvement and minimizes miscommunication.^{13 19–21}

As surgical and trauma populations age and comorbidities increase, structured patient-centered communication will become even more essential. Surgeon-led discussions, supported by specialty collaboration when needed, can reduce non-beneficial treatments, improve family understanding, and uphold ethical decision-making. Integrating palliative care into surgical practice does not reduce the commitment to lifesaving or aggressive intervention when appropriate. Instead, it ensures that surgical care remains aligned with patient values and is responsive to changing clinical conditions. Across elective surgery, emergency surgery, trauma, and critical care, early surgeon-led palliative communication represents important progress toward compassionate, patient-centred surgical care.

Managing discordant surrogate decision-makers

Discussing goals of care for complex patients can be difficult, particularly when there is conflict among surrogate decision-makers. This may occur for a variety of reasons. Family members often have conflicting cultural or religious beliefs, misaligned priorities, unknown secondary motivations, and/or an incomplete understanding of the patient’s wishes and values. Most importantly, families faced with difficult decisions are often under great emotional distress, which can cloud logical decision-making and strain family relationships. As trauma and acute care surgeons, we often play the role of objective mediators, helping to guide surrogates to make decisions based on the patient’s best interest.

The first step in mediating conflict among surrogate decision-makers is to establish that the patient does not have decisional capacity. To demonstrate capacity, patients must be able to explain risks and benefits and demonstrate logical connections between cause and effect. Capacity can be assessed by any physician, and it may fluctuate over time. Competence, on the other hand, is a legal status determined by a judge. If a patient does not have capacity, then medical decision-making falls on surrogate decision-makers with the guidance of the care team.²² This can be dictated by the patient, in the form of advance directives. If an advance directive is not available, then decisions are often guided by default surrogate laws, which vary from state to state. In rare cases, in the absence of an identified surrogate and/or in cases where clinical urgency does not warrant physician-guided substituted judgment, a hospital-appointed surrogate committee or court-appointed guardian may make medical decisions.^{3 23}

Advance care planning can take several forms. A healthcare proxy (HCP) is a person designated by the patient to make decisions on their behalf. Notably, HCP can only be assigned by a patient who has capacity. HCP forms often require witness signatures, but they do not require a lawyer. A living will, on the other hand, is a legal document that outlines preferences for medical treatment in the event that a patient becomes incapacitated. This is signed by a lawyer and often discusses situations in which a patient is in a vegetative state, which may or may not be applicable to the current medical situation. Lastly, Medical Orders for Life-Sustaining Treatment and Portable or Physician Orders of Life-Sustaining Treatment are legal forms that can be completed by a trained medical professional. They can include preferences for code status, as well as detailed preferences for artificial nutrition, dialysis, and antibiotics.

If advance directives are not available, then decision-making falls to surrogate decision-makers. Surrogate hierarchy varies by state, but in general, priority falls on the patient’s spouse or domestic partner, followed by an adult child, parents, siblings, and then extended family and friends. Currently, 44 states have surrogate consent laws. In some states, like Colorado and Hawaii, there are consensus statutes which allow all reasonably available ‘interested persons’ to come to a consensus decision. In 18 states, there are statutes that allow for dispute among surrogates at the same hierarchical level to rely on majority. In general, those who are lower in the surrogate hierarchy cannot overrule a surrogate higher than themselves without judicial proceedings.²⁴

When disagreements arise among surrogate decision-makers, the surgeon’s role is to re-center the conversation on the patient’s values and to re-establish a shared ethical framework for decision making. Two principles guide this work. The first is substituted judgment: what would the patient choose if they were able to participate in the discussion? When the patient’s preferences are unknown or uncertain, the second principle, the best interest standard, guides the team to consider what most individuals would reasonably decide under similar circumstances. In practice, this requires clinicians to help surrogates evaluate whether the anticipated benefits of an intervention meaningfully outweigh the burdens of physiological stress, procedural risk, and suffering. By returning the discussion to the patient’s goals, acceptable outcomes, and lived values, the surgeon can often de-escalate interpersonal tension and shift the focus from disagreement between surrogates to alignment around the patient.²⁵

It can be very helpful to ask open-ended questions and to be curious about the reasons for conflict. Clinicians should explore family dynamics and determine why there is disagreement. It can be helpful to determine if there is a ‘primary’ surrogate who would be willing to make decisions based on the majority of participants. It is imperative to establish rapport with family members and to build trust by acting as an objective mediator and giving consistent, clear information. This may be achieved over the course of several meetings, when the clinical situation allows it. A ‘pre-meeting’ with other medical teams to discuss goals of the conversation and to align on prognostic information can be very helpful, particularly when there are many teams involved in patient care. A helpful mnemonic to remember in these discussions is ‘STADA.’

• ‘S’ is for ‘sit down’ (often in the form of a family meeting).

• ‘T’ is for ‘tell me about your family member.’

• ‘A’ is for ‘admire,’ that is, give supportive statements to the family members to show that you see they are caring for their loved one.

• ‘D’ is for ‘discussing diagnosis and prognosis’ in a clear and concise manner.

• ‘A’ is ‘asking what the family member would want and what would be in their best interest.’²⁶

Other helpful strategies include giving the family a time-limited trial.²⁷ This involves setting a time point in the future, at which point if there is no improvement in the patient’s clinical picture, then moving forward with a particular plan. This allows for family members to feel their preferences are being honored but also sets limits on these preferences. Additionally, it gives family members time to deliberate medical decisions on their own without clinicians present. It can also be helpful to involve other members of the multidisciplinary team, including social workers and chaplains. An ethics consult can be helpful in some situations. The ultimate goal of these discussions is to maximize the likelihood that a resolution will be reached in a way that is acceptable for all parties involved.

A coordinated voice: aligning prognostic communication across trauma teams

Clear and consistent communication is a central component of high-quality trauma care, yet it remains an area in which even experienced teams struggle. In this environment, prognostic communication, particularly during the early, high-acuity phases of care, can easily become fragmented. Families may receive subtly different prognostic assessments from trauma surgeons, neuro-specialists, other physician consultants, and bedside nursing staff. These discrepancies can generate confusion, distress, and mistrust.^{28 29}

Prognostic discordance is common in critical care settings, with studies demonstrating that a meaningful proportion of surrogate decision-makers report receiving conflicting assessments of prognosis from clinicians.^{28 29} Trauma care introduces additional complexity: rapid physiological shifts, short decision windows, and the involvement of multiple surgical and critical care services. These dynamics create a clinical environment in which each specialty develops its own narrative of the patient’s trajectory. Without deliberate coordination, these narratives diverge.

Language compounds the problem. Clinicians often rely on familiar but imprecise phrases: ‘guarded,’ ‘too early to tell,’ ‘critical but stable’ that may sound reassuring or appropriately cautious but convey limited actionable information to families. These terms also create ample space for variation in interpretation across clinical disciplines. When each service uses its own preferred vocabulary for uncertainty, the result is a collection of parallel but incongruent prognostic messages.

Divergence in communication is rarely the result of negligence or lack of interest; rather, it reflects predictable structural and cultural features of trauma systems:

1. Differing cognitive frames: each specialty foregrounds different aspects of the patient’s condition. Each perspective is valid but incomplete.

2. Discomfort with explicit prognostication: many clinicians hesitate to offer clear statements about prognosis, particularly when uncertainty feels high. This leads to cautious or hedged statements that place interpretive strain on families.³⁰

3. Lack of structural alignment: parallel rounding practices and limited interservice communication mean clinicians may not regularly reconcile their mental models before meeting with families. As a result, variability accumulates unnoticed until families point it out.²⁸

Unified messaging does not require uniform wording; rather, it requires a shared conceptual framework for what the clinical team believes is most likely to occur and what the goals of care should be at a given clinical moment.^{3 4 31 32} Consistency in trajectory, rather than identical phrasing, is the objective.³³ Improving prognostic alignment requires repeatable clinician behaviors integrated into existing workflows.

Before scheduled family meetings or major clinical inflection points, a brief interdisciplinary huddle can ensure that the team agrees on key messaging. These huddles need not be long; even a 5-minute discussion can clarify goals of care, confirm who will lead the meeting, and identify which services will reinforce core messages. Ideally, the use of serious illness communication frameworks provides scaffolding for complex discussions. They reduce cognitive load, improve clarity, and mitigate the risk of inconsistent or overly ambiguous language.^{31 33} While full co-rounding is impractical for most trauma services, selective co-rounding for the highest-risk patients: those with catastrophic injuries, prolonged intensive care unit stays, or recurrent family meetings, can significantly reduce communication drift. Even a weekly shared discussion of such patients can help align messaging before it reaches families.

Aligning communication helps families make decisions grounded in a coherent understanding of clinical reality. It reduces clinician moral distress and promotes more coordinated, goal-concordant care.

Conclusion and summary

Trauma care will always involve uncertainty, complexity, and rapid decision-making. In this dynamic environment, trauma surgeons can, and should, own the communication process. Our communication can be disciplined, goal-aligned, and patient-centered. By adopting intentional structures, brief premeeting huddles, shared prognostic frameworks, intentional engagement with subspecialty palliative care, and selective co-rounding, we can reduce avoidable discordance and improve the experience of patients, families, and clinicians alike. Unified messaging is not an optional enhancement; it is an essential component of high-quality trauma care.