Lost in Transition: The Ethics of the Palliative Care Handoff

In the palliative care setting, patients and families may experience transitions of care between home and different care facilities. These handoffs between care teams and settings are opportunities for miscommunication about many aspects of care. Specifically, clear, concise, and accurate information about patients' preferences and goals may not be a part of these transitions. This article presents a case where preferences were unclear and unclearly communicated and the patient received care that was likely contrary to his goals. Suggestions are made for mechanisms that may increase the likelihood that information about goals of care and preferences is clearly communicated during these transitions.