End of Life Decisions: Given the unique needs and choices of individual patients, it is important to help identify personal goals for end-of-life care. Ideally, routine assessment of elderly patients on intake, or once trust has been established, includes plans for medical decision-making and life-sustaining treatment choices. These issues should be discussed with patients in a direct way, and documented in advance whenever possible. Social services or case management staff can assist when necessary. These documented wishes should be revisited at critical times such as a new diagnosis or health crisis. These discussions need to be approached with sensitivity and.
